COMMUNITY PRACTICE

Stepwise approach can help weed out suspicious Rxs

Every pharmacist has encountered the dreaded controlled-substance prescription that falls into the twilight zone, somewhere between obviously legitimate and clearly phony. The problem professionally and legally has always been what to do with such a suspicious script? Fill it and perhaps abet a criminal? Refuse to fill it and deny a patient relief?

One answer to the fill-or-refuse dilemma is to take a stepwise approach to suspicious Rxs, said David Brushwood, R.Ph., J.D., professor of pharmacy healthcare administration, University of Florida. He doesn't claim it's foolproof but he offers it as a way to help pharmacists do their jobs better.

"I'm trying to describe a process for evaluating a suspicious prescription," said Brushwood. "I'm not suggesting any of this process applies when a prescription is obviously valid. For heaven's sake, go ahead and fill it and don't worry about any of this. I'm also suggesting that when it's obviously invalid, for heaven's sake, refuse it and don't worry about it. Sometimes it's not so obvious. Sometimes there are suspicions. I'm trying to guide pharmacists through those suspicions to a particular action."

Step 1 is to throw out some old notions about drug-seeking behavior. For example, it's impossible to spot a drug abuser merely by the way he or she looks. In addition, off-label use of a drug has no bearing on whether a script is legitimate. Likewise, a patient aggressively demanding that the script be filled right away may just be in a lot of pain. And the ratcheting up of drug dosage or frequency may mean that the physician has decided to adjust the patient's therapy.

"None of those factors has any correlation with prescription forgery," Brushwood said. "Sometimes pharmacists confuse drug-seeking behavior with relief-seeking behavior. That's an unfortunate thing to confuse."

Setting aside the irrelevant factors, pharmacists should assess the conditions that make a script suspect. Step 2 presents factors that should raise suspicions:

• Is the patient trying to distract the pharmacist or technician away from the script or medication use?

• Does the patient have a problem of repeatedly losing medications?

• Does the patient present Rxs only for opioids?

• Is the patient getting the same drug from many prescribers?

• Does the patient always get the brand drug and always pays cash?

If one or more of the answers to the above questions point to fraud, proceed to Step 3 to confirm those suspicions.

• Does the suspicious patient refuse to let the pharmacy contact the prescriber?

• Does this patient refuse a partial supply?

• Does this patient refuse to present a photo ID and permit it to be photocopied to attach to the Rx?

Any refusal to cooperate with the above actions should be considered as confirmation that the script is fraudulent. Such a script should be refused.

"If the patient under suspicion says there's no problem accepting a partial supply and, 'here's my photo ID, copy it and stick it to the prescription,' go ahead and fill the prescription," Brushwood said. "Your suspicions were appropriate, but they've been set aside by the patient's willingness to cooperate. Most people who are drug dealers or abusers won't do that."

Sometimes R.Ph.s think they'll never have to fear administrative discipline if they ask for a photo ID and call for verification and it doesn't matter how obviously invalid the script is. Brushwood said, "No, no. If it's obviously invalid, don't fill it. Pharmacists know what that means. People bring in prescriptions for Richard Nixon and Doris Day all the time. If someone brings in OxyContin prescriptions every day for Luke Skywalker, don't tell me you didn't know there's a problem with that."

Carol Ukens

Carol Ukens. Stepwise approach can help weed out suspicious Rxs.

Drug Topics

2001;21:21.