Jason Poquette, RPh, is a 1993 graduate of the University of Connecticut School of Pharmacy. For most of his career, he has held retail pharmacy management positions. He also spent 7 years working in health plan formulary analysis and research. He currently works for Pharmacy Healthcare Solutions (PHS) as manager of an outpatient hospital pharmacy, developing programs to improve utilization of the pharmacy and transitional care for patients.
We care for patients who have serious diseases and chronic conditions, but in a sense, we stand between them and their medication.
Such a privilege and responsibility should not be taken lightly. As ethical and compassionate professionals, community pharmacists must use all available resources to help patients in any way that we can.
However, we are often confronted with individuals who want to misuse or divert drugs. I’m not talking about the occasional legitimate request for an early refill. I mean repeated requests, month after month, often from different prescribers and sometimes at different pharmacies. These “patients” may be hurting themselves or others, continuing a pattern of addiction that may eventually lead to overdose and death.
How can a pharmacist differentiate between legitimate and illegitimate early narcotic refill requests? It is not always easy.
One potential red flag is when patients regularly request early refills for narcotic prescriptions. I’m not talking about the occasional situation that could happen to anyone. A simple review of the patient’s history and any notes on the patient should be sufficient to determine whether it is a single unfortunate occurrence or a regular issue.
In the latter case, pharmacists who are repeatedly confronted with early refill requests have a responsibility to say “no.” Doing so will not necessarily eliminate prescription drug abuse, but at least we are doing what we can to slow it down. In my opinion, those who ignore this issue and repeatedly fill narcotics too soon are being careless with their license and the profession’s reputation.
How should pharmacists respond to repeated requests for early refills from “patients” who are clearly not following instructions?
For those new to retail pharmacy, allow me to share with you how I respond:
1) "The doctor wrote it, so I’m supposed to get it."
You’d be surprised how many patients think that as long as the doctor’s office gives it to them early, they can get it filled early, too. A doctor may give the patient the prescription early for many reasons, but that does not mean it should repeatedly be filled early.
I have had doctors get very upset that a pharmacist filled a prescription early, even though the prescription had no note about when it should actually be filled. To avoid this, I will often write the “due to be filled” date on the back of the prescription for their convenience.
2) "It was stolen from my home."
Theft of prescription medications happens. The first time it happens to patients, I explain that it’s their responsibility to do what they can to prevent it from happening again. They should get a lock box and keep the key with them. Also, they should always report such activity to the police and get a written police report.
When I’m confronted with this reason, I usually ask to see the police report and will not fill the prescription early without seeing this and notifying the prescriber.
3) "I was robbed."
This is similar to the second scenario. This is an awful experience and I would never want to add to the suffering that such a patient has already endured. But when this is just one of a series of attempts at obtaining an early refill, I again insist on seeing the police report and notifying the prescriber.
4) "Someone else picked up my meds and took them."
State laws vary on who can actually pick up a controlled substance prescription for someone else. Virtually all states require the person to show a valid photo ID. If it is discovered that someone picked up the prescription who should not have, then this merits a call to the police. Also, such a patient should have their profile flagged, so no one else can pick up their medications in the future.
5) "I’m traveling out of state."
People travel. It is just a part of life. But if traveling is becoming a routine reason to get an early refill, then we must remind the patient that getting it filled early one month should mean that it can be filled later the next month.
The pharmacist can also check the laws in the state where the patient is traveling. Perhaps the patient can fill the prescription there at the appropriate time, rather than filling it early here.
6) "The pharmacy miscounted the day’s supply."
I have personally seen a situation where another pharmacy incorrectly entered a prescription as a 30-day supply that should have really been 15. Mistakes happen, but there is a simple way to address this, and that is by calling the other pharmacy. Once the problem is discovered, the pharmacy can correct the previous claim and thereby fix it.
7) "The insurance allows it 5 days early."
Most insurance companies allow a patient to get a 30-day supply about 5 days (give or take) early, but it is surprising how many patients think this means that they are allowed to use up the medication 5 days early. Again, the pharmacist is looking for patterns of early refill requests and needs to address any situation in which it appears that the medication is not being used as directed.
We allow a controlled substance to be filled 2 days early, and that’s it. The only exceptions are for legitimate purposes and occasional situations.
8) "I’ll just pay cash."
Some patients wrongly believe that our issue with their repeated early refill requests is just an insurance concern, so offering to pay for it with cash eliminates the problem. The real problem is the potential misuse or diversion of medication that may be going on.
Additionally, some state Medicaid plans do not allow pharmacies to accept “cash” payment as a means to avoid billing the insurance. Whatever the case, I just tell patients that the issue is not really insurance, but rather compliance with written directions.
9) "The other pharmacist allows it."
Sadly, there are pharmacists who just find it easier to look the other way. Rather than confronting a patient or prescriber about the issue, they just fill it and let it go.
My advice? Don’t be that pharmacist.
10) "This is for my leg pain."
I have had patients present separate overlapping, short-acting narcotic prescriptions from different doctors, claiming that one is treating their back and the other is treating their leg. That may be true, but the pharmacist should introduce these 2 doctors and get them to come up with a pain plan together.
Without going into the pharmacology, we need to let patients know that their drugs don’t quite work that way, so they are going to have to use just 1 doctor for their pain.
11) "The other one didn’t work, so I flushed it."
This might be reasonable as a one-time occurrence, but flushing is not a recommended disposal approach, except for fentanyl. Nevertheless, when this statement is part of a history of early refill requests, it is quite suspicious because it cannot be proved. I would make sure that every prescriber involved is informed before filling it.
12) "You shorted me pills."
Many patients don’t realize just how tightly controlled and carefully counted our narcotic inventory is. Most pharmacies triple count all narcotic prescriptions, so shorting pills is highly unlikely.
13) “I lost them, dropped them, forgot them at a friend’s house, dog ate them, washed them...”
Some patients come up with a new reason every month for why their controlled substance prescription needs to be filled early. Pharmacists who actually care about these patients learn to respond to these repeated requests with firm yet compassionate denials.
The fact is that it is often these patients who need the most help. They may not be happy about their addiction or the lifestyle they have chosen, but we can show concern without contributing to their problem.
Nothing in this article should be construed as an attack on patients who legitimately need their controlled substance prescriptions and occasionally run into situations where they need to be filled early. Pharmacists are here to help these patients, and we do everything we can within the boundaries of the law to get them the medication they need.