PDMP Check and Suspicious Prescription for Opioids
A pharmacist in Wasilla receives a prescription for oxycodone 15 mg, #90, from a prescriber 200 miles away. The patient is a 25-year-old male who appears drowsy and has pinpoint pupils. The pharmacist checks the Alaska PDMP and sees that the patient has received three opioid prescriptions from three different prescribers in the past month, totaling 300 tablets. The pharmacist also sees that the patient filled a prescription for alprazolam two days ago. The prescriber's office is closed for the day. The pharmacist is concerned about potential abuse but also wants to help the patient's pain. The pharmacist knows Alaska has a mandatory PDMP check requirement for opioid prescriptions.
1. What are the pharmacist's obligations regarding the PDMP check and dispensing this prescription? Discuss the red flags and the pharmacist's corresponding responsibility.
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Alaska law (12 AAC 52.240) requires pharmacists to check the PDMP before dispensing an opioid prescription. The pharmacist did so and found multiple red flags: multiple prescribers, high total opioid quantity, concurrent benzodiazepine, and the patient's appearance suggesting impairment. Under federal law (21 CFR 1306.04), the pharmacist has a corresponding responsibility to ensure the prescription is for a legitimate medical purpose. The pharmacist cannot dispense if there is a red flag that cannot be resolved. The pharmacist should attempt to contact the prescriber, but the office is closed. The pharmacist should not dispense until the concerns are resolved. The pharmacist could refuse to fill and explain to the patient, or if the patient is in immediate need, refer to an emergency department. The pharmacist should document the PDMP check and the decision. Dispensing despite red flags could lead to DEA and board action. The pharmacist may also provide information about naloxone and addiction resources.
2. If the pharmacist decides to refuse to fill the prescription, what are the legal and ethical considerations? What should the pharmacist document?
Read the worked answer
The pharmacist has the right to refuse to fill a prescription if they believe it is not for a legitimate medical purpose. However, the pharmacist must not abandon the patient. The pharmacist should explain the reason for refusal, offer to contact the prescriber when available, and provide resources for pain management or addiction treatment. The pharmacist should document the PDMP findings, the red flags observed, the attempts to contact the prescriber, and the refusal. Documentation should be objective and factual. The pharmacist should also consider whether to report the prescriber to the board if there is a pattern of inappropriate prescribing. Ethically, the pharmacist must balance patient care with preventing diversion. The pharmacist should not accuse the patient but express concern. If the patient becomes aggressive, the pharmacist should ensure safety. The refusal should be communicated professionally.