Last year alone, the opioid epidemic accounted for over 8,000 drug overdose deaths in Arizona. To battle this crisis, Arizona policy makers passed more stringent laws addressing opioid medication access. How do these new laws benefit Arizona and impact Arizona pharmacists?
Limitations on Opioids:
A significant relationship exists between opioid dose and overdose death. Chronic pain patients who received 50 to less than 100 morphine milligram equivalents (MME) per day and more than 100 MME per day died by overdose at 4 times the rate, and 7 times the rate of patients who received 1 to 20 MME per day.1 The new law restricts new controlled substance schedule II prescriptions from exceeding 90 MMEs per day,2 which is also in accordance with the CDC’s Guideline for Prescribing Opioids for Chronic Pain.3 However, this new law does not apply to a continuation of a prescription order that was written within the previous 60 days. For example, a prescription order issued within the previous 60 days for a dosage amount of more than 90 MME per day will not be impacted by this law.
Initial 5-Day Limit:
Effective April 26, 2018, a licensed health professional cannot write an initial prescription for a schedule II controlled substance for more than a 5 day supply, unless the prescription follows a surgical procedure which permits a 14 day supply.3 A limit on the initial prescription for schedule II opioid decreases the probability of a first time user developing an addiction. In addition, adolescents and young adults will not have easy access to opioids, which decreases misuse of these prescription pain medications. Patients who have chronic pain, traumatic injury, cancer, palliative care, or hospice care are exempt from this limit.
Fraudulent prescriptions are common because paper prescriptions can be easily altered or forged by patients or health care professionals. Requiring all permitted Arizona pharmacies to only accept electronic prescriptions for schedule II drugs will help minimize fraudulent prescriptions. This new law is effective immediately starting January 1, 2019 in urban counties (Maricopa, Pima, Pinal, Yavapai, Mohave and Yuma), while this same requirement will not be effective in rural counties (Greenlee, La Paz, Graham, Santa Cruz, Gila, Apache, Navajo, Cochise and Coconino) until July 1, 2019. Although this new change will not significantly impact large retail pharmacies, it may pose a challenge for small independent pharmacies who may not have funds to purchase equipment to implement this requirement. However, e-prescribing allows health prescribers to easily transfer prescriptions to pharmacies and reduce the number of prescription errors.
Beginning April 26, 2018, all permitted Arizona pharmacies are required to use red caps on schedule II opioid containers and include a warning label identifying the medication as an opioid stating the risk of overdose and addiction. Because not all patients know the dangerous effects of opioids, using red caps and adding a warning label will help patients easily identify and use opioids with caution.
Prevention of Doctor Shopping:
For schedule II-V controlled substances, all permitted Arizona pharmacies need to submit a daily report to the Arizona Controlled Substances Prescription Monitoring Program, and all pharmacists are required to review the last 12-month PMP record of each patient before dispensing a schedule II controlled substance for each new course of treatment. Similarly, prescribers are required to review the last 12-month PMP record of each patient before prescribing a schedule II, III, or IV controlled substance for each new course of treatment.5 In the past, pharmacists were not required to review the PMP record of a patient prior to dispensing a opioid medication, which increased the risk of shopping for multiple doctors and prescribing deadly drug combinations. Therefore, the new law requires the pharmacist to be the last line of defense to mitigate these situations from occurring.
Although there are numerous benefits, the new policies will not be implemented without some negative impacts on Arizona pharmacists. Besides verifying prescriptions and completing other tasks, pharmacists will also need to review the PMP records for the preceding 12 months of all patients that have a prescription for a schedule II controlled substance and update their PMP records daily. Since prescriptions will take longer to fill, pharmacists will receive more patient complaints about the potentially longer wait times. Because each schedule II controlled substance needs a red cap and warning label, pharmacists will need to order and check inventory of red caps and labels each month, which adds an additional task to the pharmacist’s job. Patients with different pharmacokinetic parameters will require larger doses to achieve adequate pain control. By limiting the opioid dosage amount and days’ supply per day, pharmacists will need to make frequent call backs to their doctors to change the days’ supply or dosage amount. E-prescriptions will cause more complications for the pharmacist’s role. For example, if the pharmacy does not have the opioid in stock, the pharmacists will need to call the doctor’s office to request a new e-script to be sent to another pharmacy that has the medication in stock. Even though these new laws place a burden on pharmacists, the benefits will hopefully eliminate the effect of the opioid epidemic in Arizona by saving thousands of lives.
Katie Tam, PharmD candidate class of 2019, Elizabeth Hall-Lipsy, Assistant Professor, University of Arizona College of Pharmacy.
1. Bohnert, Amy SB, et al. "Association between opioid prescribing patterns and opioid overdose-related deaths." Jama 305.13 (2011): 1315-1321.
2. Arizona Opioid Epidemic Act, A.R.S. § 32-3248.01 (2018).
3. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1
4. Arizona Opioid Epidemic Act, A.R.S. § 32-3248 (2018).
5. Arizona Opioid Epidemic Act, A.R.S. § 36-2606 (2018).