Immunization Certification • Track & Trace • Legal Q&A
October/November 2015
Bitter Pills Prescription drug abuse: Georgia’s deadly epidemic ... and how pharmacists can fight it
Coverage You Need. Service You Deserve. A Price You Can Afford.
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cover story: Bitter Pills It’s no exaggeration to say that prescription drug abuse has reached epidemic proportions in Georgia. Pharmacists are on the front lines of this war — here’s how you can help.
3 prescript Learning by doing Grey Reybold sees firsthand how pharmacists working together can change the world.
4 news
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What’s happening in the pharmacy world Preparing for track and trace, provider status efforts gain ground, protocol agreement changes, and more.
31 contact us Who does what at GPhA, and how to reach us
32 postscript A note from President Tommy Whitworth Prescription drug abuse isn’t an abstract — it can hit close to home, and teach us what it means to care.
19 legal injection Our association counsel answers questions about Georgia pharmacy law
29 PharmPAC 23
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prescript
Shaping the future — together Before I joined the GPhA team, I devoted a large part of my legal practice to representing pharmacists and pharmacies. In my role as counselor and advocate I saw firsthand the difference pharmacists Greg Reybold make in the lives of their patients, despite, amongst other things, unprecedented regulation, archaic reimbursement processes, unfair provider agreements, and opportunistic audit practices. While having an attorney can certainly help these pharmacists work through many of the issues they face, working with GPhA this past legislative session opened my eyes to the surest way to effect change not just for individual pharmacists, but for pharmacy as a whole: working with Georgia legislators to change the laws. By way of example, before this year the Audit Bill of Rights offered pharmacists certain protections, but there was no mechanism to seek redress for violations within the state. GPhA changed that by literally rewriting the law so that audit abuses now fall within the purview of the Commissioner of Insurance. That simple change took a well-intentioned law and gave it the teeth it needed to actually be useful.
Georgia Pharmacy magazine is the official publication of the Georgia Pharmacy Association.
President and Chair of the Board Tommy Whitworth
Unless otherwise noted, the entire contents of this publication is licensed under a Creative Commons AttributionNonCommercial-ShareAlike 4.0 International license. Direct any questions to the editor at akantor@gpha.org.
First Vice President Liza Chapman
President-Elect Lance Boles Second Vice President Tim Short Chief Executive Officer Scott Brunner, CAE sbrunner@gpha.org Vice President of Communication and Engagement Phillip Ratliff pratliff@gpha.org
October/November 2015
POSITIVE CHANGE in pharmacy will come only through the collective effort of GPhA and its members. Results like these are simply unattainable for individual pharmacists (or attorneys). Positive change in pharmacy will come only through the collective effort of GPhA and its members. That is the reason I jumped at the opportunity to come on board with GPhA, and it’s the reason GPhA needs your help. Our legislative efforts are just that — ours. Together. Adding your voice by responding to our calls to action, by building relationships with your legislators, and yes, through PharmPAC investments will help you — and us — shape the future of pharmacy. My e-mail address and phone number are below. Please contact me today to learn more about what you can do. Georgia Pharmacy A S S O C I AT I O N
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Attorney Grey Reybold is GPhA’s vice president of public policy and association counsel. Reach him at (404) 419-8118 or greybold@gpha.org.
Director of Communication & Editor Andrew Kantor akantor@gpha.org Art Director Carole Erger-Fass
SUBSCRIPTIONS Georgia Pharmacy is distributed as a regular membership service, paid for with membership dues. Non-members can subscribe for $50 per year domestic or $65 per year international. Single issues are $10 issue domestic and $20 international. Practicing Georgia pharmacists who are not members of GPhA are not eligible for subscriptions.
POSTAL
ADVERTISING All advertising inquiries should be directed to Denis Mucha at dmucha@gpha.org or (770) 252-1284. Media kit and rates available upon request.
Georgia Pharmacy (ISSN 1075-6965) is published bimonthly by the GPhA, 50 Lenox Pointe NE, Atlanta, GA 30324. Periodicals postage paid at Atlanta, GA and at additional mailing offices. POSTMASTER: Send address changes to Georgia Pharmacy magazine, 50 Lenox Pointe NE, Atlanta, GA 30324.
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news Ask Senator Isakson about provider status This November, Georgia Senator Johnny Isakson is holding a “Telephone Town Hall” open to any Georgia resident. We’d love to have some pharmacists participate. It’s November 2 from 6:00 – 7:00 p.m. You can get more info from Isakson’s website: isakson.senate.gov; choose “Town Hall Meetings” from the News Center menu. Ask the senator to support the provider status bill currently in the Congress: The Medically Underserved Areas Enhancement Act (S. 314). The more he hears from pharmacists, the better. This is important: The system Sen. Isakson uses requires you to sign up for the town hall, and they call you. There are a limited number of phone lines, so it’s possible you’ll sign up and not get called. (You can also sign up by calling Isakson’s offices at either 770-661-0999 or 202-224-3643.) Even without the guaranteed call-back, it’s worth it to register and let him know that Georgia’s pharmacists are engaged… and listening.
read more @ gphabuzz.com
Track and trace is coming November 1 In case you need a reminder: On November 1 the FDA will begin to enforce pharmacies’ requirements of the federal Drug Quality and Security Act, otherwise known as “track and trace.” That means you’ll need to be recording and maintaining tracking information for products that come in, and you won’t be able to accept prescription drug deliveries that don’t already include that product tracing information. The goal of track and trace is to create a national system for tracking drugs from manufacture through dispensing to patients, which the federal government hopes will help stop drug diversion. Along those lines, it also includes national licensing standards for wholesale drug distributors, aimed at stopping the distribution of counterfeit products. The first word you need to know: Traceability. On the state level it’s often called “pedigree.” As in, legit pharmaceuticals will need to be traceable
back to their point of origin. In the case of track and trace, it means an electronic record of every step of ownership a drug goes through from manufacturer to wholesalers to pharmacies. Each step, known as a transaction, will collect the same data. If something changes along the way (e.g., 11 cartons instead of 12), it’s easy to spot where it occurred. Each time a package of drugs is transferred from one entity to another on its way to the pharmacy, it’s considered a transaction and has to be recorded. The only track-and-trace transaction most pharmacies will encounter is receiving the drugs from a wholesaler. Dispensing to patients, or transferring between pharmacies (even unrelated ones), are not considered transactions. The law requires you, as a dispenser (and the recipient of a transaction) to “pass, capture, and maintain certain types of information” about that transaction from your wholesaler. (Continued on page 5)
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(Continued from page 4)
What information? There are three parts of the transaction you’ll need to record. First, the transaction information: the name of the product, strength and dosage form; NDC; container size; shipment date; and name and address of sender and recipient. Next, the transaction history: a list of all prior transactions. Finally, a transaction statement: a declaration from your wholesaler asserting that it has complied with the law. The good news is that you don’t necessarily have to compile and store all this information yourself. You can have a third party do it for you, including your wholesale distributor. The bad news is your wholesaler doesn’t have to do it (or even that it will want to), but it’s possible some of
them will offer such services. (Note: It will require a written agreement, which could simply be part of your standard contract.) Track and trace is obviously a big deal, and GPhA has already been providing information about it. Earlier this year we presented an overview of the requirements as part of a webinar with industry expert Scott Mooney of McKesson. We’ve archived the webinar recording as a member information/ compliance resource, and we’ve made it part of the resources on our track and trace resource center at GPhA.org/trackandtrace. We’ll also be offering live sessions with more detail, including hands-on training -- keep an eye on your e-mail and on the daily GPhA Buzz digest, even past the November 1 deadline.
Georgia’s Rx Drug Epidemic
3/4 of all overdose deaths in Georgia were caused by prescription drugs.
1 in 12
Georgians — including teens — use pain relievers non-medically. More than
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Just in time for flu season 2015-16, one of GPhA’s most popular courses is here: The twice-annual, day-long immunization certificate program.
The price has been reduced this year, too. It’s only $200 for GPhA members, and $425 for non-members, which includes one year of GPhA membership.
It’s created by APhA, accredited by ACPE, and it gives 20 hours (!) of CPE — that’s including the required home-study work and the live class.
The program this is just part of GPhA’s ever-growing library of immunization resources; for more information, check out GPhA.org/immunization.
Important details:
Sunday, October 18, 2015 8:00 a.m. – 5:00 p.m. PCOM School of Pharmacy, Suwanee
October/November 2015
Space is limited, so sign up quickly.
Sources: GBI, Burruss Institute of Public Policy and Research via the Georgia Council on Alcohol and Drugs
Get immunization-certified with this popular APhA course
of 10th, 11th, and 12th graders said it was easy to obtain prescription drugs not prescribed to them. So did 11% of 6th graders.
Myth, busted:
People receiving public assistance in Georgia were much less likely to use any kind of illicit drugs, including pain relievers.
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news Pharmacist’s AJC op-ed explains provider status Did you catch pharmacist Tina Chancy’s op-ed in the Atlanta JournalConstitution on July 31? The owner of Chancy Drugs in Hahira made a beautiful case for provider status for pharmacists. (Of course, we’re a bit biased.) Here’s a snippet:
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Georgia Pharmacy
Generally, I spend two to three hours consulting with a new patient — answering questions about prescriptions, discussing side effects and performing screening tests. Monthly follow-up consultations allow me to identify whether patients are following through with recommendations. Ultimately, this ongoing care encourages patients to take ownership of their health care and overall well-being. Yet neither Medicare nor other insurance programs reimburse me, or any pharmacist, for the individualized attention we provide. Congress has the power to correct this oversight with legislation that grants pharmacists “provider status” under Medicare. This modification would ensure pharmacists are compensated for treating seniors, and it would encourage better collaboration with physicians on a routine basis. (Read more at fllw.me/tchancy.) We’re working with our friends at APhA and other organizations to lobby Congress to pass provider-status legislation, starting with the Pharmacy and Medically Underserved Areas Enhancement Act (H.R. 592 and S.314), which already has more than 200 sponsors in the House and Senate. October/November 2015
New Day(s) at the Dome for 2016 GPhA is changing our traditional Day at the Dome event for 2016. Legislative advocacy is a GPhA core competency: It’s one thing we can do for Georgia pharmacists and pharmacies that you can’t do as well by yourselves. Traditionally, we’ve demonstrated our members’ passion and personal engagment in our advocacy efforts via our annual one-day Day at the Dome. (You might remember it as “VIP Day”). The trouble is, it has become increasingly difficult for significant numbers of practicing pharmacists to attend, although student turnout is impressive. We believe there’s a better way to demonstrate and leverage pharmacists’ influence. The GPhA Board of Directors has approved a new approach for flexing pharmacy’s political muscle at the Gold Dome in 2016 — one that will ensure that pharmacists are walking the halls of the capitol each week of the legislative session, and will also allow student pharmacists to show the strength of our numbers – and the services
we can provide patients — in a capitol-based student event especially for them. Here’s how it will work: • On one day each week of the legislative session, GPhA will coordinate a team of eight to 12 pharmacists (in white coats, of course) to come to the Gold Dome to assist our lobbyists in talking with specific legislators about our bills and helping us move things along. • On February 16, GPhA will host student pharmacists — we envision 300 or 400 of them — at the capitol to provide health screenings and to target specific legislators and committees with GPhA advocacy messages. If you’re interested in serving on an advocacy team during the session, shoot an e-mail to GPhA VP of Public Policy Greg Reybold at greybold@gpha.org and let him know. We think this change will help advance our advocacy agenda and elevate the influence of pharmacists at the Gold Dome.
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October/November 2015
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Georgia Pharmacy
news In congress: TriCare Payments and “pay-to-Delay” Georgia’s Buddy Carter and 30 other congressmen wrote the DoD asking it to reconsider a policy, enacted in May, that requires all ingredients in compounded medications to be approved by the FDA, and that has Express Scripts screening those ingredients. Since that policy was enacted, the DoD’s reimbursements for compounded prescriptions fell from about $250 million per month to only $4 million. Wrote Carter, Peter Welch (D-Vt.), and 29 others: “We respectfully ask you to review and revise the current rule changes to ensure military personnel across the country have the ability to use the pharmacy of their choice for the medications they need.” In other legislative news, two U.S. seantors want to prevent pharma companies from paying generics manufacturers to delay introducing competition. Generic-drug manufacturers planning to introduce a less expensive version of a medication are sometimes paid millions by the branded-drug manufacturers to effectively delay the generics’ coming to market. Both drug companies win, but consumers and taxpayers lose — they have to continue to pay high prices for products without competition. The drug makers argue that it’s better because they don’t have to spend as much on lawsuits. The bill, introduced by senators Amy Klobuchar (D-Minn.) and Chuck Grassley (R-Iowa) is called the Preserve Access to Affordable Generics Act and would make pay-for-delay deals illegal. October/November 2015
Two court cases show MAC transparency remains a nationwide issue In a major case, a federal court has ruled that an Iowa law requiring PBM transparency (similar to the law GPhA passed in Georgia earlier this year) was legit. The PBMs had filed a suit challenging Iowa’s transparency law, which is similar to the one GPhA helped pass earlier this year in Georgia. Among other things, the law requires PBMs to justify their reimbursement rates for generic drugs, and to update them regularly. The court concluded that ‘the state has a legitimate interest in regulating PBMs in order to preserve the health of its citizens.’ In related news, Kmart joined several other major retail pharmacies in suing Catamaran, a PBM many Georgia pharmacists know well. The suit says that the company’s policies don’t reimburse pharmacies enough, forcing the pharmacies to eat the costs of many generic drugs. It also alleged that Catamaran has refused to disclose how it
determines reimbursements. The suit was filed in Kmart’s home state of Illinois. Georgia’s new MAC transparency law means that at least some of what Kmart alleges Catamaran has done would be illegal here.
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October/November 2015
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news First biosimilar drug approved for the U.S. Novartis’s heart drug, Zarxio, is the first bioisimilar drug to be approved in the U.S. Biosimilars are a lot like generics, but they’re created with a biological process rather than a chemical one. It’s a bit more complex than making typical, chemical generics, which is one reason biosimilars are relatively new. Part of the Affordable Care Act was speeding the process of approving them in order to help reduce costs for patients. In this case, Zarxio is the ‘generic’ version of Neupogen, which is used to treat certain infections in patients undergoing cancer treatment.
10 Georgia Pharmacy
Which two groups most need flu shots this year? Flu season is upon us, and if last year is any indication it’s not going to be much fun. But there are two groups of people — your patients — who are most in need of a flu shot this year. Before the season gets into full swing, you should be talking to them and encouraging vaccinations. First are seniors. Last year had the highest flu hospitalization rate for seniors since… well, in modern times. Our friends over at the National Council on the Aging are trying to get the message out that the flu can be particularly bad for older folks (they’ve got a website: ncoa.org/
Flu). There’s even a higher-dose vaccine for the older set. If nothing else, now’s the time to start reminding your older patients that they really do need to get their shots sooner rather than later. Unless they really like hospitals. Then it’s OK to skip them. The other group is pregnant women. It’s pretty simple: If you get the flu while pregnant, it doubles the risk of a baby with birth defects. Tell your patients who are expecting (and their families) that a flu shot protects their unborn child. And the CDC is clear that they should get a shot, not the nasal spray; the latter contains the live virus.
October/November 2015
Offering vaccinations? Here’s critical info about those protocol agreements works with GPhA’s sample protocol If you’ve already entered into a agreement. vaccine protocol agreement with a That means if you use another physician — or you’re planning to — protocol agreement as a template this is important. (e.g., one from the Medical Board) If you’re going to use GPhA’s you must prepare your own case patient consent form from our history and patient consent forms. Immunization Compliance Kit, you Those protocol agreements may must use our sample protocol agreehave different requirement as well. The legal ments that need to be language in the two go read more @ together. gphabuzz.com reflected in the consent form. Quick background: GPhA’s consent form Under Georgia’s new may not comply with the immunization law, prior requirements of the protocol agreeto administering a vaccination you ment you use. must, amongst other things, take a You can get all these materials complete case history and obtain — they’re free for GPhA members required patient consents. — and the entire Immunization GPhA’s sample immunization conCompliance Kit at GPhA.org/ sent form was designed to help you immunizations. meet these requirements, but it only
“It’s like she’s coming alive” At least one patient is doing much better thanks to a new Georgia law passed this spring. Two-year-old Lainey Cleveland of Winder was having as many as a dozen seizures a day before she began taking cannabis oil treatments thanks to Georgia’s new law making those treatments available to certain patients — like Lainey. Now those seizures are cut in half, and she’s able to begin learning to walk. She smiles more, too. “It was like watching your child come to life,” said her mother. Did you know: All the medical marijuana Georgia needs could be grown in a field about 2/10ths of a mile square?
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October/November 2015
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Georgia Pharmacy 11
legal injection
Q&A: Immunization With this issue we begin a new feature: Answers to common questions about Georgia pharmacy law from attorney Greg Reybold, GPhA’s vice president of public policy and association counsel. Greg can’t provide legal advice directly to members, but he gladly weighs in here on some of the more common issues he hears about.
Can I begin administering vaccines immediately once I have entered into a vaccine protocol agreement with a physician? There are several other requirements under the law that must be satisfied prior to administering vaccines, including but not limited to completion of requisite training program[s], maintaining appropriate liability insurance, and maintaining policies and procedures for the handling and disposal of used or contaminated equipment and supplies. Once the necessary prerequisites have been satisfied, it is important to be sure that the vaccine protocol agreement and other necessary documentation has been filed with the Composite Medical Board prior to administering vaccines. While the law provides that the physician is to file the vaccine protocol agreement, practically speaking it appears pharmacists are the ones actually sending the agreements to the Composite Medical Board. Once vaccine protocol agreements have been filed, it appears the Composite Medical Board is sending out approval letters. Note that there is nothing in the law that provides that pharmacists must hold off on administering immunizations until they receive approval from the Board. In light of the foregoing, pharmacists should be able to begin administering vaccines once the vaccine protocol agreement has been filed with the board. However, the most conservative approach would be to wait until receiving written approval from the Composite Medical Board or to confirm with the Composite Medical Board that it has received the vaccine protocol agreement and that it is OK to begin administering vaccinations.
Does GPhA’s sample consent form work with the Composite Medical Board’s template vaccine protocol agreement? No. GPhA’s consent form as written works with GPhA’s sample protocol agreement but not with the Composite Medical Board’s template protocol agreement. Why not? Under the new immunization law, prior to administering a vaccination you must (amongst other things) take a complete case history and obtain required patient consents. GPhA’s sample immunization consent form was designed to help you meet these requirements. However, the Composite Medical Board’s template vaccine protocol agreement contains specific case history questions that are not included in GPhA’s sample consent form. As such, if you use the Composite Medical Board’s template vaccine protocol agreement or any vaccine protocol agreement other than GPhA’s sample agreement, you need to prepare your own case history and patient consent forms or revise GPhA’s sample consent from as necessary. Does Georgia law allow me to fill a prescription for auto-injectable epinephrine to a school? Yes. Georgia law allows physicians, advanced practice registered nurses, and physician assistants to prescribe auto-injectable epinephrine and levalbuterol sulfate or albuterol sulfate in the name of a public or private school for use as provided by law in accordance with a protocol and pharmacists may dispense same pursuant to such prescriptions. The bill allowing for this was signed into law in 2015 and became effective this July. Georgia Pharmacy A S S O C I AT I O N
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Use of this article, or the information it contains, does not constitute any legal advice, does NOT establish any attorney-client relationship, and does NOT create any legal duty on the part of the author or the Georgia Pharmacy Association. When making a decision that may have legal consequences, readers should consult with qualified legal counsel.
Do you have an issue you’d like to see addressed in this column? Let us know — submit it to Greg at greybold@gpha.org. 12 Georgia Pharmacy
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A S O L I D F O U N D AT I O N FOR A BETTER PROFESSION
The Georgia Pharmacy Foundation provides scholarships, educational programs, and community-service opportunities for students and recent graduates. It supports the LeadershipGPhA program helping develop future pharmacy leaders, and it helps pharmacists and student understand substance-abuse issues through the Pharmacist Recovery Network Conference.
Your tax-deductible contribution to the Georgia Pharmacy Foundation's Annual Fund Drive makes a tremendous difference in the lives of new and up-and-coming pharmacists.
F O U N D AT I O N
cover story
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October/November 2015
Georgia’s prescription drug epidemic and how pharmacists can help By Andrew Kantor
October/November 2015
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cover story The CDC calls it an epidemic. The DEA isn’t going to argue. Prescription drug abuse is big enough that law enforcement agencies in the southeast rank it the number one or number two drug threat — right up there with crystal meth. But unlike crystal meth, when it comes to prescription drug abuse pharmacists can do something. That’s why you’re reading this. The “abuse” takes several forms. The end result, of course, is people taking painkillers like Vicodin or Percoset, not because they’re in pain, but because they’re addicted. Some simply beg or steal pills from friends and family. Others go “doc-shopping” to get multiple prescriptions. Some go through garbage cans looking
medical practice: Most were owned by physicians, they accepted health insurance, their patients made appointments and received physicals. Some offered physical therapy, and all prescribed more than just narcotics. Want to know how fast prescription drug abuse became a problem? In 2012 — just two years later — there were more than 125 pain clinics in the state. The owners often aren’t doctors and don’t live in Georgia. Many are convicted felons. And many of them also own pain clinics in other states… and often, says the DEA, have ties to organized crime. But, points out Dr. Tennant Slack of Gainesville, co-chair of the Medical Association of Geor-
In almost every case, the drugs are legally sold and legally delivered to a neighborhood pharmacy. It’s not street-corner dealers handing out the pills. It’s you. for discarded meds. And when there’s a demand, there’s an industry popping up to serve it: Pharmacy workers forge documents to divert their stock. Pain clinics appear with, shall we say, negotiable ethics — along with a black market. There’s another big difference. People aren’t cooking Vicodin in their trailer homes, or sneaking it over the border. Users don’t have to visit a shady street corner at three a.m. to score a hit. About two thirds of them, says the DEA, get their pills from a friend or relative, usually free, sometimes for cash. Another quarter get them via a doctor’s prescription. Fewer than five percent get them from a dealer. What’s the common denominator? In almost every case, the drugs are legally sold and legally delivered to a neighborhood pharmacy. It’s not those street-corner dealers handing out the pills. It’s you.
Scope of the problem It’s also doctors, some legit, some not. According to the DEA, in 2009 and 2010 there were about 15 to 20 legitimate pain clinics in Georgia. They were just what you’d expect from a 16 Georgia Pharmacy
gia’s “Think About It” campaign, “This is not a new problem. It has been with us for over a decade.” In the early 2000s the balance between effective pain treatment and overuse of narcotics began to tip. “There was a push by several major medication programs for more aggressive treatment of pain,” he said, including the powerful Joint Hospital Commission. “This set the stage for further opioid prescribing,” he said, and “by 2010, [prescription opioids] were responsible for twice the deaths of cocaine and heroin combined.” Here’s a scary stat for you: The Georgia Bureau of Investigation’s Medical Examiner’s Office found that deaths related to prescription drug overdoses accounted for three-quarters of all accidental drug deaths in the state. And that number, it said, continues to rise. That’s not surprising. A needs assessment created for the Georgia Council on Alcohol and Drugs found that 4.6 percent of Georgians over 12 used pain relievers non-medically. For kids 12-17, the report found the number was much higher: “[N]early seven percent used pain relievers nonmedically.” Only alcohol and marijuana had more users. October/November 2015
Considering the amount of news coverage we give to terrorism, shark attacks, and airplane crashes, you would think you’d hear more about an issue that’s killing a lot more people. For now, though, this is a quiet little war — one with pharmacists on the front lines. It’s not a fun place to be. You want to help stop the drug-abuse problem, but you don’t want to be so suspicious that you deny medication to legitimate users in legitimate pain. Slack, who’s a pain physician himself, sees the big picture clearly. “We need to provide patients who have legitimate, persistent pain problems with appropriate access to pain care, which in some cases includes narcotics,” he said. “On the other hand, we have to be careful to protect the public from the consequences of prescribing too many of these medications.” And for about the past decade and a half, he explained, “The scale has tipped very much in favor of more prescribing rather than less prescribing.”
What’s a pharmacist to do? Most people would prefer to prevent a problem from occurring rather than deal with the consequences. That’s one reason the Office of National Drug Control Policy has a multi-pronged approach to the issue of prescription drug abuse, with “enforcement” as the last resort. The first line of defense is education, and it’s the best starting point for pharmacists. Educate patients and their families. It might seem obvious, but many people don’t even realize there is a problem with prescription drug abuse in Georgia. It might not occur to them that there are plenty of people who would love to get their hands on those pills they’re taking. That in mind, when you dispense a prescription for painkillers — or any drug likely to be abused — offer a simple verbal reminder to patients to be careful about how they store their pills (especially if there are children, teens, or potential abusers in the house). Just making them aware of the problem might make a big difference. You might also suggest that they keep track of their pill supply — a simple weekly pill keeper can help — and maybe let them know how to deal with any unused meds (see below). October/November 2015
yes, harm. yes, foul. Prescription drug abusers usually don’t start because they’re seeking a high. For three-quarters of them it begins innocuously, according to the DEA — they get hooked after taking a legitimate medication for a legitimate reason. Once that hook takes hold, though, addicts will bend over backwards to get another hit. That starts by faking pain and getting another prescription... or two, or three. Then comes begging and stealing from friends and, often, doc-shopping. Doc shopping — seeing multiple doctors and getting multiple scripts for pain meds — will raise flags with insurers, which means addicts can find themselves forced to pay cash. That’s when irony rears its ugly head, and those addicts find that street-corner heroin is actually less expensive than prescription meds. (So concluded the DEA in its 2015 National Heroin Threat Assessment Summary.) And with the boost to the heroin trade comes all the associated problems, from overdoses to crime to HIV/AIDS, which has been spiking lately thanks to the sharing of dirty needles. A more direct issue is simple overdosing. In 2013, almost twice as many Americans died from ODing on prescription opioids (16,200) than on heroin (8,300). Think about that : More than 16,000 Americans died in a single year from overdosing on prescription painkillers. And then there’s the monetary cost: lost labor, hospital bills, emergency responders, police, and so on. Earlier this year, the DEA calculated that, “The economic cost of non-medical use of prescription opioids alone in the U.S. is in excess of $53 billion annually.” That’s a lot of money that could be used in a lot of other ways. The business of prescription drug diversion is big enough and profitable enough that criminals, street gangs, and organized crime groups are starting to go for a piece of the action. Considering where most prescription drugs come from — your shelves — that doesn’t bode well for pharmacies.
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cover story A Partner and a plan:
The Think about it Campaign The Georgia Pharmacy Foundation — and many other organizations — have partnered with the Medical Association of Georgia Foundation’s Think About It campaign (rxdrugabuse.org). Its goal is simple and broad: to work with healthcare workers, law enforcement, schools, and religious, civic, and social organizations to help eradicate prescription drug abuse across Georgia. It’s working on several fronts: • Changing Georgia’s prescription drug monitoring program so we share data with healthcare professionals in other states. • Encouraging consumers to have safe storage locations for their drugs • Establishing ongoing drug take-back programs in communities • Raising money for prescription-drug dropboxes in local law enforcement offices • Increasing the availability of drug-abuse treatment for Georgians • Having the judicial system focus on reducing recidivism and substance abuse, rather than simply punishment • Educating consumers about ways to reduce the chances of drug abuse or addiction through safe storage and disposal of medication It’s also working to educate healthcare professionals with seminars, webinars, handouts, and other information about the drug abuse problem.
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One of the most notable projects from Think About It is called Project DAN — for deaths by naloxone — specifically, the prevention thereof. Naloxone is to opioid overdose what an EpiPen is to anaphylaxis: Instant, safe emergency treatment. Thanks to a fundraising effort from the Medical Center Foundation (of the Northeast Georgia Medical Center), Project DAN is hoping to stock pharmacies in 13 northern Georgia counties with naloxone nasal atomizers starting in October. Prescriptions will allow them to distribute those atomizers to police free of charge, according to Lori Murphy, director of program development for the MAG Foundation. “We’re asking that these pharmacies have it available so when a representative from each county’s police department comes around, each police officer will have at least one naloxone kit on his person at all times,” Murphy said. The program will also provide training for police on how to administer the drug. (In Georgia, a Good Samaritan law protects people who call 911 because of a drug overdose.) Murphy said she expects the Project DAN pilot program to last at least a couple of years, and hopes it can be expanded to other counties as money allows. “We’ve already had requests from Savannah and Athens,” she said, but it has to start slowly, if for no other reason than the lack of naloxone supply. Simply put, Murphy said, “There’s not enough out there.”
October/November 2015
we won! In 2015 GPhA scored two major victories: expanded immunizations and MAC transparency. Crucial to those wins: friendly legislators, elected with the help of PharmPAC.
PharmPAC is GPhA’s political action committee. It works to elect candidates who think like you do, and who understand the challenges you face in serving your patients and running a business.
But it won’t keep working without you. By investing in PharmPAC, you help protect your practice, your patients and the pharmacy profession from bad law and policy, and you join with hundreds of other investors in growing your profession’s political influence.
PharmPAC helps make sure pharmacists have a seat at the table. And it works.
Invest today — in PharmPAC and in your practice — at GPhA.org/pharmpac.
50 Lenox Pointe, NE, Atlanta, GA 30324 | tf: 888.871.5590 ph: 404.231.5074 | f: 404.237.8435 | www.gpha.org
cover story
ask yourself this Michael Moné of Cardinal Health, along with the Minnesota Hospital Association, offered several suggestions for what to consider when deciding whether a patient might be abusing painkillers — or helping someone else do it. • Do you know the patient? Do you know the person picking up the prescription? • Is the patient returning too frequently or requesting early refills? • Has the patient been prescribed a variety of different controlled substances? • Has the patient received controlled substance prescriptions from multiple providers? • Is the patient paying cash for controlled substance prescriptions? Does the patient have insurance that the patient doesn’t want adjudicated? • Where is the patient’s address in relation to the pharmacy? • Do patients appear with several prescriptions for the same product or written in the names of other people? • Is the patient receiving 90-day supply of medication for an acute injury? • Is this prescriber writing for larger quantities than other practitioners in the area? • Does the prescriber write for antagonistic drugs? • Is the quantity of medication or strength prescribed unusually high? • Do a number of people appear within a short time, all bearing similar prescriptions from the same practitioner? • Is the prescriber writing a prescription outside of his knowledge base (e.g., methadone)? • Does the prescription contain all of the information required by law? • Where is the physician located in relation to the pharmacy?
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And of course explain why. In the absence of an ABC Afterschool Special on the subject, it’s critical to shed as much light on the issue as possible. In fact, this kind of education is a goal of the Medical Association of Georgia’s “Think About It” campaign, of which GPhA is a partner: Spread information and resources about the problem across Georgia. (See the sidebar, “A Partner and a Plan.”) Support a strong Georgia prescription drug monitoring program. Almost every state, including Georgia, has a prescription drug monitoring program — a PDMP — for doctors and pharmacists to check a patient’s history of narcotic use. Unfortunately, Georgia’s has what might be considered a glaring flaw: Unlike most states, our PDMP doesn’t allow Georgia doctors and pharmacists to share their data with other states. Because our neighbors’ PDMPs do allow data sharing, Georgia becomes, in the words of the Georgia Prescription Drug Abuse Prevention Initiative, “the path of least resistance for those seeking to abuse the system.” People can buy prescription painkillers here knowing that those purchases won’t show up on other states’ records. (Healthcare workers here, including doctors and pharmacists, can check records from neighboring states, but only if they have taken the trouble to register with those states for access to their PDMPs. Few have.) There are other issues with Georgia’s PDMP, including funding (it will run out at the end of June 2016 without the state legislature’s intervention), law enforcement access, and integration with patients’ medical records. That’s why GPhA will be working with the Medical Association of Georgia and other agencies to clarify the law in 2016 to improve the program. Help with drug disposal. Although federal law allows pharmacies to accept unused drugs for disposal, Georgia law does not. (And even if it did, the requirements for a legal disposal system are so strict — and expensive for pharmacies — that it’s unlikely many pharmacies would participate.) Still, you should tell patients two easy way they can dispose of leftover drugs: Via dropboxes located in police departments and sheriffs’ offices (there’s a full list of locations at stoprxabuseinga.org) October/November 2015
By mixing it with something disgusting (e.g., cat litter, rotten food) and throwing it in the garbage — not down the drain. Even with the best-laid plans of mice, men, and pharmacists, prescription drug abuse will continue to be a problem. That’s reality. So when early prevention fails, your next step is to intercept the problem at the counter.
most-abused drugs
Barbarians — and drug abusers — at the gates Helping prevent someone from illegally getting hold of prescription drugs can be as simple as recognizing the signs of patients who might be doc- or pharmacy-shopping and declining to fill the script. Both Michael Moné, associate general counsel at Cardinal Health, and the Minnesota Hospital Association offered a list of behaviors to consider when receiving a prescription. For example, how well do you know the patient? Is he paying cash? Does he bring in prescriptions from multiple doctors? And so on. Think about the prescriber as well: Is it a doctor you know? Is the practice nearby? Are scripts from that office in line with other doctors in the area, or are they heavy on the painkillers?
Narcotic Pain Killers Hydrocodone Lortab Vicodin Norco Oxycodone Percocet Roxicodone Endocet Oxycontin Methadone/Morphine Avinza Kadian Fentanyl Duragesic Fentora Codeine Anti-anxiety meds Xanax, Valium, Ativan Source: Drug Enforcement Administration, 2013
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The Georgia Pharmacy Association is growing — in new directions and soon to a new location. Later this year, GPhA will relocate to a new suite of offices in Sandy Springs. We’ve launched a fundraising campaign to help furnish our new home. It’s simple: We’d like leaders in the pharmacy profession and industry to demonstrate their support for GPhA. Anyone giving a gift of $1,000 or more will receive permanent recognition on GPhA’s Leader Wall in the foyer of the new office suite.
Send your gift to our current office marked “GPhA Furnishings Fund.” You can also reach out to GPhA CEO Scott Brunner personally at sbrunner@gpha.org and share with him your pledge. Georgia Pharmacy Association 50 Lenox Pointe NE Atlanta, GA 30324
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Georgia Pharmacy A S S O C I AT I O N
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cover story (Those are just a few suggestions of what to consider. For a more complete list, see the box, “Ask yourself this.”) There’s also Georgia’s PDMP. You have to put information into the system, but the law also allows access “[t]o persons authorized to prescribe or dispense controlled substances for the sole purpose of providing medical or pharmaceutical care to a
The important thing to remember is that you’re not required to fill a prescription that raises those red flags. “The law,” says the DEA, “does not require a pharmacist to dispense a prescription of doubtful, questionable, or suspicious origin.” You wouldn’t be alone. There are pharmacies that have simply refused to fill prescriptions from doctors’ offices they consider to be pill mills.
If you fill a questionable script when you should have known better, you could be looking at felony charges “for knowingly and intentionally distributing controlled substances.” specific patient” — in other words, you are allowed to look at the data if you’re providing pharmaceutical care. If a patient has rarely or never gotten an opioid prescription before, you might be able to breathe a little easier. Okay, but what if you do hear some alarm bells? Now what? (Hint: One drug combination the DEA automatically considers a red flag is benzodiazepine, carisoprodol or tramadol, and any opioid-containing medication.)
Oh, and if you’re thinking that you’d rather not play the role of gatekeeper, guess what? You don’t have a choice; you can’t fall back to “I’m just following the doctor’s orders” because the DEA doesn’t buy that. The law (Title 21 of the Code of Federal Regulations, to be specific) is quite clear:
What if the pharmacist has the problem?
So yes, you’re on the hook. Nor, if you have a legitimate reason to suspect the prescription is bogus, can you fill it and then report it. A pharmacist is prohibited — again, this is the DEA talking — “from filling a prescription for a controlled substance when he either ‘knows or has reason to know that the prescription was not written for a legitimate medical purpose’.” And by the way, as the DEA’s Office of Diversion Control explains, “The person knowingly filling such a purported prescription, as well as the person issuing it, shall be subject to the penalties provided for violations of the provisions of law relating to controlled substances.” (Again, emphasis ours.) You read that right. If you fill a questionable script when you should have known better, you could be looking at felony charges “for knowingly
Pharmacists certainly aren’t immune to the pull of addiction. If you or someone you know in the profession needs help, GPhA might be able to provide it. PharmAssist is a program designed specifically for pharmacists who are struggling with addiction issues. The calls and help are strictly confidential. The first step isn’t easy, but it’s still far better than not taking it: Call (404) 419-8130.
22 Georgia Pharmacy
The responsibility for the proper prescribing and dispensing of controlled substances is upon the practitioner, but a corresponding responsibility rests with the pharmacist who fills the prescription. (Emphasis ours.)
October/November 2015
and intentionally distributing controlled substances.” How likely is that to happen? A better question is, do you really want to find out? The reality is you probably don’t want to be calling the feds as part of your job. You’re in this business to help people, not to help them go to prison. That’s why the goal is to stop addiction before it starts, and to make it harder for prescription drug abuse to occur in the first place.
In your pharmacy Pharmacists, technicians, and other pharmacy employees certainly aren’t above reproach. Just as with patients, there are two angles of attack here: prevention and enforcement. We would all like to hire and work with perfect people, but those simply don’t exist. So the first step towards stopping a pharmacy employee from becoming part of the drug-abuse problem is to make it difficult to do. According to a Minnesota Hospital Association report, there are a number of steps and programs in place at various chain pharmacies (although spokespeople for those pharmacies declined to discuss their specific business practices with us). Most if not all educate their employees about the problem, and will keep and check detailed inventory records. Some go further. For example, many chains prohibit their techs from bringing personal belongings such as purses or backpacks behind the counter; several, including Costco, Rite Aid, and Walgreens, have a similar prohibition for pharmacists, according to the report. Stores will have other policies in place, from strict control of garbage all the way to electronic surveillance and random drug testing. Even with a slew of protective policies in place, where there’s a pill there’s often a way. Cardinal Health’s Moné suggested several behaviors that might cause you to raise an eyebrow… and look a little further: Someone who’s always offering working extra shifts, or offering to shelve orders as they arrive. Excessive bathroom breaks can be a sign as well, or always volunteering to take out the garbage. Hiding drugs in personal belongings is obviously a common way of removing drugs from the
reporting a loss Let’s say you believe a controlled substance was stolen from your pharmacy. Not only do you have to notify the local constabulary, but you have to file a report with the nearest DEA field division office if that loss was “significant.” And you have to determine what constitutes “significant.” You need to report what was lost, how much of it, whether a specific individual was at fault, whether something unique was going on with it, whether the loss is part of a pattern (and if so what you’ve done to try to prevent it), whether you think the drug was stolen for a specific reason, and if there are any “local trends” of such theft that might explain it. So unless you have a particular love of paperwork, it’s better to do everything you can to prevent that from happening in the first place.
pharmacy, but using the trash or salvage bin to get them out of the store works just as well. Some employees have even used the mail. Why risk being caught sneaking something out when you can have the postman or UPS guy unwittingly do it for you? Then there are more sophisticated tricks: shorting patients, creating fake transactions, forging entries in the C-II log, or otherwise cooking the books. Keeping your eyes — and mind — open is, as always, one of the best ways to prevent employee theft. Prescription drug abuse isn’t going to end. It’s not a war that can be won. But it is a war that can be managed, and one where we can reduce losses and save lives — and pharmacists have a critical role to play. Georgia Pharmacy A S S O C I AT I O N
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SUNdAY, OCtOBeR 25, 2015
•
MACON MARRIOtt & CeNtRePLex
SAVE THE DATE
AiP fAll MEEtiNG • 3.0
CEUs • Immunization Information • Network with Colleagues • Meet with Partners CONtINENtAl BREAkfASt & lUNCh PROVIDED
AGENDA 7:00 – 8:00AM Registration & Continental Breakfast 8:00 – 9:00AM Compounded Medicines: New Laws, New Responsibilities, New Questions David G. Miller, R.Ph., EVP & CEO, International Academy of Compounding Pharmacists (1.0 CEU ACPE)
9:00 – 10:00AM Immunizing in Georgia: What You Need to Know Greg Reybold, GPhA VP of Public Policy and Association Counsel (1.0 CEU GA Board of Phy) 10:00 – 11:00AM Clinical Services Profit Ignitor Nicolette Mathey, Pharm.D., R.Ph., Pharmacy Development Services (1.0 CEU GA Board of Phy)
11:00 – Noon Network with Partners Noon – 1:00PM Lunch 1:00 – 2:00PM HP: How to Bill Immunizations for Medicaid 2:00 – 3:00PM Critical Key/Specialty Pharmacy Update 3:00 – 4:00PM Legislative Update
SHOW YOUR SUPPORT — ATTEND THIS YEAR’S AIP FALL MEETING Registration: Please fill out and fax back to (404) 237-8435 Member’s Name:
Nickname:
Pharmacy Name: Address: E-mail Address (please print): Will you be joining us for lunch (Noon – 1:00PM)? How many total will be attending? Names of Staff/Guests:
q Yes
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Investing in PharmPAC is investing in your practice. 2015 PharmPAC investors The following pharmacists, pharmacy technicians, students, and others have joined GPhA’s PharmPAC.
The contribution levels are based on investment for the calendar year as of September 18, 2015.
Diamond Investors ($4800 or $400/month)
Charles Barnes Valdosta
Scott Meeks Douglas
Fred Sharpe Albany
Titanium Investors ($2400 or $200/month)
Ralph Balchin Fayetteville
T.M. Bridges Hazlehurst
DAVID GRAVES Macon
Greg Hickman Monroe
THOMAS LINDSEY Omega
Brandall Lovvorn Bremen
Jeff Sikes Valdosta
Danny Smith McRae
TED HUNT Kennesaw
DEAN STONE Metter
David Graves, Macon, PharmPAC chairman October/November 2015
Georgia Pharmacy 25
2015 PharmPAC investors Platinum Investors ($1200 or $100/month) Thomas Bryan, Jr. William Cagle Hugh Chancy Keith Chapman Dale Coker Al Dixon Jack Dunn Martin Grizzard Robert Hatton William Huang Ira Katz Jeff Lurey Jonathan Marquess Pamala Marquess
Silver Investors
($300 or $25/month)
Renee Adamson Nelson Anglin Larry Batten Chandler Conner Mandy Davenport Gregory Drake Bill Dunaway Eric Durham Marshall Frost Amanda Gaddy Amy Galloway Carson Gleaton Johnathan Hamrick Willie Latch Kalen Manasco Bill McLeer Donald Peila, Jr. Daryl Reynolds
(continued)
Gold Investors ($600 or $50/month) Larry Braden William Brewster Bruce Broadrick Liza Chapman Blake Daniel Mahlon Davidson Sharon Deason Robert Dickinson Benjamin DuPree Kevin Florence Kerry Griffin Micheal Iteogu Stephanie Kirkland Mike McGee
Ivey McCurdy Drew Miller Laird Miller Mark Parris Houston Rogers Daniel Royal Wade Scott Terry Shaw Tim Short Chris Thurmond Danny Toth Alex Tucker Tommy Whitworth
Ashley Rickard Sharon Sherrer Richard Smith Archie Thompson Austin Tull Flynn Warren Bronze Investors
($150 or $12.50/month)
Phil Barfield Robert Bentley Elaine Bivins Nicholas Bland James Carpenter Mark Cooper Jean B Cox Cox Michael Crooks Melanie DeFusco Rabun Dekle Christina Futch
Bobby Moody Brian Rickard Andy Rogers Bill Scrogins Teresa Smith Michael Tarrant Carey Vaughan Chuck Wilson William Wolfe
Krista Stone Sonny Thurmond Erica Veasley Angela Wampler Amanda Westbrooks Steve Wilson George Wu
John Gleaton Fred Gurley Ann Hansford John Hansford Larry Harkleroad Hannah Head Phillip James Henry Josey Susan Kane Josh Kinsey Brenton Lake Micheal Lewis Mack Lowrey Eddie Madden Susan McCleer Mary Meredith C Perry Laurence Ryan Jim Sanders Kimmy Sanders
Member Investors (amount below $150)
Marla Banks Ken Couch Anonymous Donor James Graves Max Mason Roy McLendon Sherri Moody Debbie Nowlin Leonard Templeton Lindsey Welch
Three Months and $35,000 to goal PharmPAC funds help elect legislators who are friendly to pharmacy. As of September 18, 2015, we still had a long way to go to meet our goal for the year. Visit GPhA.org/PharmPAC to find out more.
GOAL
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$40,000
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Reach out to us Our phone number is 404.231.5074 Our Website is GPhA.org Our blog is GPHABuzz.com OPEN
For questions about our magazine, Web sites, or social media Andrew Kantor Director of Communication akantor@gpha.org FLAT COLOR GPhA Leadership
President & Chair of the Board Tommy Whitworth twhitworth@corleydrug.com President-Elect Lance Boles lanceboles@hotmail.com First Vice President Liza Chapman liza.chapman@kroger.com Second Vice President Tim SHORT garph9@aol.com Chief Executive Officer Scott Brunner, CAE sbrunner@gpha.org
For questions about engagement with the Georgia pharmacy community, our events, or CPE credits Phillip Ratliff1 Vice President of Communication and Engagement pratliff@gpha.org For membership questions Tei Muhammad Director of Membership Operations (404) 419-8115 tmuhammad@gpha.org For questions about any of our insurance products Denis Mucha Manager of Insurance Services (404) 419-8120 dmucha@gpha.org
For questions about governmental affairs Greg Reybold Vice President of Public Policy greybold@gpha.org For questions about the Board of Directors or for scheduling the CEO Ruth Ann McGehee Executive Assistant and Governance Manager (404) 419-8173 rmcgehee@gpha.org For operational or accounting questions: Dianne Jones Vice President of Finance & Administration (404) 419-8129 djones@gpha.org Patricia Aguliar Accounting Coordinator paguliar@gpha.org (404) 419-8124
For assistance with independent-pharmacy issues Jeff Lurey, R.Ph. Vice President of Independent Pharmacy & Director of AIP (404) 419-8103 jlurey@gpha.org For questions about your AIP membership Verouschka “V� Betancourt-Whigham Manager of AIP Member Services (404) 419-8102 vbwhigham@gpha.org AIP Member Service Representatives Rhonda Bonner (229) 854-2797 rbonner@gpha.org Charles Boone (478) 955-7789 cboone@gpha.org Melissa Metheny (404) 227-2219 mmetheny@gpha.org Gene Smith (423) 667-7949 gsmith@gpha.org
Got a concern about a GPhA program or service? Want to compliment or complain? Contact GPhA CEO Scott Brunner at sbrunner@gpha.org.
October/November 2015
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postscript
Mankind is our business On its own, it was enough to send me reeling: seeing one of my patients slowly succumb after her long battle with cancer. But what made the situation all the more tragic was how her illness impacted tommy whitworth the patient’s daughter. During the last few years of her illness, the mother consumed large doses of powerful prescription narcotics to control her otherwise intolerable pain. Meanwhile, the daughter endured her own agony, watching her mother die. And, as you may have already suspected, the daughter discovered a quick means of a relief: her mom’s pain medication. It didn’t take long for full-blown addiction to set in. The daughter’s addiction came to light a few weeks after her mom’s funeral. The daughter’s neighbor contacted me, concerned that the daughter hadn’t been seen for several days. A few hours later, after literally bursting through the woman’s locked front door, I found the
daughter in a fetal position on her bedroom floor. Having run through her mother’s supply of medication, she was almost comatose. The daughter’s road to recovery was arduous. After several months of rehabilitation, she sent me a letter, thanking me for caring enough to read the signs and intervene. Caring means just that: when we encounter patients who we suspect are abusing prescription medications, we knock down doors, pry open windows, and step into their lives. Life is a precious gift from God, but it’s also fragile, fraught with the temptation to squander this gift. Prescription drug abuse is just such a temptation. Georgia ranks third in the nation for the number of pain killers sold, and most drug overdoses here were from prescription medications. But behind the statistics are patients who depend on us. Even when they aren’t looking to us, we have to be looking out for them. We have to read the signs. Georgia Pharmacy A S S O C I AT I O N
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Tommy Whitworth of LaGrange is GPhA’s 2015-2016 president.
thinking about it GPhA has partnered with the Medical Association of Georgia Foundation’s Think About It campaign to help reduce prescription drug abuse. Some of the campaign’s goals: IMPROVE Georgia’s prescription drug monitoring program
TRAIN healthcare and law-enforcement personnel in the use of naloxone
PROVIDE drug take-back programs and dropboxes in communities
EDUCATE consumers about the dangers of prescription drug abuse and how they can help prevent it ESTABLISH Project D.A.N. to provide naloxone to law enforcement in 14 north Georgia counties 28 Georgia Pharmacy
Learn more and do more at rxdrugabuse.org.
October/November 2015
Student loan refinancing for GPhA members SoFi saves pharmacist borrowers an average of $21,544 *
ENJOY A .125% RATE DISCOUNT AT SOFI.COM/GPHA
Average savings calculation is based on all SoFi Pharmacist borrowers who refinanced between 2/1/15 and 6/16/15. Prior to refinancing, borrowers taking 5 and 10-year terms had an average balance of $95,297 and lifetime payment of $137,696 at a rate of 6.77%, and borrowers taking 15 and 20-year terms had an average balance of $142,463 and lifetime payment of $234,933at a rate of 7%. After refinancing, 5 and 10-year borrowers have an average lifetime payment of $114,556, and 15 and 20-year borrowers have an average lifetime payment of $217,497, based on a weighted average of new rates received across both types (fixed and variable) and respective loan terms with AutoPay. Savings calculation assumes no change in interest rates, on-time payments, and no prepayment of loans. Borrowers refinancing loans into longer terms typically forfeit savings for lower monthly payments.
Georgia Pharmacy A S S O C I AT I O N
50 Lenox Pointe NE, Atlanta, GA 30324
BLACK & WHITE
OPEN
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GLOSS/GRADIENT
FLAT COLOR
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