Rx Red Flags: A Community Pharmacist's Perspective

OCTOBER 25, 2015
Community pharmacists are called upon to perform an increasing number of daily duties. Not only do we have technical functions that seem to grow in number at least weekly, but we are also tasked with assuring appropriateness of therapy with each and every prescription that crosses our bench.
This clinical judgment seems to come up more and more these days with regards to high-dose opiate treatment. 
We have all heard the term “red flags” and have our own understanding of what they are. Each store has its own internal policies regarding opiate prescriptions; however, they all include some level of pharmacist due diligence. 
This process of due diligence may include looking up the patient on the state’s prescription drug monitoring program (PDMP), calling the patient’s physician, reviewing or implementing a pain contract with the patient, or one of many other specifics.
Quite often, one red flag on a prescription will wave in front of us, but based on our due diligence, it may be overridden. As the number of red flags increases, pharmacists’ concern over the situation deepens.
When 4 red flags all wave at once, as it happened in my pharmacy the other day, the prescription comes to a screeching halt until appropriate due diligence is confirmed. 
Here are the 4 red flags we observed upon the patient handing the prescription over to the pharmacist:
1. Store closes in 5 minutes.
2. Patient does not want insurance billed.
3. We haven’t seen this patient in our store for more than 7 months.
4. Prescription is for a high-dose opiate.

In a respectful manner, we explained that we would not be able to fill this prescription this evening because we needed to speak with the physician first. The patient had the opportunity to take the prescription to another pharmacy, but he understood that it would be the same situation.
If this had been an emergency and the patient was in pain with no medications, then we would have referred the patient to the local emergency room for acute care. But that was not the case, and he reluctantly agreed to come back the next morning.
First thing the next morning, we ran a PDMP report and discovered that this patient had been receiving the same medication from the same pharmacy and physician on a regularly increasing basis for the past 6 months. This time, however, he was 2 weeks early.
I called the previous pharmacy and a staff member stated that he had been in their store last night, as well, but he left once he heard that they needed to contact his physician.
I proceeded to contact the patient’s physician, who thanked us for calling and stated that in order to maintain the patient’s pain contract, he needed to pick up the hard-copy prescription and proceed back to the pharmacy he had previously been using. The physician said she would contact the other pharmacy and explain the situation.
Red flags are meant to catch a community pharmacist’s attention. The flags themselves do not dictate our practice, but they do show us where we should begin our due diligence.

Steve Leuck, PharmD
Steve Leuck, PharmD
Steve Leuck, PharmD, has been practicing both hospital and community pharmacy for over 30 years. He founded AudibleRx, in 2011, which provides Consumer Medication Information which is both Useful and Accessible. Content designed to meet health literacy guidelines. Format designed to "read along" with the audio presentation in a simple to use web application. More information at AudibleRx.org.