Physician dispensing and the opioid crisis

Every day, roughly 130 people die in the United States from misuse of and addiction to opioids, including both prescription pain relievers, as well as drugs like heroin and fentanyl. Several studies have shown that use and misuse of prescription opiates are very significant drivers of heroin use. In addition to this human cost, the Centers for Disease Control and Prevention estimates that the financial cost of prescription opioid misuse to be more than $78 billion per year.

With the spotlight being directed at prescription drug abuse, some observers have questioned whether physician dispensing programs are contributing to this opioid crisis.  

Physician Dispensing Versus Pharmacy Dispensing
Examining the impact of physician dispensing in office can be a highly charged issue, since economic incentives overlap with incentives around patient care, but do not match them perfectly. Put simply, when a doctor or other medical practitioner writes and then fills a prescription themselves, pharmacists are completely shut out of the process. Fewer patients and prescriptions to fill also mean less revenue for pharmacies.

Many have questioned whether the economic incentives for doctors to engage in point-of-care dispensing distorts patient care and/or adds unnecessary costs to the healthcare system. While there are no studies that conclusively show that dispensing doctors specifically are more likely to prescribe opioids, industry observers have noted that economic incentives do consistently impact care decisions, including prescription decisions, made by some doctors and medical practitioners. Further studies have indicated that overprescribing is a major contributor to the opioid epidemic.  

Taking the pharmacist out of the process also can increase risk by removing a pharmacist’s expertise, as well as a second set of eyes. In the traditional method of pharmacy dispensing, that expertise and double-checking reduces the possibility of errors and/or malevolent drug interaction effects. One in-office dispensing provider claims in its marketing material that clinics can dispense prescriptions within approximately two minutes, which does not leave much time for review or double-checking.

Physician Dispensing: Implications for Pharmacists
If the only effects of dispensing prescriptions in office were increased risk of abuse or overprescriptions, pharmacist associations would have an easy time convincing regulators to curtail the practice. Instead, proponents of physician dispensing advance several arguments in favor of the practice, which point to challenges and opportunities in the traditional dispensing model.

Physician dispensing companies often point out that between 20% and 30% of prescriptions in the United States are never filled. By making the process more convenient for patients (and removing the need for pharmacy visits), physician dispensing can improve patient medication adherence and, ultimately, patient outcomes. That patients often will knowingly pay more to purchase their medications directly from their doctor suggests that they very much value the convenience and time-saving of in-office dispensing. This presents a key implication for pharmacies to continue to invest in convenience.

Next Steps
In order to respond to the downsides that physician dispensing poses to retail pharmacy, pharmacists and pharmacy organizations should respond along a variety of tracks, including pressing state regulators for more studies, more transparency and strict regulation around physician dispensing, in particular to address potential misalignment of incentives between doctor and patient, and to protect patient safety.  

In addition, they should note the perceived benefits to patients of the in-office drug dispensing model, such as convenience and privacy, and invest in their own capabilities in these areas. The good news is that many pharmacies have already done so and are doing so, with meaningful benefits to themselves and the patients they serve.