Dispensing prescription narcotics can bring out the worst in retail pharmacists. It’s sad how certain phrases have become second nature in a healthcare business. Built in defense mechanisms against business risk and professional liability.

“Sorry, we’re out of stock.”

“We hit our ordering limit.”

“We have to save medicine for our regulars.”

All the while, the pang of guilt starts to compound after each lie you tell. This doesn’t feel right..

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Is It Really Worth it?

But I get it. When you’re filling 1,000 prescriptions per day, you may not feel like it’s worth the risk and headache of taking in a brand new #120 Oxycodone 30mg prescription. 

You never know how demanding that patient will be each month when they call in for early refills. You don’t know if they’re a few doses away from a breathing emergency. Or if they’re even taking the medicine or selling them on the street. Who knows how many other red flags are hidden beneath the surface. Have fun explaining all this to a DEA agent. 

But let me tell you a story. The kind pharmacists don’t ever share.

A patient comes in with Oxycodone 30 mg #120 and Oxycontin 10 mg #60. They usually fill at another pharmacy, exactly 3 days early every month. They’re on two benzodiazepines, and a muscle relaxer. Lots of red flags. My favorite.

As a corporate pharmacist, my job is to balance healthcare and regulatory risk. Unfortunately, this patient does not look good. 

I Never Lie to My Patients

But as a clinical practitioner, I vowed to never lie to my patients. Staring this patient in the eye, I said, “We have this medication in stock, but I have some concerns about filling your prescription.”

Now, whenever you hint to a patient that you may not fill their prescription, their defenses activate. Their fight or flight response kicks in, and they’re ready put up fists. At the very least, they must give a twenty minute dissertation on their medical history and disease states. 

Therefore, I preemptively seek more information. 

“Could you tell me more about your diagnosis and medical conditions? This dosage is higher than the usual clinical standards.”

Of course, there are things about this regimen that I inherently do not like. The high dosage over CDC guidelines, the concomitant use of benzodiazepines, and the lack of adjunct therapy are all severe red flags.

Who let you get to this point? 

They finish telling their story which paints a brutally accurate picture of what their quality of life is like. I could feel the pain of all their previous surgeries and attempts to fix a never-ending problem.

It’s clear that they have severe, chronic pain, and they need some relief now. But I have a more important job than just dispensing treatment. I have a corresponding responsibility to ensure their safety, both short and long-term.

Compassionate Side of the Spectrum

As a Corporate PharmD, I am required by state and federal laws to conduct a clinical review on every controlled substance. What does that mean? 

Every pharmacist does this differently. Some just check the state PMP. Others call the doctor and ask for a diagnosis code. Some only do this plus look for signs of red flags. Any reason not to fill.

Not me. I practice on the opposite side of the spectrum: compassionate care.

I need reasons to fill, but I can’t do this without information. The only way I can truly help this patient while exercising my corresponding responsibility is to acquire and utilize clinical knowledge. Without enough information, I risk making a unilateral decision based upon zero evidence. 

This is what happens every day when pharmacists lie about their inventory and false ordering restrictions they don’t understand. If we only check a PMP and what a person looks like, we give up our privilege to utilize our license and practice healthcare at the highest level. We turn a patient into the enemy and essentially turn our backs on them in what could be our greatest hour. 

So, I tell them I need more clinical information; I need to speak with their physician in order to ensure I am part of the treatment process. I am not going to turn them away prematurely just because I don’t have this.

Sure, there are some patients who don’t understand that pharmacists are part of the healthcare team. We are not the doctor, but we have the same responsibility to make sure our patients get the right treatment. If a patient doesn’t agree, they can disagree by choosing to select another healthcare provider. One who won’t stand up for good patient care.

Transparency Makes All the Difference

However, this patient is different. They are distrusting and confused at first by all the new protocols and information I am requesting. But I walk them through the logic, being transparent and open to questions. My tone of voice is consistent and caring, so they let me guide the conversation. They want their prescription sooner than later, and I want as much clinical information as possible. We agree that the doctor is the rate-limiting factor and decide that a business day or two is a reasonable timeline to get a hold of them. 

Even though we agreed on the process and the timeline, we still didn’t agree on the dosage. I voiced my concern because it is my responsibility. There were some definitive opportunities to optimize their pain regimen. With a 360 degree treatment plan, I assured the patient it would be possible to manage (not completely eliminate) pain so they would have a good quality of life now and greater longevity in the future.

If this patient wanted to fill his prescription at my pharmacy, he would have to let me be part of the healthcare team. He would have to let me care for him. We shook hands, and I became his pharmacist.

A year and a half later, this patient came by the pharmacy. I hadn’t seen him in a few months, so I assumed he had moved away. 

He flagged me down at the counsel window, and I braced myself for what I thought was going to be some extravagant ordeal. Instead, he extended his hand and said, “Because of you, I made the choice to get off my pain meds. I’ve been narcotic free for 3 months. Thank you for showing that there was a better future.”

Some patients want to be in control of their healthcare and improve quality of life. Some are looking for help and resources to escape addiction and dependence. Others simply need someone to care enough so they can take care of themselves.

Which side of the spectrum do you practice? I’m on the side that saves lives.

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Business Tips from The Corporate PharmD

  • Never lie to patients about your refusal to fill
  • Gather as much information as possible to prevent making a unilateral decision
  • Exercise and defend our corresponding responsibility to treat and protect our patients from harm
  • Create and implement a protocol for conducting clinical reviews for every patient and controlled substance 

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