Tuesday, December 9, 2014

Feeling Uncomfortable about Filling Prescriptions

"Dr. RxMan, my name is Detective Daniels. I'm with the Snootyville Police Department. We'd like to ask you some questions."

"Certainly, how may I be of assistance?"

"On November 22, did you fill a prescription for the generic Norco 5/325 to a Mrs. White?"

"Yes, I did."

"Are you aware that the quantity you filled was for 180 tablets?"

"Yes, I know."

"Didn't that seem like a high amount of tablets?"

"Yes, of course. I verified the quantity with the prescriber."

"Are you aware that you filled this prescription 20 days AFTER you filled the same quantity for the same patient?"

"Yes, of course. Mrs. White indicated that she was going on vacation 'somewhere in the middle of Nevada' where 'there are no pharmacies.' When I called the doctor, he approved filling the medication early."

"Were you not concerned for the health and welfare of Mrs. White? Did it not occur to you that so many tablets of Norco might endanger her if taken incorrectly?"

"I'm always concerned about all the medications we dispense. We counsel every patient about the dangers of these medications."

"Are you aware that Mrs. White was found dead in a motel room here in Snootyville? She left a suicide note indicating her intentions. The forensic team is still working on the case, but it appears Mrs. White died from an overdose of Norco."

"Oh my gosh! That's horrible!"

"Our concern is that you ignored a clear and present danger to Mrs. White and YOU are partly responsible for her death. We will be taking evidence to the grand jury for an indictment. Please do not leave the state, Mr. RxMan..."

NO, this didn't really happen...

but could it?

Recently I've seen blog posts ranting and raving about chronic pain sufferers being "mistreated" by pharmacists and pharmacies all over the country. Some encourage the patient to hire a lawyer if they feel like the pharmacist has somehow mistreated them by "keeping them" from their pain meds. They also encourage patients to invoke a clause in the American Disabilities Act to pressure pharmacies to fill without questioning quantities or timing.

Another comment talks about how pharmacists should never say they're "not comfortable" with filling a prescription... the author suggests that no matter what the situation, simply presenting a prescription to a pharmacist FORCES them to fill it without question. 

Mind you, we're only hearing the disgruntled rants of the "mistreated patients," but lets consider the point of the blog: You should never turn down filling a prescription because you feel uncomfortable about it. Is that the correct thing to do? No, it's not. Let me tell you why:

If you're a pharmacist, YOU have EVERY RIGHT to question ANY PRESCRIPTION presented to you, and YOU have EVERY RIGHT to NOT FILL IT for WHATEVER REASON if it makes YOU feel UNCOMFORTABLE. 

If it doesn't feel right, then don't fill it. Are there some people that will feel "mistreated" because you don't fill it? Maybe. Are there some people who are chronic pain sufferers who might slip through the cracks? Possibly. Should we just give out medication to anyone that asks for it and take the risk upon ourselves that people might do what Mrs. White did? Hell no.

No pharmacist anywhere wants people to suffer! But we will NOT be extorted into filling anything and everything because some people, including retired pharmacists, feel like its not our business to assess situations and deny filling. It is our job, and we will do our job.

And in case you don't think scenarios like the one I suggest above with Mrs. White isn't possible... think again. I personally had a very similar situation actually happen to me. It DOES happen. I did not fill a prescription for a large quantity of generic Ambien because I did not feel comfortable doing so, despite having prescriber approval. As it turns out, the man (and his wife) who wanted the large quantity of Ambien were planning on using it to commit suicide! Read that story here. 

I was NOT comfortable filling the prescription as stated in that blog story... and as it turned out, it was for a good reason. If I had ignored my "uncomfortable feelings," I would have had to explain to the police and the victims' families why I filled the medication. And who knows? Maybe I would have been implicated and/or sued by the surviving family? And/or lost my license? Above all else, I would have known forever that I played a part in their suicide. What would that do for your "comfort" zone, pharmacist?

So if you're a pharmacist that feels uncomfortable filling a medication, you go right on feeling uncomfortable and don't fill it. There's a reason why you're feeling that way. Don't feel bullied or pressured into filling anything that you're not comfortable with filling! Period.


Anonymous said...

I agree that no one should feel forced to involve themselves in any situation that feels in any way sketchy. Patient satisfaction should not be more important than patient safety. Sadly, your concerns are valid because this is a product of the society we live in. Patients love to sue, families of deceased patients love to sue, the whole judicial system loves to find someone to blame instead of admitting that most situations involving patient harm are multi-faceted.

It should not be this way and I hate that my pharmacist has to worry about this sort of thing. If he or she has to worry about anything I would like it to be the chemical interactions and medical side effects that the drug might cause, not the legal repercussions.

Pharmacy should never be blamed for an MD who over prescribes or for a patient who has deceived every medical professional in their path. I think placing the blame on the pharmacist when they have done nothing more than fill a valid prescription is just as ridiculous as blaming the manufacturer for making the medication available. But I am not the police, or a judge, or a lawyer involved in the death of a patient. I am just a nurse who used to be a pharm tech so I certainly wouldn't understand all of this as well as someone employed in the legal field.

As a side note, should the scenario you described ever actually occur do not expect the company lawyers to defend you properly. They are only interested in the best outcome for the corporation, not for you.

Anonymous said...

Thank you. Thank you thank you thank you.

And can I get an Amen....

Anonymous said...

Amen, Crazy! I don't see any problem in protecting my license when necessary. I don't see color, gender, or economics when I'm filling. I see dates, directions, and strengths. If those don't line up, I'm "not comfortable" and they can try the next pharmacy on the next corner.

Anonymous said...

Crazy...do you know of any instances where a pharmacist was held accountable for the actions of a patient after receiving a 'questionable' prescription filled by that pharmacist?

If so, what were the details of the case?

I ask, because as a pain patient I've yet to run into the "I don't feel comfortable..." at my pharmacy, and am wondering how prevalent the issue is and why.

Crazy RxMan said...

I do not have a confirmed story of such an instance. I have heard credible accounts of such issues from other pharmacists, however.

The heart-broken mom in the tragic case of the overdose of her son wants "laws that would require certain agencies — including the pharmacy board, medical boards and medical examiner — to be more proactive in preventing overdose deaths." See: http://bit.ly/1qq9Ds4

HPSO (Healthcare Providers Service Organization) provides liability insurance to healthcare providers. In a PDF file published in 2013 they list an analysis of pharmacist liability claims. In this analysis, "wrong dose" accounts for 31.5% of all closed claims. It doesn't require rocket science to know that a lawyer could try a court case claiming that a pharmacist who dispensed a high-dose medication early could be thought as a "wrong dose," regardless of prescriber approval. See: http://bit.ly/12nKvqY

Given the slap-happy "sue you" nation we live in, if this hasn't happened already, it certainly will. I do know that there have been some odd court cases where the pharmacist has been held partially liable for poor doctor handwriting. See: http://bit.ly/1zKbUOX

More on "refusal to fill" found here: http://bit.ly/1wcvpz6

bcmigal said...

I have had the police or coroner bring a bottle of pain killers (legitimate Rx with our label) when a pt died after combining prescription drugs, street drugs, and alcohol. Also after a DUI traffic collision. Gives one a horrible feeling.
Just this past week, we had a regular customer with an rx for 120 Percocet 10. Physician okayed an early fill because the pt was traveling. For some reason, I did have a "gut feeling"so I consulted the PDMP. The pt had filled 450 Percocet in a month. He does not have any documented conditions which would justify this kind of "therapy". When the pt returned 8 days later with another rx (going on a business trip), we refused to fill it.

Ms. Donna said...

Thank you. But, can I post from a pt. perspective?

I had an injury that caused a lot of pain. "Lot" is a small word for what a not-obvious injury was causing. Try a blast furnace, and that will come to the first level.

My Dr. rx'd and I took (reluctantly, as I feared addiction) a relatively high dose of painkillers. The pills let me work, interact with my kids and stand the physical therapy needed to fix the problem.

It worked. I realize now that I would not have been able to have a normal life (or what passes for normal )then if it weren't for the painkillers. Someone at a pharmacy all but accusing me of being an addict would have made me stop the medication.

So, yes, please be careful and do what you believe to be right, but PLEASE remember that the person on the other side of the counter is not always pill-shopping, or out to "get" you. Sometimes, they just need help.

Anonymous said...

I once worked for an attorney - until he and his wife killed themselves together (along with their dog, who probably didn't get a vote). It was all very tragic. They didn't go by Ambien but their circumstances are eerily similar to the ones in your post. They just hopped into their vehicle and did the ol' exhaust pipe to window trick. So sad.

Anonymous said...

I wish we had more pharmacists who were uncomfortable. I know of a mildly-demented 76 y/o pt who was Rx'd 80 Lortab, along with a big batch of Valium. No surgery, no injuries, just some "back pain." Grrr. Not a fan of that doc, especially after I checked his Rx habits on ProPublica's database (admittedly limited data since for elderly pts, it draws data from Medicare); still... He needs to stop it.

I may have veered off topic into a rant. Sorry.

Anonymous said...

30 years ago I had patient who got Darvocet N 100 and one day he showed up with a PCS card to pay for his Rxs.. I got notice that he had 100 filled at another store a couple of days before.. As a "good Pharmacist" I notified the prescribers and other pharmacies involved... and he was cut off cold.. a week later I had the privilege to meet his wife and his two young children.. at HIS FUNERAL because he took a 38 to his head... those in chronic pain are twice as likely to commit suicide.. as has been stated.. they will find someway to get it accomplished whether we are or not part of the equation.

boilerrph87 said...

I always use our INSPECT to check. My experience, I find out how long the patient is going to be gone on vacation. Chances are they arent going to be gone that whole month. That's when I can get creative with the fill if I don't want to give the whole thing but I know it's a legit need. It was easier when HCP wasnt a CII, but one can still be creative with the "refill". Chances are she wasnt going to be gone an entire month and was 'going to run out before she got back' where I would only give her enough to last til she got back...Make her pay for whole thing, give her the few and hang on to the rest in stock as 'Paid" for her to pick up. OR offer to mail it to her. BUT seems she had other motives in mind which were due to a MENTAL ILLNESS. Meaning she would have taken what she had anyway probably with a bottle of booze, so it almost doesnt matter...if they REALLY want to commit suicide, they will. Means her pain may have been under treated and she found no other way. You'd probably still be on the hook for the original 180 dispensed. This is the ugly side of chronic pain. We need a better mental health system in addition to improved pain mangement for legit pain patients instead of automatically lumping everyone into the 'addict module" and punishing them. Just my 2cents.

Anonymous said...

I agree to an extent. But if the uncomfortable feeling comes because of what you think your EMPLOYER or DEA will do to you, that is not ok.

We are here to care even for the difficult people.

Anonymous said...

I've had chronic pain since 2011 with endometriosis, pelvic adhesive disease, degenerative discs in my neck and lower back. I've seen the same pain management specialist for 2 years. I get drug tested EVERY time I go in. I am prescribed 180 percocet 10s per month. I take them as prescribed along with my cymbalta to help with pain. I don't abuse my medication or use them for "fun" I use them to work, clean, take care of my child and try to live a normal life. Luckily my pharmacy knows me but occasionally a new pharmacy tech or new pharmacist treats me like an addict. My point being: You don't know how much pain someone else is in. Pity is not requested but a little understanding would be nice. Not everyone who takes pain meds are addicts. Until you know what it feels like to not be able to sleep because of pain or for it to hurt so badly that you can't do anything but lie in bed and cry...please don't judge

Anonymous said...

Thing is (I know thus is an older post), I am also on Norco 7.5/325 and no matter how long we have been on them oor our age (33) or what our issues are (deteriorating neck cartilage and bone on bone in right hip), we are all addicted, maybe as functioning or not but for 17 years I have been on it, couldn't imagine my 6 a day. To me, it's a lose lose situation...pharmacists are not doctors but doctors are not pharmacists...they both play a part but as a human, if I were to overdose on my pain meds, who is the first person my family is going to? My pharmacy so....