Providers can help pharmacists to help patients through the opioid epidemic.

Pages 73-75

Your patient is living with severe, intractable pain. You have done a full patient evaluation, considered the risks and benefits of the potential treatments (including a review of the patient’s previously failed approaches), and ultimately settled on treating their pain—for now—with an opioid analgesic. Next, you conduct a patient consultation, obtain informed consent, document the reasoning for your decisions in the patient’s medical record, execute a treatment agreement, and prescribe the opioid medication in alignment with all relevant rules and guidelines. But, despite all of your best efforts, your patient is unable to fill the prescription at their local pharmacy.

Does this story sound familiar? If so, what can you do to help ensure your patients are able to obtain their legitimately prescribed medications going forward?

The Rise in Denied Opioid Prescriptions is Not New

The above scenario is all too common for clinicians trying to help their patients relieve chronic pain. So common, in fact, that the Alaska Board of Pharmacy recently issued a letter to pharmacists, followed up with a press release, in which they stated that the Board has had an influx of communication concerning patients not able to get their controlled substance prescriptions filled for various reasons, even when signs of forgery or fraudulence were not presented.1,2 In that letter, the Board issued guidance and strong reminders regarding the dispensation of pain medications, reminding pharmacists, among other things, that “Extreme caution should be used when deciding not to fill a prescription…” and “If a prescription is refused, there should be sound professional reasons for doing so…” As a “professional reminder,” the letter stated, “failing to practice pharmacy using reasonable knowledge, skill, competence, and safety for the public may result in disciplinary actions under Alaska statute and regulation…” going so far as to include the relevant disciplinary provisions.

It is clear from this unprecedented and strongly-worded letter that the Alaska Board of Pharmacy had come to believe that its own pharmacists were, with some level of frequency, making unwarranted and inappropriate refusals to fill prescriptions for pain medication. It may be safe to assume that most licensed pharmacists are well-intentioned in their current actions, striving to fulfill their own professional obligations to the best of their ability. So what is going awry, and what can be done to fix it?

Although an unfortunate and unintended negative consequence of the battle against opioid overdose and misuse, the fact is that patients with legitimate prescriptions being turned away at the pharmacy is not a new phenomenon. Shortly after the CDC identified prescription drug overdoses as a US epidemic in 20123 and then again in 2013,4 people being treated for pain conditions started to report troubles at the pharmacy. By early 2014, Gerald Aronoff, MD, past president of the American Academy of Pain Medicine (AAPM), shared with the media that multiple colleagues had called him with stories of their patients, with legitimate chronic pain problems, who had been appropriately using their pain medications for years, and were now going from pharmacy to pharmacy to find their medications. Leading up to the Alaska Board of Pharmacy’s letter, there were similar reports. The newer reports, however, tended to reflect aspects of the since-released CDC Guideline for Prescribing Opioids for Chronic Pain,5 often sounding something like, “My pharmacy won’t fill my opioid prescription because it is for more than 90 MME/day.”

Refusing to Fill an Opioid Prescription is Not Without Validity

The reasons that a pharmacist may ultimately refuse to fill a prescription are numerous. First and foremost, pharmacists have a “corresponding responsibility” under the Code of Federal Regulations6 to ensure that a prescription has been issued for a legitimate medical purpose by a prescriber acting in the usual course of his or her professional practice. Unfortunately, the Code does not further define “corresponding responsibility” or the behaviors associated with the pharmacist’s proper exercise of that responsibility—so other sources, such as the CDC, the DEA, state-level policies, and internal pharmacy policies, often fill in the blanks for pharmacists.

Fear of DEA scrutiny is a strong motivator for pharmacists in the current environment as it relates to opioids, and the DEA is quick to remind them that, “the pharmacist who deliberately ignores a questionable prescription when there is reason to believe it was not issued for a legitimate medical purpose may be prosecuted along with the issuing practitioner…”7 Further, some states now require pharmacists to check for specific items on the face of a prescription prior to filling, with Florida going so far as to require a pharmacist to check for the terms “Acute Pain Exception” or “Nonacute Pain” on prescriptions for Schedule II opioids issued for more than three days.8 Other states, including California, have created checklists related to corresponding responsibility to help pharmacists in their decision-making.9

Finally, in an effort to do their part in reducing opioid overdose and misuse, many pharmacies have instituted their own internal policies related to opioid dispensing, some of which have misapplied aspects of the CDC guideline (which was aimed at primary care providers), such as instituting outright bans on filling prescriptions for opioids of more than 90 MME/day (while the CDC cautions against increasing to ≥ 90 MME/day, it does not prohibit it and merely recommends careful justification and documentation in those cases where it is necessary). While these internal policies may help pharmacists determine the legitimacy and safety of prescriptions, they may also conflict with a pharmacist’s own professional judgment, causing potential ethical dilemmas which further complicate matters.

Serving the Patient’s Needs

It is obvious that pharmacists are truly caught in the middle, striving to best serve the needs of their patients while fulfilling their (sometimes unclear) professional obligations. See “Helpful Recommendations” for pharmacists and prescribers alike on how to ensure your patients get the treatment they need.

While taking these extra steps may seem burdensome, they will go far in helping people living with pain to receive the ethical, humane healthcare that they are entitled to by law. As the Alaska Board of Pharmacy so aptly stated as they closed their letter, “If in doubt, we always recommend partnering with the prescribing practitioner. We are all licensed healthcare professionals and have a duty to use our knowledge, skill, and judgment to improve patient outcomes and keep them safe.”

Helpful Recommendations

Prescribers–to ensure your patient is able to fill the prescription you wrote:

Be open to receiving calls from pharmacists. If a pharmacist calls your office to verify a prescription for an opioid, try not to treat that call as an unwarranted and/or unappreciated interference with your practice of medicine. Remember that the pharmacist is trying to fulfill their own professional obligations, and that a positive and informative conversation with you will allow them to help your patient.

Get to know your local pharmacists. When you develop a professional relationship with the pharmacists in your community who most often fill prescriptions for your patients, you improve their confidence in you and your practice. You will still receive verification calls, but they will undoubtedly be fewer in number and likely easier to handle.

Consider writing guiding information on the prescription to aid the pharmacist. As mentioned above, Florida has implemented rules requiring prescribers to identify, on a prescription’s face, that the prescription is for nonacute pain—this helps the pharmacist to understand the high dosage/duration prescription is for a chronic condition without needing to verify the information. While most states do not require this sort of statement, it can be helpful in letting the pharmacist know, preemptively, that the prescriber wrote the prescription for a legitimate medical purpose. However, before taking this step, ensure that whatever you write is consistent with both state and federal privacy laws.

Pharmacists–before refusing to fill a prescription:

Use extreme caution. Keep in mind that a patient who suddenly discontinues a long-term medication, particularly an opioid medication, may experience negative health consequences, including withdrawal and even death.*

Contact the prescriber. If a pharmacist has any concern regarding a prescription, he or she should attempt to have a professional conversation with the prescriber to resolve those concerns and not simply refuse the prescription. A short conversation with the prescriber will either alleviate the pharmacist’s concerns or substantiate them—in either case, this is important information to have.

Speak up if you notice potential complications. Rather than simply refusing to fill a prescription, let the prescriber know if you have identified potentially dangerous drug interactions, exceedingly high doses, etc. You are invaluable as a healthcare professional in terms of your medication expertise, and you should feel empowered to utilize this expertise as part of any dialogue with a prescriber regarding potential alternatives, changes in the prescription strength, and directions to the patient.

In nearly all cases, a professional conversation between the prescriber and pharmacist will resolve any concerns with the underlying prescription. However, pharmacists should remember that they must refuse to fill a prescription that is clearly fraudulent; moreover, suspected fraudulence should be reported to the prescriber’s licensing board. On the other hand, a prescriber writing legitimate prescriptions whose patients are continually refused by a particular pharmacy and/or pharmacist should feel free to file a complaint with their state’s Board of Pharmacy.

*In mid-April 2019, both the CDC and FDA announced reports of serious harm done to patients who are physically dependent on opioids when their opioids are discontinued abruptly.

Last updated on: May 6, 2019

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Gaps in the Pharmacist’s Pain Management Role