Our organization often hears from consumers who report the quantity of medicine they receive from the pharmacy is less than the amount prescribed by their physician. For example, we recently received a report from a young patient who had dental surgery and received a prescription for the narcotic painkiller Lortab (hydrocodone and acetaminophen). On the prescription the dentist wrote for 24 pills to be dispensed. The patient’s mother had the prescription filled at a local pharmacy. When she returned home she counted only 21 pills. The mother called the pharmacy because she wanted to make sure the pharmacist was aware that a mistake had been made in the count. But the pharmacist became defensive, even suggesting that the woman’s daughter must have taken the pills without her knowledge.
Nearly all of the complaints we get like this involve opioid narcotic prescription products like Percocet, Oxy-Contin, Vicodin, Lortab, etc. The pharmacy always seems to say that the patient or someone in their home removed some tablets (either for themselves or to sell on the street) and the patient says the same about the pharmacist and/or their staff. In truth, research shows that theft by pharmacists and pharmacy employees does take place and it’s not that uncommon. At the same time, people who abuse pills are often able to obtain their drugs through someone’s medicine cabinet.
The importance of preventing drug diversion is a constant concern. It came to light when the CDC reported that overdose deaths have skyrocketed in the past decade, largely because of prescription painkillers. According to the CDC overdoses of prescription painkillers have more than tripled in the past 20 years, killing more than 15,500 people in the United States in 2009. With this growing epidemic, it’s time we reconsider the way these drugs are commonly dispensed in the US. Our current system may be making it too easy for people who abuse drugs.
In the U.S., community pharmacists dispense almost all oral solid drugs, including narcotics and sedatives, as loose tablets/capsules in a plastic vial that is labeled for the patient. That makes diversion easy because you can’t prove in a quick glance how many pills are in the container. Drug control is far better outside the US where a system of packaging called “patient packs” or “unit of use” (a sealed patient package containing a quantity that is typically prescribed) is used almost exclusively. Manufacturers, doctors, pharmacists and computer system vendors have worked together to standardize the available quantities. Pharmacists don’t have to count pills and they rarely ever hear from a patient about missing doses.
The manufacturer’s unit of use package provides tablets or capsules enclosed in individual blisters in strips of 10. They are sold in sealed containers holding quantities typically required for dispensing a prescription. Inside, the pills are numbered so the quantity can be recognized at a glance even if the box has been opened (Figure 1). These are already available here for many drugs used in hospitals. Unfortunately though, community pharmacists rarely use them.
If patient packs were used for oral opioids in the US, most of the count disputes would easily be eliminated and it would be much harder for drugs to be diverted. 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 amount at the point of sale (as per amount printed on outside of the sealed container or the actual count). Such packaging would also help consumers in detecting home diversion by a teen or other person who has access to their home because the quantity remaining would be readily identifiable.
Unit of use packaging can increase safety in other ways too, including medication error prevention. Each blister strip has the drug name printed, which can help people spot a dispensing error, especially on prescription renewals.
Unfortunately, chain pharmacy corporations and independent pharmacy owners have not embraced the patient pack concept in the US. This is probably because it costs a few more cents per dose and also because patient packs would take up more pharmacy storage space. In addition, doctors would also have to prescribe only the quantities available in patient packs, which initially might cause some confusion. But given the crisis we’re seeing with prescription drug abuse, this is a critically needed change that will cut into some of the problems we’re having.
For now, if you have a prescription filled and it isn’t in a patient pack, consider counting the pills with the pharmacist while still at the counter. Ask the pharmacist to document the count right on your receipt - with a signature. Also, if you suspect a problem, you should report it to the State Board of Pharmacy. If they see a pattern they can investigate.
