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Red flags-and what to do when your suspicions are aroused
Editor’s note. In his column, “that’ll be 240 ‘blue roxys’” David Stanley, RPh, tells of a close personal encounter with someone trying – unsuccessfully to fill an obviously fraudulent prescription. Mr. Stanley raises the issue of red flags, the Nation’s growing awareness of narcotics, and the pressure to fill scripts. This article is a response to that essay.
More than four billion prescriptions are written in the U.S each year. Among those billions of prescriptions are the bad ones - the ones that are fraudulent, forged, or play some role in an illegal activity. How can a pharmacist and pharmacy staff guard against them and stop them before they are filled?
Learning to see the warning signs of bogus prescriptions is the primary safeguard in dealing with them. Pharmacists must stay alert and look for any red flags . . . not just in an individual prescription, but also in the patterns of prescribing that could point to a possible pill mill, a drug diversion operation, or to an individual patient with an addiction problem.
There are several types of fraudulent prescriptions, according to the DEA. They could be written on stolen prescription pads, be completely counterfeit, or they could have originally been a valid prescription that was altered.
This could include changes to the return phone number so that a verifying phone call reaches someone other than the prescribing doctor.
“A pharmacist has a corresponding responsibility to independently make a determination that a prescription has been written for a legitimate medical purpose and that it is a legitimate prescription intended for a patient, said Ned Milenkovich, PharmD, JD, a principal at Much Shelist, P.C., in Chicago. The responsibility for ensuring that a prescription is good lies with the healthcare provider who wrote it, but “corresponding responsibility” means the pharmacist must also exercise professional judgment in determining if the script is genuine and issued for a legitimate reason.1
Learning to see the red flags
The pharmacist should look to see whether the physician who wrote the prescription is prescribing within his or her specialty, Milenkovich said. Are the physician and patient local and does the patient live near the physician? “There are things a pharmacist can do to get to the bottom of the prescription’s legitimacy beyond reviewing the piece of paper it is written on,” he said.
Pharmacists need to learn the red flgs and act on them, said Mohamed Jalloh, PharmD, Assistant Professor in the Clinical Sciences Department at Touro University California College of Pharmacy in Napa, CA. Jalloh is a spokesperson for the American Pharmacists Association. A warning sign could be a prescribed quantity of a controlled medication that is not appropriate or common, such as 500 tablets of oxycodone/APAP, he said. States may have specific laws regarding how pharmacies should deal with a bad script, he added.
Other red flags include changes to the prescription or if it is from an unknown physician, added Jerry Callahan, RPh, of Elsberry Pharmacy in Elsberry, MO. Callahan owns six pharmacies in the St. Louis area. Badly written directions can be another indicator, such as “q every 6 hr” rather than “q6h,” he said. Bad directions like that can be a tip-off, even with a phoned in prescription, he noted.
Familiarity with the handwriting of frequent prescribers is a good habit, added Jalloh. “As a community pharmacist for a few years, I generally have an idea about how the handwriting of specific prescribers looks. When I see handwriting from a doctor that is ‘too good’ or ‘legible’, that is huge a red-flag to me,” added Jalloh.
“In-house training can be one of the safest and most cost-effective ways to prevent against fraudulent prescriptions,” said Jalloh. Pharmacists can study such topics as the recommended quantities or dosages of potentially abused medications, he noted.
“The key is constant training and teaching. It never stops.” Callahan said.
He uses the bad prescriptions that he and his pharmacists have stopped as training aids in his pharmacies. “Anytime we come across one, we share the script with all the staff and explain ‘here is what is wrong and here is how we caught it.’ ”
“Most of the big chains offer great training to help us identify bad prescriptions,” Jalloh added.
Drug Topics reached out to several large pharmacy chains to ask about specific training programs, but none were available for comment. Great resources for pharmacists are the prescription monitoring programs (PMPs), said Rusty Payne, a spokesperson with the DEA in Washington, DC. These are databases that have been set up by individual states to track patterns in fraudulent prescriptions. They are also used to spot patterns that might point to a prescriber operating as a pill mill or organized drug diversion activity.
These programs vary from state to state in their scope, he noted, but can often let a pharmacist see that the customer has been to several pharmacies with prescriptions for the same drugs in a short period.
The DEA also has a database on physicians who are under investigation. It is at https://www.deadiversion.usdoj.gov/crim_admin_actions/. The same database lists investigations against pharmacies.
And knowing what to do next
Once a pharmacist’s suspicions are raised and the bogus prescription spotted and stopped . . . what then?
Pharmacists should call their local police if someone presents them with a forged or fraudulent prescription, Jalloh said.
Having the reputation as the pharmacy that calls the police can be useful in reducing the number of phony or fraudulent prescriptions brought in, Callahan added. “That is the best way to deter these guys. If they know they are going to get caught, they are going to avoid you.”
In fact, Callahan says that he sees relatively few fraudulent or forged scripts at his Elsberry pharmacy. “We are in a small town and we know everybody. They just know not to bring it. They tried us in past and we catch them.”
The risk to the pharmacist Even with the best training and a high level of alertness, a bad script will get by a pharmacist, Milenkovich noted. Most pharmacists will not get into difficulty for letting a couple of bad scripts through.
“If they continue to get by the pharmacist, however, that would be troubling,” he said. A pharmacist’s history of not performing due diligence and of continuing to fill prescriptions from unknown physicians would be more likely to draw scrutiny from a state pharmacy board or the DEA, he added.
Fraudulent and forged prescriptions can look very good and can be easy to mistake for legitimate scripts, DEA’s Payne said. The people who are trying to obtain controlled substances in large amounts often have skills in this area, he added. “Addicts are desperate and a criminal network with organized trafficking can be very sophisticated and very good at this stuff.”
“We don’t track prescriptions, we look for larger patterns,” said Payne, including patterns in purchasing. “If a pharmacy is buying ten times more of a controlled substance than they were the year before, we are going to want to know why.” The agency also relies on information from state medical and pharmacy boards, he said. “We share with them and they share with us.”
Valerie DeBenedette is a Contributing Editor.
1. Cote L. A pharmacist’s obligation: Corresponding Responsibility and Red Flags of Diversion. DEA Chronicles. Available at http://deachronicles.quarles.com/2013/08/a-pharmacistsobligation-corresponding-responsibility-and-red-flags-of-diversion/. Accessed on Nov. 13, 2016.