Pharmacist raises awareness for underestimated opioid drug

SAN ANTONIO – One local pharmacist is raising awareness about a C4 controlled substance that many people tend to underestimate. The drug is called Tramadol.

"It is a synthetic opioid that is in the same family as morphine, heroin, and opium, however it is one of the only non-schedule two opiates still available on the markets," said Scott Frishman, the pharmacist in charge at Oakdell Pharmacy.

The Drug Enforcement Administration rates controlled substances on a level from one to five with five being the weakest.

"The DEA has deemed these products to have some harm or physical dependence that can be done," Frishman said. "Schedule 2 is your hydrocodone, that's your morphine, that's your oxycodone that's those guys. Tramadol is a step down from it. It is like the younger brother or little cousin to those C2 narcotics. Once hydrocodone went C2 narcotic, it used to be a C3, Tramadol kind of replaced hydrocodone as the easy access opioid."

A C2 substance has strict guidelines to go through before it can be released.

"It has to come on a particular form or through an e-prescription that is only good for 21 days," Frishman said. "Tramadol, though it is not a C2 substance, it  is still a controlled substance and is regulated by the DEA, just not as heavily controlled. Because it is not heavily controlled, it doesn't have to be on those particular needed forms."

Tramadol does still have to be prescribed.

"They can be on phone calls, which is where a lot of abuse happens," Frishman said. "They can be by fax, hard copies and e-prescriptions, so they can be sent in to us four different ways. The law is subject to change in the next few years."

Specifically what Frishman said he sees at his pharmacy is people posing as doctor's office officials, providing the needed information, and fraudulently phoning in a prescription.

"Tramadol and another agent would probably make up about 80% of my fraudulent prescriptions because it can be called in. It is not heavily scrutinized," Frishman said. "It is still a controlled substance, so we do our due diligence, and we check the prescription monitoring program (PMP) to see if the prescription is legitimate."

He said the PMP is an online portal from the State Board of Pharmacy that they can check in addition to their own fact checking they do.

"We are going to be required to check PMP next year for all of the prescriptions," Frishman said. "We can use that, but sometimes the patients don't exist or it may be their first time filling that prescription. PMP can tell you whether that person has filled it. You can see their filled history which is something we can do to illicit prescripts from going out but if that patient doesn't exist or is a fake patient or something like that based off of a fake prescription, they can sometimes sneak past a pharmacist."

At his pharmacy, Frishman said the main thing he looks for is a date of birth when a patient is coming to pick up a controlled substance.

"They have to have a driver's license saying who they are, and my policy is that we have to have a written or phoned in notice," Frishman said. "If you have a gut feeling that something is wrong, you can even ask other questions as well like the reason they are taking it, or their address as well as where they have gotten it before."

The PMP program helps in many aspects.

"I can search a patient by name, date of birth and see all of their controlled substances, where they were filled, when they had them filled, what day it was filled, when it was written, when it is due, whether they are on insurance, Medicaid or private pay," Frishman said. "There are several states that share that information."

Frishman said although these kinds of drugs can be abused, there is a reason why they exist.

"Pain is a legitimate thing," Frishman said. If you are in legitimate pain, you need things like Tramadol, so it is hard to read between those lines but there are folks who just abuse the system."

He said Tramadol can be fatal, especially when mixing it with other substances.

"What is the one thing that all opioids have in common? It slows your respiratory rate down," Frishman said. "There are several classes of drugs that can be mixed with opioids that can potentially make it between five to nine times more likely to have an opioid overdose and that is per the CDC guidelines. There used to be something called the trifecta which is a third product that exists on the market but if you were on that third product, that's a red flag. But if you are on that third product then you are 7-9 times more likely to have an acute overdose."

He said he hopes to raise awareness about substances like Tramadol along with ways to combat it like using Narcan or the generic form of it, which is available at their pharmacy.

"If you have a fear in your family that someone might be doing something illicit with their narcotics, then come and talk to their pharmacist. That Narcan is actually the first prescription in the state of Texas called the third-party prescription. So, my spouse will be able to be given that prescription under her name for administration for patient X. You can actually write that prescription for someone else to be administered to this person in case of an overdose. There is help out there."

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