Watch for these red flags when dispensing opioid prescriptions
Thursday, March 30, 2017
When I graduated from pharmacy school almost 25 years ago, filling prescriptions for opioids in a community setting wasn't a topic of great concern. We did it. We made sure the dosing was appropriate and counseled the patients about side effects such as drowsiness, nausea and constipation. We knew about forged prescriptions and probably caught some.
But today's pharmacists must take many more things into consideration whenever we fill a prescription for a controlled substance.
I recently had the opportunity to serve as an expert witness in a case involving alleged opioid diversion. This experience — along with the literally dozens of news stories about pill mills that are being conducted throughout our country — leads me to want to share some words of advice to my fellow pharmacists who work in settings where you dispense controlled substances.
I hope you will take what I am about to tell you to heart. I do not want, in any way, to interfere with the dispensing of legitimate opioid prescriptions to patients with chronic pain or diseases that require these medications to provide a reasonable quality of life. At the same time, I can say without hesitation that you as a pharmacist are expected to notice any red flags and to respond to them appropriately.
1. Determine the legitimate medical purpose
Understand that you will indeed be expected to determine (within reason) if the prescription is for a "legitimate medical purpose." Now, I know that this phrase has been thrown around and is difficult to define.
But, for example, you will be expected to have noticed things like that patient's appearance, the patient's companions and how far the patient has traveled to obtain the prescription. You will be expected to be at least a little suspicious of a cash prescription.
None of these things alone is a perfect test for "legitimate medical purpose," but as a pharmacist you will be expected to have paid attention to them and responded appropriately.
2. Get to know the prescriber
You are likely to be expected to know something about the medical practice from which these opioid prescriptions are coming. Is it a pain clinic? Does it specifically say that on its website and/or prescription pads? Do the doctors writing the prescriptions have any special training in pain management?
Yes, you can ask. If a clinic opens up near your pharmacy and you begin to fill prescriptions for their patients, you should do your research on the practice and prescribers.
3. Pay attention to volume
Understand that volume will draw attention to your pharmacy. If you suddenly begin filling more opioid prescriptions than usual, and especially if those prescriptions are coming from a small number of prescribers, you should fully expect that this will call attention to what you are doing.
Be prepared. Consider calling other pharmacies in the area and talking to their pharmacists about any trends like that going on in your area.
4. Be cautious about prescription cocktails
Be especially concerned about what is commonly referred to as a prescription "cocktail" such as the prescribing of an opioid, a benzodiazepine and a muscle relaxer such as carisoprodol. This combination is a highly prized mixture of drugs used for illegitimate purposes on the streets.
While there is no "contraindication" to combining these in certain circumstances, the combination should nevertheless be handled carefully.
5. Document everything
Any suspicions you have should be researched and documented. If you believe a physician is prescribing inappropriately, you should contact that office and ask to speak to the M.D. If you are really concerned, you should put a call into your Board of Pharmacy and specifically ask for their advice.
But whatever you do, write it down. Definitely document your refusals to fill. I suggest keeping a separate file or notebook in which to document your research. Writing it on the hard copy of the prescription alone will be difficult to find if you should need to defend your dispensing.
I suspect some of my fellow pharmacists will read this and think it is unnecessary. Others may believe they simply don't have time to do all that. Trust me, I understand. But I also have seen the consequences of ignoring the warning signs of a bad prescriber, and I can assure you that you do not want to be the target of such an investigation.
We are living in a different world today than 25 years ago with respect to opioid dispensing. Pharmacists are being expected to step up and help out in our national effort to curb our addiction and overdose crisis.
While these drugs all have legitimate medical purposes and most patients are using them appropriately, we still have to do our part to prevent abuse and diversion.
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