The Suspicious Pattern at the Counter
A pharmacist notices that a patient has filled prescriptions for a benzodiazepine and an opioid at the pharmacy three times in the past two months, each time from a different prescriber and each time paying cash. The patient's file shows no drug interaction warnings were addressed, and the patient has declined counseling each time. Today the patient presents a new prescription for a higher-strength opioid from a fourth prescriber, again paying cash. The pharmacist checks the state prescription monitoring program and sees the patient has received overlapping supplies from two other pharmacies. The patient is in the lobby and is becoming impatient.
1. What should the pharmacist do before dispensing the new opioid prescription?
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The pharmacist should review the prescription monitoring program data, the patient's profile, and the prescriber information. The overlapping supplies and the pattern of multiple prescribers and cash payments are red flags that warrant verification. The pharmacist should contact the prescriber to confirm the prescription and discuss the patient's other medications, particularly the benzodiazepine and opioid combination. The pharmacist should assess the prescription for legitimacy and consider whether the patient is at risk for misuse or diversion. The pharmacist should not dispense solely because the prescription appears valid on its face. The pharmacist should document the review and the steps taken.
2. The patient declines counseling again. What is the pharmacist's obligation regarding counseling and the interaction risk?
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The pharmacist should make a reasonable effort to counsel the patient about the risks of combining an opioid with a benzodiazepine, including sedation and respiratory depression. If the patient declines, the pharmacist should document the offer and the refusal. The pharmacist should not use the refusal as a reason to skip the safety assessment. The pharmacist should consider providing written information and should document the interaction review. If the pharmacist believes the combination poses an immediate risk, the pharmacist should discuss the concern with the prescriber before dispensing.
3. If the pharmacist decides not to dispense, what should the pharmacist do and what are the limits?
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The pharmacist may decline to dispense if the pharmacist has a legitimate concern about the prescription's validity or the patient's safety, but the pharmacist should not refuse based on a protected characteristic or without a documented professional reason. The pharmacist should explain the concern to the patient, contact the prescriber, and document the decision and the reasons. The pharmacist should follow pharmacy policy and Arkansas requirements on refusing to fill and on reporting suspected diversion or misuse. The pharmacist should not confiscate the prescription or accuse the patient of wrongdoing without a factual basis. The pharmacist should also consider whether a report to the appropriate authority is required or permitted.