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Pharmacists dealing with Rxs for controlled substances have their lists of red flags and greens flags. Are they now showing the white flag, as well?
Ken BakerI am concerned about the increasing problem of pharmacists being pressured to turn down legitimate prescriptions. What particularly concerns me is that in some cases real pain patients have been refused prescribed medication.1 In one case, I wrote about a patient who left the pharmacy not only in pain but also in tears after being accused by a pharmacist of being a drug abuser.1
Increasingly pharmacists are told to solve the overuse of drugs by adopting an attitude of: “when in doubt, don’t fill.” Pharmacists have a legal and ethical duty to refuse to fill prescriptions when they know - or by applying their knowledge and experience should know - that they are not for a legitimate medical purpose.
Tools, not answers
To assist the pharmacist, a list of “red flags” has been developed. In a perfect world, a “red flag” should be resolved before the prescription is filled. But “red flags” are tools, not answers. The real answer must be found in the question: “Is this prescription for a legitimate patient with a legitimate medical need?”
If patients are taking too much medication or refilling it too early, this may be a “red flag” pointing to a pharmacy and medical problem, not a legal problem. The pharmacist’s job is to work with the patient and the prescriber to resolve pharmacy and medical problems.
If the pharmacist decides that the patient is not in legitimate pain and that there is no legitimate medical purpose for the prescription, then the pharmacist has decided the Rx is not valid. In that case, as a pharmacist and a former prosecuting attorney, to me the answer seems relatively easy - a crime is being committed and the police need to be notified.
The pharmacist need not call the police while the person is still in the pharmacy, as that may be dangerous, but the prescription should not be filled and the police should be notified when it is safe for the pharmacist to do so.
In real life, of course, nothing is quite this easy, but it offers a way to think about the question. It provides the pharmacist with an answer in stark terms: Is the individual presenting the prescription a crook or a patient with a pharmacy and medical problem?
In the April issue of Drug Topics, I wrote about “green flags” that a pharmacist can use, along with “red flags,” to help identify legitimate prescriptions, even if the patient is not using the medication as he or she should be, according to the directions.2 I repeated my belief that pharmacists are often pressured into a “do not fill” attitude toward legitimate pain patients.
After the April issue of Drug Topics was published, I received a letter from Joe, a pharmacist who has practiced for several years. Joe asked whether, when the pharmacist decides the prescription is OK to fill, he or she is now thinking, “but wait, will this be the one script that puts [the pharmacy] over that ‘mystical limit’ with [the pharmacy’s] supplier?” Will the pharmacist then think, “[What if the wholesaler notifies] my boss and even my boss’s boss?” Joe’s concern is that pharmacists may be giving into pressure and raising a different flag - “the white flag!”
Perhaps Joe’s fears are right. Sometimes pharmacists give into the pressure and find it easy to “just say no.” While the Code of Ethics for Pharmacists includes an ethical duty to society as a whole, we have an overriding ethical duty to our patients.
As pharmacists we can do much to reduce the very real problem of prescription drug diversion, but we must also care for patients. Sometimes we will be wrong. The law does not demand that pharmacists be perfect, only that we think before we decide and that we not force a legitimate patient in real pain to leave without at least a hope of relief.
Ken Bakeris a pharmacist and an attorney. He teaches ethics at the Glendale, Arizona, campus of Midwestern University, and risk management for the University of Florida. He consults in the areas of pharmacy error reduction, communication, and risk management, and is an attorney of counsel with the Arizona law firm of Renaud Cook Drury Mesaros, PA. E-mail him email@example.com.