Monday, July 30, 2012

Addictionist Perspective: Narcotic Market Solutions

A complete discussion is insufficient without clear solutions (please see and for the foundational assumptions for this post).  After considering narcotic issues as a problem of medication pricing, several solutions emerge. 

First, legislation is needed to allow the return of unused narcotics to approved health care and law enforcement facilities.  This would be akin to states recycling aluminum cans using the recycling machines at grocery stores and recycling centers.  Without making a legal way to return narcotics, the only current disposal methods are flushing medicines down the toilet, throwing them in the garbage or selling them on the street; none of these options are appealing.

Next, narcotic packaging needs to change from dispensing pills in bottles to dispensing individually packaged blister packs for several very specific reasons.  First, simple blister packing can help prevent overdosing ( by reducing impulsive behavior.  There are obvious ways around this, but with patients with impulse control problems, it is an effective aid to assist self-control.  Second, this packaging could contain lot numbers for the pills and a printed, standardized return price.  This would solve problems during the return process such as medication legitimacy (via lot number, tamper free packaging, etc.), having a universal return price for each medication type (clearly printed on the blister pack; it could be cross referenced with the lot number), and accountability (tracking where medicines are traveling via check out at the pharmacy point of pick up and check in at point of return).  Third, machines similar to can recycling machines would be needed for scanning the packaging, identifying how many blister-packed pills are present, and dispensing the cash for the pills returned.  This would automate the return process, reduce pharmacist time spend on returns, and lock the narcotics in a machine similar to an ATM for safe disposal with armored vehicles.

As a more controversial step, insurers need to substantially step out of the role of paying for short-acting narcotics.  As long as the subsidization of narcotics continues, there will be rampant mispricing.  Short-acting narcotics should be non-covered medications with the exceptions of an objective diagnosis of cancer, a recent diagnosis of an inpatient surgical procedure and hospitalization, or a certification of hospice care.  If insurance stopped paying for short-acting narcotics, then a truly efficient payment and return process can be constructed and implemented. 
Finally, a return price must be set on the narcotics truly reflective of the medicine’s value.  As a concrete example, if one went to the dentist, had a tooth pulled, and received 30 pills of Vicodin for post-operative pain, the price needs to be set high enough to incentivize the return of the medication.  So if the cost of the 30 pills of Vicodin was $150 and only 5 were used, a $5 return policy would mean a return value of 25 pills would be $125 dollars.  That sum would definitely incentivize most people to return their unused pills.  If the previous steps were set up, an obvious choice emerges:  which is more palatable, returning your pills to the pharmacy for a clean, legal and hassle-free $125 or selling them on the street with the risk of physical harm, felony charges, and jail time for a possible but not guaranteed $125?  If costs of narcotics rise, physician practices will change too (fewer pills would be prescribed once the economics change).

What would be the net result of these changes?  There would be decreased subsidization of narcotics, clear return policies that are safe and effective for patients, barriers preventing impulsive use of medication, and greater transparency in monitoring prescription drug mobility in the country.  Hopefully, these thoughts will not fall on unengaged minds.  Change is needed. 
Have better plans?  Please share them.

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