The Heroin Crisis: A 3-Day Series

In NH, pharmacists work to fight tide of overprescription

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Gatekeepers in the war on drugs

Salem pharmacist James Tomacchio, Sr., of PerforMIX Specialty Pharmacy, holds the dispensers for compound medication using suspension agents that can deliver any number of prescriptions topically -- including those for pain relief -- through the skin, localizing the benefits of their properties, while not introducing them into the body systemically, risking side effects, interactions with other drugs, and addiction.

Pharmacists are often the gatekeepers in the war against drug abuse, the medical professionals charged with ensuring potentially addictive medications are used properly and do no harm.

They scrutinize controlled substance prescriptions carefully, question and warn customers about their use, call doctors to verify issuance, make sure drug interactions don’t occur, turn people away when things don’t feel right, and even warn colleagues when they believe people are fraudulently trying to get prescriptions filled for misuse or resale.

In spite of all that, prescription drugs are increasingly finding their way into the wrong hands, contributing greatly to the latest wave of opiate abuse sweeping the region. Patients abusing opiates — either to use themselves or to sell to others — will often try to get multiple prescriptions from different doctors, filling them at different pharmacies to escape detection. The consequences have been staggering.

In New Hampshire, a state with about one-fifth the population of Massachusetts, the number of drug deaths in 2014 grew to 280, nearly 100 more than in 2013. Of those deaths, 231 involved opioids or synthetic opioids.

But in Salem, N.H., and on the New Hampshire Seacoast, two pharmacists with a combined 55 years of experience are working outside the traditional pharmacology box to try to halt the scourge of addiction and death opiates have brought.

A pharmaceutical alternative

Methuen native James Tomacchio left the pleasures of retirement behind him in November to open PerforMIX Specialty Pharmacy in Salem, a format combining the fields of specialty and compounding pharmacology.

“I came out of retirement to start this because I felt the opiate problem is not going away and that I can make a difference here,” Tomacchio said. “According to figures from the World Health Organization, in 1991, 76 million prescriptions for opiates were dispensed. In 2010, 210 million prescriptions for opiates were dispensed. It’s a threefold increase. That goes beyond population growth.”

A medical technologist, registered and nuclear pharmacist, Tomacchio has spent decades in various venues, including nursing homes, retail pharmacies, managed care and as an on-site pharmacist and compounding specialist to four major hospitals.

Tomacchio believes opiate medications, when needed, can be better managed through specialty and compounding pharmacology.

The premise behind both types of medicinal dispensaries is that no two people or their illnesses are completely alike, and often should be treated differently.

“Why does one size have to fit all?” Tomacchio said. “It doesn’t.”

Through a specialty pharmacy, pharmacists work with doctors and patients to supply appropriate medication for diseases such as cancer, Crohn’s disease, HIV/AIDS and hepatitis C.

“These conditions require special consideration for proper care of patients,” Tomacchio said. “We work with doctors, follow patients to make sure they take the medication prescribed correctly. We do follow-up with the patient, then report back to doctors.”

In compounding, Tomacchio is going back to the roots of the profession.

“We’re not a drug manufacturer,” he said. “We’re doing what pharmacists used to do long ago. We’re taking chemicals and mixing from scratch compounds requested by physicians for their patients.”

Benefits come from unique formulations, but also from the way medication is delivered to the body.

With compound pharmacology, pharmacists can work with physicians to come up with treatments that are localized at the site of their patients’ problems. Using creams and gels as delivery agents, various medications can be mixed and applied topically, and absorbed through the skin. That offers the benefit of minimal absorption of the substances into the blood stream, reducing the likelihood of patients getting addicted.

“Say a patient has back pain. We can make a cream that has an anti-inflammatory, mix in a muscle relaxer and even a pain reliever,” Tomacchio said.

Because it’s applied locally at the site, the remedy won’t have the sedation effect that muscle relaxers or strong pain relieving opiates have when they’re taken orally, which affects the body and brain systemically, he said.

“The compound won’t have the addictive properties of opiates,” he said. “Patients wouldn’t get that pleasure effect opiates cause. And it’s our job to get out and educate physicians on what we can provide.”

Many doctors, especially young ones, don’t know about compounding pharmacies, he said, or even what’s available in the realm of pharmaceuticals.

“You’ll find that medical schools don’t cover much about medications,” he said. “Doctors learn about a handful of medications related to their specialties. Then (when they start practicing), their drug company representatives come in to talk to them about the next greatest prescription on the market.”

In the past 30 years, he said, more powerful pain-relieving opiates have hit the market. The increased circulation of opiate medications indicates that doctors turn to them as the solution when a patient presents with pain, instead of the less-powerful drugs used in the past. This happens even though the pain may be temporary or less than extreme.

And when doctors won’t prescribe them anymore, users turn to other sources.

“When I worked in retail pharmacies, what always set bells off with me was when a customer said, ‘Don’t run this through my insurance; I’ll pay for it myself,’ “ Tomacchio said. “They didn’t want their insurance company to know about the prescription.

“Opiates get their hooks in them. They need to feed the beast and feel the rush more and more. They’ll turn to buying them on the streets. They’ll crush and snort them. And then they’ll turn to heroin, which is easier to get and cheaper.”

A legislative alternative

A pharmacist for 20 years on the New Hampshire Seacoast, Andrew Gyorda has seen things change a lot since he started. Dosages of opiate pain relievers have increased significantly, and they’re being prescribed more often and in higher quantities.

In 2004 and 2005, the recreational use of these drugs began killing people with jaw-dropping frequency. Drugs were being diverted for recreational uses, and soon they’d become the most common cause of addiction and drug-related deaths in the region.

In recent years, however, restrictions on prescribing these potentially addictive drugs have been eased, Gyorda said. Previously, doctors in New Hampshire could not prescribe more than a 34-day supply — or 100 doses — of so-called Schedule II and III drugs.

In 2009, just as the prescription drug addiction epidemic was skyrocketing, the numerical restriction of 100 pills was removed from New Hampshire’s controlled substances regulation, although the 34-day limit continues.

Gyorda questions the overall value of prescribing large numbers of addictive drugs at one time. Given the highly addictive nature of the drugs, he believes, doctors need to keep close track of patients who take these drugs, catch addiction if it occurs and provide treatment. They also need to detect those obtaining prescriptions only to resell them on the streets.

“I feel strongly that the 100-dose limit ought to be placed back into the statute,” Gyorda said. “Doing so is certain to curtail some of the diversion and death now occurring.”

Last year, Gyorda turned to his state senator, Nancy Stiles, R-Hampton, who tried to get the language putting the 100-dose limit restriction back in the law. But that effort died because legislators feared it would force those in chronic pain to repeatedly go back to their physicians for new prescriptions.

Prescription of Schedule II drugs, like hydrocodone (Vicodin), oxycodone, (Percocet, OxyContin), and methadone cannot be written with refills. Depending on the number of pills patients are prescribed to take each day, a month’s prescription can add up to more than 100. For example, two tablets every four hours would equal eight a day, or 240 in 30 days.

The cause hasn’t been lost, Stiles said. During this year’s legislative session, she signed on to a bill sponsored by Democratic Manchester Sen. Lou D’Allesandro that calls for the establishment of a commission to study “opioid misuse” in New Hampshire.” It passed the Senate in mid-March, but is still held up in the the House.

According to the bill’s text, along with supporting patient access to and the use of appropriate pain treatment, treatment of substance abuse and opioid addiction, the commission would review and consider the benefits of mandatory drug testing for those using opiates for long periods of time, as well as requiring that anyone on long-term opiate use enter into a treatment agreement with their prescribing health care providers.

If SB-67 does become law, the commission would include members of the House and Senate, as well as state law enforcement, and correctional, judicial, educational and medical professionals, along with some social service groups, such as the Partnership of a Drug Free New Hampshire.

“Other groups have studied this problem, but we’ve never had a commission with legislators on it,” Stiles said. “After studying the issue, legislators could come back and recommend and propose important legislation in coming sessions.”

In mid-May, the House HHS Committee voted to retain the bill and not act on it. That means committee members will study the bill itself, not the problem it hoped to solve, and report out for next year’s session its recommendations to either pass or kill the bill.

Stiles, who testified on the bill’s behalf in the House Committee, didn’t understand what the House Dommittee’s problem was.

“I am disappointed that the House Committee held up the study of such an important issue devastating many of our youth,” she said recently. “I am pleased that the Senate version of the (next state) budget included funds for community services to support individuals that are seeking treatments, and I hope it stays in the final version of the budget.”

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