Sitting in a courtroom is an unpleasant experience at best. The witness stand feels much more uncomfortable than it looks. And lonely. And the jury are strangers. The prosecuting attorney, especially if they work for the DEA, is not your friend. You think you’re ready. You’re not. Hard questions are about to come at you faster than a Nolan Ryan pitch in his prime.
I know all this because I’ve been there. Thankfully, in my situation, I was not the accused. I was merely invited in as an “expert witness” to educate the jury on the role and responsibilities of the pharmacist when it comes to dispensing controlled substances. Even just being there as an educator was no picnic.
Confucius supposedly called “experience” the “bitterest” of ways to learn wisdom. He may be right. But, bitter or not, this experience taught me some things about protecting your license when treating pain.
As retail pharmacists we (most of us) dispense controlled substances every day. We do so because, for the vast majority of our chronic pain patients, they provide an improved quality of life. These are legitimate prescriptions, and we fill them.
At the same time, not every prescription is valid. And pharmacists need to remember that federal law expects you to take reasonable steps to be sure the prescription is being written for a legitimate medical purpose.
The most important thing you can do as a pharmacist, based upon my courtroom experience, is to document your efforts to be sure the prescription is appropriate. Written documentation of every effort you made to do your job lawfully is the best friend you can have in a court of law when it comes to a drug diversion case. If you don’t write it down, it didn’t happen.
What if it is discovered that a doctor in your community has been shut down by the DEA for drug diversion? What if your pharmacy filled many of his/her prescriptions? What if you personally filled many of them? Don’t imagine that because the doctor had a license to practice that you are protected. You’re not. Remember that “a corresponding responsibility rests with the pharmacist who fills the prescription.” [CFR 1306.04(a)]
What should you do now, in your practice, to help protect your license? I suggest you get a diagnosis from the doctor’s office and document it for all chronic opioid prescriptions. Ask the patient what their diagnosis is too, and document it. Check the state PMP (prescription monitoring program) for duplicate fills or early fills, and document it. Is the dose unusually high? Talk to the patient and the doctor about that. Document it. Provide literature or studies to support your concern and document the fact that you shared these with the provider.
Pharmacists should be aware of the obvious red flags like requests for early refills, patients traveling from a distance to a pharmacy or doctor, paying with cash or other factors mentioned in the DEA guide to prescription fraud. Be aware that certain combinations of medications, such as an opioid, benzodiazepine, and muscle relaxant are frequently abused. Consider suggesting a store or company policy to require pharmacist consultations for any patient receiving an “above-average” opioid dose for non-cancer pain (say anywhere from 120mg to 200mg of morphine equivalents).
The opioid issues facing our nation are both troublesome and complex. While protecting our licenses may not be the biggest problem, it is surely a real problem, and one that we pharmacists must consider. And better to learn these things by reading and reflecting, than by a personal and bitter experience of a cold and lonely courtroom.