Combating drug abuse and diversion: the right approach

The issue is complex with social, economic, and political dimensions.. There a number of stakeholders that have a responsibility to address and manage this issue, including benefit managers, physicians, pharmacists, government (e.g., ministries of Health, Social Services, and other relevant departments), law enforcement, and drug manufacturers. It is evident that there are numerous gaps within the supply chain, from prescription to payment, that allow abuse and diversion to occur. This indicates that the problem is not endemic to any one group—rather, it is systemic and therefore a solution necessitates the cooperation of all stakeholders.

As part of a collective effort, each stakeholder has an obligation to take the necessary steps to limit the risks of drug abuse and diversion within their own spheres of influence. This problem will only be addressed through collaboration. This article will explore this issue through a broad and comprehensive approach, by examining the roles that key stakeholder can play toward developing a solution.

Benefits managers
The private drug benefits industry recognizes the severity of drug diversion and invests significant resources each year to fight it. These activities include conducting random and targeted audits of claims transactions, on-site audits of pharmacies, data profiling, and trend analysis to identify suspect utilization patterns and the presence of red flags, which may include:

• plan members demonstrating high-dollar narcotic claims or a high volume of claims;
• unusual duration of treatment;
• double-doctoring;
• attending multiple pharmacies; and
• early refill (e.g., requests for replacement for “lost” drugs).

In addition, the Canadian Health Care Anti-fraud Association (CHCAA) has focused training efforts on drug diversion and abuse over the past number of years. We have engaged with law enforcement, government, and health care professionals to raise awareness and develop integrated strategies and best practices for preventing and detecting this problem.

While current efforts are having an effect, drug benefit managers admit that there is always more to be done. The solution proposed by Mike Sullivan in his August article represents one important part of a larger strategy. Nevertheless, it is important to note that simply refusing to pay claims is not actually a solution to the larger problem and may in fact drive it underground. Moreover, insurers operate outside the normal circle of care that includes the patient, prescribing physician, and pharmacists. Hence, there is a need for a collaborative effort to make the insurance industry a more integrated part of efforts to come up with a solution.

Physicians
Physicians have a duty to ensure that patients are receiving only necessary treatment and should be mindful of any obvious signs that their patient is abusing prescribed medication, particularly when known narcotics are involved. There is no doubt that most physicians take this duty very seriously. In Ontario, the College of Physicians and Surgeons (CPSO) is an active member in the Opioid Public Policy Project and the Narcotics Advisory Panel, dedicated to developing solutions that address painkiller abuse.

According to CPSO Registrar Dr. Rocco Gerace, “the multi-stakeholder Opioid Public Policy Project hopes to craft policy recommendations by spring 2010 related to opioid distribution, dispensing, prescribing and diversion.” A comprehensive study commissioned by the U.S.-based Coalition Against Insurance Fraud (CAIF) advises that the medical profession can add to the solution if, as a group, they:

• “greatly increase abuse and diversion training of physicians, both in medical education curricula and in continuing professional education programs;
• support stronger requirements for specialization and credentialing in pain management and prescription of controlled substances;
• formally discuss the widespread off-label prescribing of some controlled substances, and its impact;
• support the ongoing examination, and potentially greater limiting, of pharmaceutical manufacturers’ means of influencing physicians’ prescribing behaviour; and
• support strong licensing sanctions and other penalties against physicians found guilty of drug diversion.”