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Governor's Conference
Wyoming State Board of Pharmacy
Update on Prescription Drugs and
Opioids in Wyoming
May 25, 2017
Lisa V. Hunt, RPh, Chief Compliance Officer
Wyoming State Board of Pharmacy
1
Conflict of Interest

I have no actual or potential conflict of interest to
declare regarding this presentation
2
What Does the Board do?



Licensing/Disciplinary Actions/Rules
Inspections/Every pharmacy at least
annually, some CSR for CS security
Investigations of Complaints/Referrals,


BOM, BON, DEA, DCI, Office of Civil
Rights, …http://pharmacyboard.state.wy.us/Complaint.aspx
Information/Education, …WORx
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Why?


Protect the public
Abuse/Misuse & Drug
overdose death rates

Keep current with
changing federal and
state laws
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Why? – Some People Take Rx Drugs
and Drive


2014 study found 10 million people
drove in the last year while using
illicit drugs1
“A 2010 nationwide study of fatal
crashes found:
 46.5 % of drivers who tested
positive for drugs had used a Rx  The most common prescription
drugs found were:
drug,
 “alprazolam (Xanax®) 12.1%
 hydrocodone (Vicodin®) 11.1%
 36.9 % used marijuana, and
 oxycodone (OxyContin®) 10.2%
 9.8 % used cocaine.
 diazepam (Valium®) 8.4%2
1.
2.
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2014 National Survey on Drug Use and Health (NSDUH),
Wilson, 2010 http://www.drugabuse.gov/publications/drugfacts/druggeddriving;- David Wills
Rx Abuse Update CDC Statistics

U.S. Drug overdose death rate increased from:


US deaths:

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12.3/100,000 in 2010 to 16.3/100,000 in 2015
2014: 47,055 to 2015: 52,404
Of these deaths, 63.1% involved an opioid, driven by
heroin and synthetic opioids other than methadone



Natural/semisynthetic opioids deaths up 2.6%
Heroin deaths up 20.6%
Synthetic opioids other than methadone up by 72.2 %
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Natural opioid analgesics, including
morphine and codeine, and semi-synthetic
opioid analgesics, including drugs such as
oxycodone, hydrocodone, hydromorphone,
and oxymorphone;
Methadone, a synthetic opioid;
Synthetic opioid analgesics other than
methadone, including drugs such as tramadol
and fentanyl; and
Heroin, an illicit (illegally-made) opioid
synthesized from morphine that can be a
white or brown powder, or a black sticky
substance.
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Centers for Disease Control
(cdc.gov/mmwr)

Wyoming has had a decrease in the number of drug overdose
deaths from 2013 to 2015
2013: 98 WY 846 CO 117 NE 55 SD 137 MT 594 UT 207 ID
2014: 109 WY 899 CO 125 NE 63 SD 125 MT 603 UT 212 ID
2015: 96 WY 869 CO 126 NE 65 SD 138 MT 646 UT 218 ID

Source: National vital Statistics System, Mortality file using
the ICD-10 classification, underlying cause of death codes
X40-X44, X60-X64, X85 and Y10-Y14.
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What has the BOP done?

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New Rules/Education/WORx Updates
Partial filling for Schedule II medications now Allows for
periods of longer than 72 hours (CARA of 2016)




Reduces amount of drugs in home or on hand
Allows for less without voiding the Rx & requiring a new office visit
Studies show sources of abused Rx drugs are diverse but include
“stealing from grandma’s medicine cabinet” and “doctor shopping”1
Continue inspections, investigations, and disciplinary actions
1. Mechanisms of Prescription Drug Diversion Among Drug-Involved Club- and Street-Based Populations; Authors James A. Inciardi PhD,9
Hilary L. Surratt PhD, Steven P. Kurtz PhD,Theodore J. Cicero PhD, 1 February 2007, DOI: 10.1111/j.1526-4637.2006.00255.x
W.S. 35-7-1033 “doctor
shopping”
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“…[U]nlawful for any person…[to:]
[…obtain a prescription for, any controlled substance by
misrepresentation, …includes but is not limited to:
(A) Failing to disclose to a practitioner that the person has
received...[a] prescription for a controlled substance from
another source within the prior thirty (30) days;
(B) Alteration or forgery…
(C) The use of a false name or address
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What is WORx?



Monitoring tool
No diagnostic information
Protected patient information/limited access:

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Dispensing data (data in, data out),

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
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Patient’s practitioners & pharmacists
Law enforcement only with open investigations.
Pharmacy’s must report data by COB on the business day
immediately following the day the controlled substance
was dispensed (24 hours depending on business hours)
Rx not picked up by patient/Returned to stock
Reporting errors, incorrect practitioner “dr. shopper”, etc…
WORx is not an official record of what occurred!
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350
300
Total Number of Unsolicited Profiles in Wyoming
Since 2009
316
288
250
265
200
196
150
169
100
115
120
50
75
0
2009
2010
2011
2012
2013
2014
75% drop in suspected “doctor shopping” since 2009
2015
2016
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Why pharmacists? 21 CFR 1306.04(a)

Pharmacist is not obligated to fill a prescription


just because a prescription is presented by a patient or demanded
to be filled for a patient by a practitioner does not mean the
pharmacist has to fill it.
“A prescription for a controlled substance…must be
issued for:


a legitimate medical purpose …by [a] practitioner acting in the
usual course of his professional practice.
The responsibility…for…prescribing…[CS]…is upon
the…practitioner, but a corresponding responsibility rests with
the pharmacist who fills the prescription.”
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Education:
 BOP Staff: Mary K. Walker, Executive Director
 Example report reviews
 CDC Opiate Prescribing Guidelines, MME’s
 Importance of patients education on:
 opiate risks
 dangers of mixing medications
 need to keep all providers informed of
medications & history
 proper storage and disposal
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BOP Education
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PDMP tools like WORx:



21 states require reports prior to prescribing opioids
in some form (1st time) -18 do not
Kentucky mandated use in 2012 and there was a 25%
reduction in deaths due to opioid overdose
Pharmacists and practitioners can use reports to help:


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identify patients obtaining CS from multiple providers, &
calculate the possible MME per day
may identify concurrent use of benzodiazepines or other
drugs that can potentiate or impact opiate effect
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Changes to WORx
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Method of payment (Ins/cash) reported – maybe an indicator
of need for drug interaction screens
Report/monitoring three non-scheduled drugs:
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Implementing delegate registration:
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when notified health care professionals can register/manage their
delegates and each will have their own user name and password.
Implementing interstate data sharing:
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gabapentin i.e. NurontinR ,
cyclobenzaprine i.e. FlexerilR, and
naloxone i.e. NarcanR prescriptions dispensed
Not immediate/will need the entire legal name of the patient but will be
able to get reports from surrounding states.
Updating website
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What is Naloxone Rescue


Real Stories from Real People:
https://www.narcan.com/
http://www.empr.com/narcan-nasal-spray/drug/34524/
http://www.chaindrugreview.com/cvs-to-provide-narcan-spray-at-discount/
https://www.nytimes.com/2014/06/13/nyregion/anti-overdose-drug-becoming-an-everyday-part-of-police-work.html?_r=0
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Impact of Opiate Overdose
Emergency Treatment to Pharmacists

Who may benefit from this?

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Opiate naïve patients prescribed opiates for the first time
Surgery patients who are prescribed high MME’s of opiates
Persons who provide care for individuals who self
administer opiates (first responders, family member, …)
Any persons at risk for an opiate related over dosage
Employee risk of exposure
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Continued…
“Ohio SWAT member also needed a trip to the local ER
recently while entering a house where the suspect was trying
to destroy a large amount of heroin/fentanyl in the toilet.
This has prompted drug units to carry nasal naloxone as this is
not an isolated problem. Fentanyl is bad enough, but some
agencies are experiencing carfentanil, the elephant
tranquilizer, mixed in with heroin and/or fentanyl.”
https://www.statnews.com/2017/05/16/overdose-officer-fentanyl-east-liverpool/
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Impact of Opiate Overdose
Emergency Treatment to Pharmacists

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SF0042 - W.S. 33-24-158 (new) Pharmacist
prescribing, rules promulgated with BOM
W.S. 35-4-901 (new) Definitions
Practitioner or Pharmacist may prescribe without
a prescriber-patient relationship to:

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a person at risk of an opiate overdose
a person in a position to assist
a person who may encounter a person experiencing an
opiate overdose
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SF0042 Opiate Overdose Emergency
Treatment continued…

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BOM/BON…“Entity” by standing
order can establish policy/procedure
Report to DOH
Voluntary
Immunity from liability
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Immunity for prescribing opiate
antagonist W.S. 35-4-906

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Personally immune from civil or criminal liability
for any act or omission resulting in damage or
injury (prescribe or administer)
Prescribing an opiate antagonist shall not
constitute unprofessional conduct
Administration of an opiate antagonist:

“act in good faith if appears to be experiencing an
opiate related drug overdose”
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Continued…
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Pharmacists education:

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Recognize and respond
Administer naloxone
Ensure additional medical
care

Training:

90% of licensed pharmacy staff have already
completed opiate/naloxone CE, per BOP CE audit
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Questions?

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[email protected]
1 (307) 634-9636
WORXPDMP.com

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
David Wills, MBA, Data Management Specialist
1 (307) 634-9636
Atlantic Associates, PDMP Vendor
1 (800) 539-3370
Pharmacyboard.state.wy.us
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