Simple Packaging Change Could Help Reduce Drug Diversion

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Excerpt

Consumers sometimes tell us their pharmacy dispensed fewer tablets or capsules than prescribed when filling their prescriptions. Nearly all of the complaints involve controlled substances like OXYCONTIN (oxyCODONE), and VICODIN or LORTAB (HYDROcodone and acetaminophen). When reporting the shortfall, consumers report that the pharmacist often suspects that the patient or someone in their home removed some tablets for themselves or to sell. Patients tend to say the same about the pharmacy staff. In truth, although not the only problem, pill-abusing middle school and high school students do sometimes obtain drugs from a family member's medicine cabinet. At the same time, research shows (www.ismp.org/sc?id=1646) that diversion through “shorting” (undercounting) and pilferage by pharmacists and pharmacy staff also takes place. So really, it's essential that we find better ways to control these drugs.
The way that community pharmacists dispense controlled substances as loose tablets/capsules in a vial makes it easy to divert the drugs; at quick glance, you can't tell how many are in the container. Control is better outside the United States where most drugs, including opioids, are dispensed using a packaging system called “patient packs” or “unit of use” (a sealed patient package containing a typically prescribed quantity). Manufacturers, doctors, pharmacists, and computer system vendors abroad have worked together to standardize the available quantities. Overseas pharmacists we speak with are happy to not count pills, and they say they rarely hear from a patient about missing doses. The manufacturer's package provides tablets or capsules enclosed in individual blisters, often in strips of 10, often on flat cards that take up little space. The drugs are sold in sealed containers holding quantities typically required. Inside, the slot for each individual tablet is numbered, so the quantity can be seen at a glance, even if the box has been opened. Patient packs are available in the United States for controlled drugs dispensed in hospitals (Figure 1). But, community pharmacies rarely use them.
If patient packs were used for oral opioids in the United States, most of the count disputes would be eliminated, and drugs would be harder to divert. Patients and pharmacists would be able to readily identify the quantity of pills being dispensed, and the patient could be asked to sign for and agree to the quantity at the point of sale. Such packaging would also help consumers in detecting diversion at home because the quantity remaining would be readily identifiable. Unit of use packaging can also help people spot a dispensing error, especially with renewals, as each unit dose package in the blister or strip has the drug name and strength printed on it. Also, dispensing certain drugs in calendar packs can prevent errors, including fatal oral methotrexate errors (www.ismp.org/sc?id=1703).
Sadly, U.S. community pharmacies have not embraced patient packs. They may cost a few cents more per dose and take up a bit more storage space. The individual blisters would need to be in individually sealed child-resistant blister packs, and the blisters may be difficult to open. Doctors would also have to prescribe only the quantities available in patient packs. But given the crisis with prescription drug abuse, we see this as a critical change.
Given the national opioid abuse crisis, we've entered a world of “abuse-deterrent” technologies for oral dosage forms, state prescription monitoring programs, and changes in how, when, and to whom opioids are prescribed. We think it's also worth looking into packaging and dispensing changes that might help reduce diversion.
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