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How to ID an addict - (10/30/2018)

By Dr. Ron Gasbarro 

The pharmacist looked up just when he was coming through the pharmacy door. It’s "Mr. Early Refill.” Always an excuse as to why he needs an early refill on his pain medication. “I left them in Florida.” “My cousin stole them.” “They fell into the toilet.” Narcotics are dispensed according to how the doctor prescribes them. For example, 120 pills for 30 days. No more, no less. Insurance companies balk at paying for what should have been a 30-days supply at Day 22. 

“Oh, wait! You’ll pay cash for them?” Paying cash to circumvent the patient’s insurance is a sure sign that the patient has an addiction problem. Some patients erroneously believe that the issue with repeated early refill requests is just an insurance concern, so offering to pay for it with cash eliminates the crisis. The real problem is the potential misuse or diversion of medication. Also, some Medicaid plans do not allow pharmacies to accept “cash” payment as a means to avoid billing the insurance. Whatever the case, the patients are told that the issue is not insurance, but rather adherence to written directions. 

Then, there is the person who insists that the pharmacist shorted him some pills. “The doctor wrote for 100 pills. But I only received 88!” Many patients do not realize just how tightly controlled and carefully counted a narcotic inventory is. Most pharmacies triple count all narcotic prescriptions, so shorting pills is highly unlikely. A visit to the narcotics log will confirm that 100 pills were dispensed at the time and there was no excess of the “missing” 12 pills in the inventory. 

"The other pharmacist lets me have early refills. Will she be in tomorrow?” Surprisingly, there are pharmacists who simply find it easier to look the other way. Instead of confronting a patient or prescriber about the issue, they just fill it and let it go. The pharmacist’s partner has a bad habit of giving early refills. She is jeopardizing her pharmacy license and possibly the reputation of the store. 

“Do you have the Watson brand of Vicodin? That is the only brand that works for me. You know, the yellow ones.” Take note if the patient asks for a certain controlled substance by color, trade name, or based on specific pill markings. Question the prescriber if a patient presents a prescription for a large quantity of an opioid or multiple prescriptions for controlled substances. Pharmacists should be cautious if a patient comes in with prescriptions for two or more long-acting opioids and/or two or more short-acting opiates. Again, a private call to the prescriber should give the pharmacist more information, which he should note on the back of the prescription if he decides to fill the prescriptions.

New patients, patients from out of state, or patients who have driven 50 miles to get controlled substances filled are red flags. These people need help whether they are addicted or whether they are selling pills to other addicts, which is illegal. The pharmacist should not judge these people but should show concern without adding to their problem. If the patient gets surly, then the pharmacist knows to physically separate himself from the patient. That person may be desperate and saying “no” will not please him. Violence could ensue. The pharmacist emphasizes that patients who legitimately need their controlled substance prescriptions are not under attack. Accidents and mistakes do happen. One can leave their sleeping pills in Florida! Pharmacists are here to help these patients and do everything within the legal boundaries to get them the medication they need.

Ron Gasbarro, PharmD, is a registered pharmacist, medical writer, and principal at Rx-Press.com. Read more at www.rx-press.com


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