Pendulum table tennis – trendeepro

As a young pharmacist, I gave thousands of conjugated estrogens (Premarin) in 1982. We bought Premarin 0.625mg and 1.25mg in bottles of 1000 and moved them over the course of 3 or 4 weeks. Every woman took this drug. We sold 100 tablets for about $15 and my customers seemed happy. Today, a bottle of 100 Conjugated Estrogen Tablets of any strength costs over $600.

The pendulum has swung the other way for estrogen use, as my veteran fellow pharmacists can attest: two studies – HERS¹ (NCT00319566) and WHIA² (NCT00000611) – essentially brought the pendulum to where it is today. Even I have shouted from the lecture halls of St. Francis University that “estrogens should only be used to relieve vasomotor symptoms, at the lowest dose for the shortest duration.”

Another pendulum that has shifted is the prescription of opioids. When I was young it was rare to see a 60 pill oxycodone/acetaminophen (Percocet) prescription. Thanks to the explosion of oxycodone (Oxycontin) in the mid-1990s, health care providers became too lazy to prescribe opioids and the opioid pendulum went wild. About 10 years ago, however, the pendulum began to return to the center as the opioid release rate dropped from 81.3 to 43.3 per 100 people today.³

The subsequent heroin addiction crisis was addressed by the Drug Addiction Treatment Act 2000,^4.5 with waivers allowing doctors, after 8 hours of training, to write prescriptions for buprenorphine (Suboxone), which were then dispensed at community pharmacies. This change was made to avoid the stigma of waiting in line at a methadone clinic and was intended to help our citizens living with opioid addiction. We were told that buprenorphine is a partial agonist, with less potential for euphoria, and that naloxone helps reduce the potential for abuse. Buprenorphine has a morphine milligram equivalent (MME) factor of (x30). The combination buprenorphine/naloxone (8 mg/2 mg) administered twice daily is equivalent to morphine 480 mg or oxycodone 80 mg administered four times daily. I know opioid experts who disagree on some of these points.

We community pharmacists see the benefits of prescribing buprenorphine every day. Patients come for their 2 or 4 week care after a day’s work as a mechanic, plumber, roofer or mother. I also know many pharmacists who won’t dispense buprenorphine because they don’t want “those people” in their stores. However, these pharmacists dispense oxycodone, hydrocodone, oxymorphone, and fentanyl, probably unaware that these people are already in their stores.

When I view the prescription drug surveillance program,⁶ the MMEs for buprenorphine no longer exist. The 480 MME used to be on the list, but I’m told it’s been removed to avoid stigma. When a new patient comes to the pharmacy, I equip them with a naloxone rescue kit and a pamphlet describing the MMEs of buprenorphine. In response, many patients tell me it’s the first time they’ve been treated with respect. I have studied this disease enough to understand that it really is a mental disorder, usually due to childhood trauma. It has been postulated that 75% of women who abuse alcohol and drugs have been victims of sexual abuse⁷; It’s not in my wheelhouse to determine who deserves compassionate care—all my patients do.

Pharmacies often get calls from their warehouses with questions about their buprenorphine purchases. Wholesalers are doing this on behalf of the Drug Enforcement Administration, as the big 3 wholesalers have been pushed around for the sale of opioids in the past. Pharmacists are aware of the microscopic analysis of their buprenorphine purchases, while the Department of Health and Human Services would like to see more buprenorphine prescribers.^8th

I certainly don’t want my fellow professionals to be stigmatized for providing such life-saving drugs, including buprenorphine, to people with addictions. Pharmacists don’t ride on a pendulum; we are more like a ping pong ball being beaten back and forth between government agencies.

references

1. Hulley S, Grady D, Bush T, et al. Randomized trial of estrogen plus progestin for secondary prevention of coronary artery disease in postmenopausal women. Heart and Estrogen/Progestin Replacement (HERS) Research Group. JAMA. 1998;280(7):605-613. doi:10.1001/jama.280.7.605

2. Henderson VW, Lobo RA. Hormone therapy and the risk of stroke: perspectives 10 years after the studies of the Women’s Health Initiative. climacteric. 2012;15(3):229-234. doi:10/3109/13697137.2012.656254

3. Map of US Opioid Tariffs. CDC. Reviewed November 10, 2021. Accessed July 13, 2022. https://www.cdc.gov/drugoverdose/rxrate-maps/index.html

4. Become a buprenorphine-free practitioner. Administration of Substance Abuse and Mental Health. Updated April 21, 2022. Accessed July 12, 2022. https://www.samhsa.gov/medication-assisted-treatment/become-buprenorphine-waivered-practitioner

5. Articles of Association, Regulations and Policies. Administration of Substance Abuse and Mental Health. Updated July 1, 2022. Accessed July 12, 2022. https://www.samhsa.gov/medication-assisted-treatment/statutes-regulations-guidelines#DATA-2000

6. Prescription Drug Monitoring Programs (PDMPs). CDC. Accessed February 12, 2021. Accessed July 12, 2022. https://www.cdc.gov/opioids/providers/pdmps.html

7. Liebschutz J, Savetsky JB, Saitz R, Horton NJ, Lloyd-Travaglini C, Samet JH. The relationship between sexual and physical abuse and the consequences of substance abuse. J Drug abuse. Treat.2022;22(3):121-128. doi:10.1016/s0740-5472(02)00220-9

8. HHS publishes new practice guidelines for buprenorphine that expand access to treatment for opioid use disorders. press release. Department of Health and Human Services; April 27, 2021. Accessed July 12, 2022. https://www.hhs.gov/about/news/2021/04/27/hhs-releases-new-buprenorphine-practice-guidelines-expanding-access-to-treatment – pre-opioid-use-disorder.html