James L. Lindon, PharmD, PhD, JD
This isn't my question, it's a pretty realistic article by a pharmacist and now attorney.
When can a pharmacist legally refill a controlled substance prescription early?
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.
According to the Drug Enforcement Administration (DEA) Pharmacist's Manual, pharmacists are responsible for protecting themselves against drug diversion. 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." 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."
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. 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. 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. 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.
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.