Sometimes I play street hockey. Well, actually it is more like driveway hockey. And I only play goalie. That’s because my 10 year old son loves to shoot and score on his old man.
But sometimes he misses.
And sometimes I make an awesome save. DENIED!
As pharmacists we sometimes have to take the same approach to prescriptions we are asked to fill. Like my son’s slapshots, they must be denied. Sometimes I feel bad about this. There are patients that have real problems with abusing medications. I know, for some of them, there is nothing they would like more than to STOP abusing.
But they’re addicted. And the addicted mind doesn’t always respond in calm, rational, logical ways to problems.
So we have to listen, sympathetically, to the “reason” why this prescription should be refilled early. Then we, usually, have to say no.
Reasons we sometimes hear include, but are not limited to…
- I lost my prescription
- My pills fell into the sink, toilet, drain, floor, trash can…
- The dog ate them
- The cat ate them
- The fish ate them
- My prescription was stolen
- I’m going out of town for a funeral
- The doctor told me to increase the dose
- My insurance said it was okay
- Your records are wrong, they are due to be filled today
Note: All of the above reasons are plausible. Even the fish one (I’ve kept virtually every type of fish at one point or another – and I guarantee you my cichlids could have swallowed a methadone tablet given the opportunity).
But being in healthcare means making judgment calls.
All the time.
Particularly in retail pharmacy.
And sometimes that means saying no.
We’re guarding the net – which in this case is BOTH the patient’s health and our professional and legal responsibilities as pharmacists.
But unlike when I play driveway hockey with my son, this isn’t always fun.
I don’t relish telling someone their script is too soon to fill (again) or, even worse, making the necessary phone calls to alert a prescriber that their patient is using multiple pharmacies and multiple physicians.
And I still consider myself “learning” all the time about the best way to handle these scenarios. There is no easy way out. No simple “text book” answers. And I often wish I had more time to really talk with such patients.
Do I have any tips for younger or new pharmacists who find this situation very uncomfortable?
FIRST – DO your research. Be sure that this patient is, actually, over-using their medication before making any such suggestion. Check carefully that the last prescription was actually entered correctly. Double check the math, being sure to calculate the days-supply accurately. Pull the original script, or check out the scan, to be sure it was read correctly. Take the 31-day months into consideration. Make sure the previous fill was actually picked up (check signature records if necessary).
SECOND – DON’T get angry. Patients will often respond with frustration and anger at your refusal to fill. Don’t go down that road. Ever. Stay calm. Don’t interrupt them. Treat your patient with respect. You can even express your sympathy with their situation, while at the same time sticking to your guns.
THIRD – BE careful. If you feel as though an encounter with a patient could lead to a violent reaction, be sure you have backup. Ask another member of the staff to stand nearby, or call for store management to come to the pharmacy. I have, more than once, suggested to a female pharmacist that she ask for a male member of management to escort her to her car at night.
FOURTH – BE ready with options. Seasoned pharmacists learn how to provide reasonable options to upset patients about their requests for early refills on their prescriptions. These options will vary based upon the circumstance of course. But they may include suggesting the patient get a “new” prescription with the new directions, or return to the “previous pharmacy” that filled their Vicodin last time, or offering to call their physician and convey their request for an early refill. Remember, as a pharmacist you have a LEGAL responsibility to be sure this prescription is being used appropriately. So it is perfectly legitimate to say that the “law” requires you to….[fill in the blank]….before you can fill it. You need to do whatever you need to do to ensure the script is legit and appropriate.
FIFTH– Don’t worry if you have gotten burned. It happens. I certainly have. Big time. I’ve been played like a fiddle. I’ve been fed lies and swallowed them like they were crab rangoon. I remember one patient. She limped around the OTC section looking for Advil. I came out and talked to her. She was clearly in pain. She said she just went to the ER, and only wanted some ibuprofen. I sympathized. What? The ER? And they didn’t give you an Rx for the pain? Well…she said…they did, but she doesn’t like taking pills. I gave her the “speech” about how short-term use of pain relievers is perfectly safe. She conceded…and hobbled back out to her car to get the script. Percocet. Fifty of them. I filled it. Felt like a hero being there to counsel my patient and was sure she would thank me after a few days.
What really happened there? I was scammed. The Rx was bogus. She was a rogue ex-nurse on the run from the FBI for counterfeit Rx’s in multiple states. Truth. She was good. I found all this out because the next day I had this funny feeling about the Rx and called to discover it was a stolen blank. In fact, an agent from the FBI ended up coming in and actually giving me a website from which he asked me to pick out my “patient” from a lineup of photos. I did. I never heard from them again.
So yeah. Denying isn’t any fun in the pharmacy. But man…in the driveway…I can do it like a beast and LOVE it.
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