Filling prescriptions for controlled substances: Establish a protocol

Recently, Drug Topics published an article I wrote, titled “DEA vs. ADA: Pharmacists and the rock or the hard place” (March 10). In it, I pointed out that when pharmacists refuse to fill legitimate prescriptions presented by chronic pain patients and others, they may become vulnerable to prosecution under the Americans with Disabilities Act.

Drug Topics also published a page of instructions I created, advising patients who have been denied fills how to file complaints with the appropriate authorities (“When valid prescriptions are refused,” April 3).

The magazine has received numerous e-mails reacting to these articles, and it appears from what some readers are saying that I may not have made clear why I take the position I take. It is difficult to address such a complex issue in 650 words or less. So the editors of Drug Topics have given me the opportunity to try to clarify a point that has come up in many e-mails.

Questionable prescriptions

Many of the readers who took exception to what I wrote thought that I was saying that there are only two kinds of prescriptions, those that are legally written by a doctor and those that are illegal/fake.

Of course, we all know that there are questionable Rxs, prescriptions that are legally written for questionable medical need. And indeed, such prescriptions are questionable and should be dealt with properly.

In my opinion, that means that our decision to accept or deny a prescription should be based on facts, as described below.

Types of patients

The person handing you a prescription for a controlled substance typically falls into one of four categories:

1. The legitimate patient.

2. The pseudo-addict. This is someone who has not found a prescriber who will provide adequate pain management and who therefore is seeing multiple prescribers in an attempt to gain optimum quality of life, so that he/she can continue to function as a good spouse, parent, or worker.

3. The substance abuser. This is generally someone who has some mental health issues and is self-medicating to fight off the monkey on his back or the demons in her head. This person will find some substance to abuse. It really doesn’t matter what it is.

4. The diverter. Diverters probably do not abuse substances. They are in the business of selling drugs on the street for a profit. These people really need a new business plan.

Reasonable protocols

As I mentioned above, the prescription that is handed to you normally falls into one of three categories: Illegal/fake, questionable, and legit.

What you do with the first and last is pretty obvious. The second one, the one that is “questionable,” falls into what can become a very gray area.

In my opinion, the prescription department needs to establish some reasonable protocols derived from a consensus of the pharmacists working in the department, protocols that everyone in the prescription department adheres to religiously.

I believe that the decision to fill or deny a prescription for a controlled drug should be based on facts, not on “the little voice within” or “my professional discretion,” which can be heavily influenced by personal biases or phobias. If you have a questionable prescription, hold onto it until you can confirm whether it is or is not written for a legitimate medical reason.

Document

To play it safe, you should copy every prescription you refuse, and the copy should be annotated with the reason that the patient or prescription threw red flags, according to the protocol established by the prescription department.

Likewise, if you fill a prescription that does throw more than one red flag, document the copy of the Rx with the reason the prescription was filled against the prescription department protocol.

Most likely, if a legitimate patient files a complaint with the ADA or BOP, an investigator is going to “Monday-morning quarterback” your decision months after you turned the prescription down.

Without proper documentation, it is unlikely that your reason/excuse that you used your “professional discretion” will hold much water. Remember, if it is not documented, it did not happen.

Even if you are fined, the experience will provide a valuable insight into how you can refine your protocols to help prevent other fines in the future.

Follow the protocol

Of course, a prescription presented for a new patient, outside of office hours, for a large quantity, with a doctor and patient address that are out of the area, is “questionable.” In fact, if the patient lives more than five miles from the doctor's office, work, or home, that is questionable. The vast majority of patients come from a 2-3 mile radius of the store. 

If you have established a protocol that states that these are red flags and more than one red flag is thrown, turn the prescription down - but offer an option.

Ask new patients presenting an Rx for more than 24 doses to bring in a utility bill that matches their driver's license. If they show you such a prescription outside of the doctor's office hours, then offer to give the patient enough medication to last until the prescriber is back in the office.

If the prescription is for a large quantity, as it may be for a chronic pain patient, and you can't find anything in the PMP, require the patient to bring in a print-out from their former pharmacy, to show that they are opioid-tolerant.

In my opinion, that above three items would knock out all but about 5% of questionable prescriptions.

For the rest, your protocol might even require new patients presenting an Rx for a large quantity to bring in all their meds, since it is very unusual for a chronic pain patient to be taking only an opiate. If they want to be your patient and agree with that condition, fine. If they just want to be a customer buying opiates, they can take a walk. The legitimate chronic pain patients will line up. The bogus patients will head for the hills.

If you want, when you offer the limited number of doses, you can say that you are low on inventory. It is most likely that all but the legitimate patient will turn you down and take the prescription back; patients who are not legitimate will not want to risk losing the doses that the prescription represents, and they know they won’t be coming back to pick up the remainder and risk being arrested.

You have not refused the prescription. You have not told the patient no. The patient has decided not to accept your offer.

It is very unlikely that someone with a really questionable prescription is going to file a complaint with any of the various bureaucracies. People like that are not going to call attention to themselves.

You have to ask yourself, which is the better alternative? To let a few doses of a controlled substance go? Or to cause a chronic pain patient to go into elevated pain, withdrawal, a possible hypertensive crisis, stroke and/or death?

Which can your conscience handle more easily?

Steve Ariens is a pharmacist, a pharmacy advocate, and National Public Relations Director for The Pharmacy Alliance (www.thepharmacyalliance.com). You can e-mail him at steve@steveariens.com or check out his blog, pharmacist steve (www.pharmaciststeve.com/).