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View Full Version : When Can Controlled Substances Be Refilled Early?



jill
09-23-2011, 08:07 PM
James L. Lindon, PharmD, PhD, JD
Posted: 09/23/2011

This isn't my question, it's a pretty realistic article by a pharmacist and now attorney.

Question

When can a pharmacist legally refill a controlled substance prescription early?
http://img.medscape.com/person/lindon_james.jpg Response from James L. Lindon, PharmD, PhD, JD
Director, Pharmacy Law and Intellectual Property, Lindon & Lindon, LLC One of the more uncomfortable situations a pharmacist and patient can face is when a patient requests a refill of a prescription for a controlled substance sooner than when records indicate that the patient should be out of medication. The patient may state that the medication was lost or stolen, that the patient will be out of town on vacation when the prescription is due for a refill, or that the prescriber told the patient to take more medication without providing a new prescription to the pharmacy. Whatever the reason for the request, controlled substances always present the possibility of abuse.

Anytime when a pharmacist dispenses medication, particularly controlled substances, the pharmacist must be vigilant to ensure that it is for a "legitimate medical purpose." Although pharmacists need to be vigilant, there can be a thin line between professional diligence and paranoia. A pharmacist's ability to be a pharmacist is judged on whether the law believes that medication dispensed by the pharmacist is for a legitimate medical purpose.

Prescription drug abuse has come under greater focus from law enforcement. The 2008 National Survey on Drug Use and Health reported that an estimated 4.7 million Americans over 12 years of age had used prescription pain relievers in the past month. Of the approximately 68,000 survey respondents who admitted to nonmedical use of prescription pain relievers in the previous 12 months, 5.4% reported obtaining the drugs from a friend or relative without asking.[1]

According to the Drug Enforcement Administration (DEA) Pharmacist's Manual, pharmacists are responsible for protecting themselves against drug diversion.[2] The DEA Code of Federal Regulations Section 1306.04 states that "the responsibility for the proper prescribing and dispensing of controlled substances is upon the prescribing practitioner, but a corresponding responsibility rests with the pharmacist who fills the prescription.[3]" This regulation also indicates that a person knowingly filling a prescription for illegitimate use "shall be subject to the penalties provided for violations of the provisions of law relating to controlled substances.[3]"

Further, pharmacists are held accountable by state licensing boards that can conduct pharmacy inspections and audit prescription records. Penalties for infractions may include fine, probation, and loss of pharmacy license. To guard against these penalties, pharmacists must be aware of the tactics used to divert prescription drugs.

Patient Internet blogs include postings by patients who state that they feel like criminals when they discuss use of controlled substances with their pharmacists. Patients describe feeling violated when asked, "Why do you want to fill this prescription earlier than you should be filling it?" They don't understand the reason for a pharmacist being "rude" or "prying."

State boards of pharmacy are on record disapproving of providing early refills in some cases. In November 2008, a North Carolina pharmacy technician was noted as having improperly provided early refills of the controlled drug alprazolam without authorization by the prescriber.[4] In January 2006, a pharmacist cited a "stressful environment and dealing with customers who were requesting early refills on their prescriptions" as mitigating factors for lapsing into substance abuse as noted in meeting minutes of the Tennessee Board of Pharmacy.[5] In October 2006, a pharmacist was accused of providing early refills in North Carolina, according to a Consent Order settling the matter. Among the findings was that the pharmacist filled a prescription for hydrocodone 4 days early and another prescription for hydrocodone 6 days early. The pharmacist was also accused of dispensing excessive amounts of controlled substances. The pharmacist was publicly reprimanded.[6] A pharmacy in North Carolina was accused of dispensing the muscle relaxant carisoprodol "sooner than permitted" on several occasions in 2008 and was publicly reprimanded.[7]

The point is that Boards of Pharmacy are watching.

Whether any given instance might be considered "too soon" would probably have to take into account all the circumstances. For example, an elderly patient with a long history of severe pain from several surgeries who relied on a relative for transportation to the pharmacy would probably be permitted to have an early refill 3 days early. However, a young patient with a minor ankle sprain with a history of having several early refills might not convince that same pharmacist to give a refill 3 days early. Is that fair? Pharmacists have been forced to make judgment calls and be prepared to answer in court -- and they are going to make judgment calls. They will be inconsistent.

Dilauday
09-25-2011, 03:24 PM
Thanks for posting this article Jill, it's interesting to hear from the 'other' side and to get some insight into how pharmacists look at this.

It really has a lot to do with the individual and their history, some young kid who has continually "lost" their meds is deffinately gonna get treated different than some old with a solid history of chronic pain. Having someone on your side, a pharmacist and/or doctor can make all the difference. As well just because a pharmacist doesn't give you meds 5 days ahead of schedule doesn't mean he isn't a nice person or isn't truly doing everything he can for you, is sympathetic to your cause etc. Some people are just really assholes and abuse their power.

It is amazing someones how situations like this are actually up to the pharmacists (individual) disgression. Obviously sometimes even the nicest pharmacist cannot help someone else, when the situation is going to get them in trouble no matter how it is explained. Many times, however, when a pharmacist says they cannot help you due to policy etc, they actually could but just choose not to.

I've experienced this a few times myself, where I was off by one day as in on the 28th day itself and not the following day making a full 28 days, and had some kind of bitchy pharmacists just become really rude saying they cannot help me. When on a few other occasions I was helped by the head pharmacist himself who is a really nice guy, saying oh well are you pretty much out, or well are you in need right now? and has filled them right then and there within 10 minutes, just truly sympathetic and genuine. Explaining that because I haven't gotten any exceptions on my perscription that is the reason why there is an issue, but that he will still help me out. Showing how much it really depends on how the pharmacist feels about the situation and if he feels that it is a true need. Again though, even with the old lady who has been on meds for over 30 years, you still get some cranky and anal pharmacists who will just NOT make an exception, for anyone. Obviously I wouldn't want to see anyone get in trouble and understand the reasoning.

Regardless if you have a nice dr or pharmacist you still do not want to "lose" your misplace or have your perscription stolen, for when it actually happens you might have already screwed the pooch. Most people never do or might once or twice in their life, if you lose it once, most people would make sure it doesn't happen again, honesty is the best policy, especially with yourself, and if it is getting out of hand you need to take a step back, if you have a real reason for needing these meds and understand how these type of things are looked at in our society, you have to still be careful and play your cards right.

Anyway, thanks for posting Jill it's good info :)

OpiatedChronically
09-28-2011, 10:34 PM
Very interesting indeed. It's funny, because my monthly PM appt almost always on the 26 - 28th day after my last refill, and sometimes my appts are on the 30th day after, so most of the time I SHOULD have a surplus of at least 2 - 4 days worth on the days that my appts are scheduled.

Walgreens has never given me any trouble. I take in my script and they happily give me my meds along with a "have a great day sir!" I think, and I may be wrong, that in my state as long as you have a hard copy script they will have to fill it. I don't get actual "refills" per say, I go see my doc, we talk for a while, he gives me my script and I leave.

On one occasion, my appt was scheduled 6 days before my 30 day script period was over, and my insurance STILL covered it except for my $35 co-pay of course.

Do different states have different laws about this?

jill
09-28-2011, 11:02 PM
Yes, the laws regarding "refills" (no such thing on a CSII Rx), are different in many states. My state as no limit on "early" refils (I usually fill about 6 days before all my Rxs run out), every month.

States like NY, have a total number of days early for the year that a script can be filled, say it's 5 days. If you fill early 3 days once, then you only 2 days left to fill "early" for the year. Once all those days are gone it reverts to the standard, like 30 days.

chillbreh
09-29-2011, 07:27 AM
good ol' south carolina has a 30 day manditory waiting in between controlled substance refills...it sucks making my xanax last 30 fuckin days taking "as perscribed"....well its better then no xanax at all !!!!

upstate_007
09-29-2011, 07:57 AM
I don't give a fuck how they feel.

Fill my prescription, shut the fuck up and leave me alone.

Power tripping assholes. Pissed off that you went to school for years and years and are now stuck inside a grocery store filling meds? Fuck you, do your job like the trained monkey you are.

norseman
09-29-2011, 08:16 AM
Up here in Canada I don't think there is any mandatory waiting period. It may be that all provinces are different. But it seems in my province it is up to the discretion of the pharmacist.

The only controlled substances that I get refills on are methadone and kpin and that is at the clinic, so they are really strict compared to other pharmacies. But I do know a few folks that have CP and it seems they have no problem refilling even a week early sometimes on things like fent and dilly, but funny enough Ontario is really strict with Oxy now and don't refill early at all on them???? I guess the wannabe Dr's/pharmacists that sit in Parliament think Oxy is like synthetic heroin or sumfing.

maycausedrowsiness
09-29-2011, 03:27 PM
My main doctor writes me scripts for #120 oxycodone 30mg and will most of the time tell me to come in again after 3 weeks, but many MANY times I have walked in there after 2 weeks and come out with an rx…

I go to a cool pharmacy and my pharmacist knows me by name and he will fill pretty much anything for me as long as I have a script and its been at least 14 days, anything under that I havent really tried but I have friends who have filled at the same pharmacy after only 10 days but I dont want to press my luck.

Sometimes I use my insurance to pay for the RX, and sometimes I pay cash, depending on certain factors.. But the rule of thumb for my pharmacist seems to be that if he runs the script through my insurance and they are willing to pay for it, he is willing to fill it for me, whether or not I actually decide to go through with paying with insurance or with cash.

I know alot of people say you cant fill a script until its been 28 days or whatever, but i know it is possible, and if my doc is writing the script, I dont see how I could get in trouble. My pain meds are for pain AS NEEDED, so sometimes I run out early, sometimes i (hypothetically) will fill when its been over a month, but rarely.

I dont feel as though I am breaking the law and it doesnt help to have a great relationship with your doctor and your pharmacist.

Cheers

reddragon3668
09-29-2011, 04:25 PM
That was an interesting article. Jill, you are a pharmacist, right? I usually get all my meds filled around the 28/29 day mark. I've never had any trouble, but I always go to a M&P pharmacy; the same one every time. I know most chain pharmacies wouldn't do that for C2 meds. However, my insurance doesn't hiccup at 28 days, and you would think that they wouldn't pay for anything if they had an out to not do so. The state board would never reprimand my pharmacist for filling my insulin medicine on day 28. I feel like its a matter of being villigant so as to proctect oneself from ever running out on any medicine that I take. In doctor's offices, you are always encouraged to get refills before you absolutely need them so you don't find yourself with out them. Any thing can happen, so its prudent in my opinion to get them done a day or so early. Is there any problem/potential problem with doing this every 28 days. I've done it for years in NC and I've never had a problem thus far. However, I certainly do not want to get my doctor or my pharmacist in trouble. What's one more day, or two for that matter, in the grand scheme of things?

jill
09-29-2011, 09:09 PM
I know alot of people say you cant fill a script until its been 28 days or whatever, but i know it is possible, and if my doc is writing the script, I dont see how I could get in trouble. My pain meds are for pain AS NEEDED, so sometimes I run out early, sometimes i (hypothetically) will fill when its been over a month, but rarely.

This is an inaccurate statement as each state has there own laws, obviously some states are the same or similar. I gave an example of one above. Obviosly the states you have filled in have rather lenient laws, as well as perhaps lenient pharmacists.

--- auto merge ---

Right, Red, it really comes down to what state you live in first, and then the leniency that the pharmacist feels. Many have been burned and are forever cautious. Or give a deposition once and appear in court and people have a different perspective on what they will do to risk their license.

I consistently fill my CSIIs at a chain pharmacy, 5-7 days before I run out. I don't like last minute surprises.

But for those that are in states such as NY, the laws are more stringent.

upstate_007
09-30-2011, 07:30 AM
In doctor's offices, you are always encouraged to get refills before you absolutely need them so you don't find yourself with out them. Any thing can happen, so its prudent in my opinion to get them done a day or so early. Is there any problem/potential problem with doing this every 28 days. I've done it for years in NC and I've never had a problem thus far. However, I certainly do not want to get my doctor or my pharmacist in trouble. What's one more day, or two for that matter, in the grand scheme of things?

I wish my doc were like that.

They write a script for 30 days of medicine. I can not get the next script filled until day 31. I have enough for all 30 days (or should have enough). Then have to try and get it filled as early as I can the next day. It fucking sucks. With my work schedule I have to wake up at 4am if I want to get it. Otherwise I have to go all day till about 7pm till I can get them. Fucking bullshit. I have complained about it numerous times and they wont budge.

jill
09-30-2011, 08:01 AM
Yeah, that sucks, Upstate, your state law is a tough one and people have probably been burned on it many times.

I can say I have never been to court for anything pharmacy related, but have been many times for nursing BS. However, my state is more lenient on prescribing laws.

I'm sorry you're having an especially tough time right now, too.

reddragon3668
09-30-2011, 08:33 AM
Wow, that really does suck. So, they do that because of the state law or is it the doctor or pharmacist? I doubt it would be the latter because you could just go to another pharmacy. No matter what though, that is fucked up. I bet they wouldn't do that to me over insulin. Its like they treat CP as a sub-standard problem... so, if I run out of pain meds and have to wake up hurting like a dog and get out at 4am to get a script filled so I can function on day 31, who gives a shit? In my area, you'd have to drive 50 miles to find a pharmacy open 24 hours. So, you'd be stuck until 9am no matter what. That is just plain wrong. I hope you can find another doctor, and if its the state laws that require this stuff, find another state. You can pack up the wife and kiddies and come hang with the Dragon family. You just have to share your drugs. ;)) Hang in there bro!


I wish my doc were like that.

They write a script for 30 days of medicine. I can not get the next script filled until day 31. I have enough for all 30 days (or should have enough). Then have to try and get it filled as early as I can the next day. It fucking sucks. With my work schedule I have to wake up at 4am if I want to get it. Otherwise I have to go all day till about 7pm till I can get them. Fucking bullshit. I have complained about it numerous times and they wont budge.

jill
09-30-2011, 08:37 AM
^ Red, no, of course, they wouldn't do that to you over insulin, BP med or anything non CSII, and yes, NY has stringent CS laws.

You may have to pay cash if it's too early for a refill and a bottle broke or something like that though. (Don't know if you have insurance).


Also, remember, Everyone, this guy is writing from the point of an attorney now, not really a pharmacist.. So he is sharing "ideal", perfect practice theories, thoughts related to law.

upstate_007
09-30-2011, 10:38 AM
Thanks Red and Jill.

The state laws here in NY are pretty strict, but this particular policy is one (my now former!!) doc made up. No matter how many times I tried to reason with them they would not budge. So, yes, I ended up driving 45 minutes each way to a 24 hour pharm at 4AM so that I would not have to go all day without meds. It was downright cruel for them to do that.

I am ok with having to wait till day 30 to fill. Even though I was usually short by then, but that is my own fault. But that 31 day thing is insane.

As Jill said, here in NY you have a 7 day grace period over the life of the script. Unless the script changes, you are bound to that 7 day rule. One way around it I found was to fill out of state once in a while. With no record of having filled it totally fucks up their 7 day plan. Since I am about an hour from the state border it is not a huge hardship.

Pdotizzle
10-03-2011, 10:51 AM
By me in LI / NY...the Dr. can write it for up to 5 days prior to it being a month...and the pharmacy could fill it...but not more than 5 days.

jill
10-03-2011, 11:19 AM
By me in LI / NY...the Dr. can write it for up to 5 days prior to it being a month...and the pharmacy could fill it...but not more than 5 days.

Right, but 5 days is for the total life of the Rx. Are you talking about non CS's too? (I don't have a NY license, so I am not 100% on all the details, I just have friends that work there and know from them, the general rules).

upstate_007
10-03-2011, 12:05 PM
I believe some pharmacists here in NY also use their own discretion.

With a long term percocet script I had at one point I filled up to 3-6 days early every single month at a particular place. Never asked a question, always filled it with no issue. If I tried the same thing at another place (same chain) they would not budge. Too bad the first location closed down.

jill
10-03-2011, 12:24 PM
I believe some pharmacists here in NY also use their own discretion.

With a long term percocet script I had at one point I filled up to 3-6 days early every single month at a particular place. Never asked a question, always filled it with no issue. If I tried the same thing at another place (same chain) they would not budge. Too bad the first location closed down.

Yes, I have no doubt on that. The laws for CSII's there are so strict that it leaves little room for discretion, but I know several pharmacists (personally) that do use their discretion on a lot of matters because of pain management education I have done with them. Some are at chains and 1 or 2 are at mom n pops.

I hope someone is getting them instead of some of the asswipes I hear about!

Import
10-03-2011, 12:35 PM
"[4] In January 2006, a pharmacist cited a "stressful environment and dealing with customers who were requesting early refills on their prescriptions" as mitigating factors for lapsing into substance abuse as noted in meeting minutes of the Tennessee Board of Pharmacy."

I liked the article, but this is a load of shit! People will grab onto anything as an excuse of why they are a drug addict... A stressful work environment and people needing to fill their scripts early doesn't cause drug addiction. I shouldn't judge this person without knowing them, but this just made me roll my eyes.

Anyways, thanks for sharing the article Jill. It doesn't really affect me, although I am prescribed a CII. It's amphetamine though, so I don't have to worry about any REAL w/d if I have to go without. Point is, I just thought it was interesting!