In the early 1980s I was working relief a day every week in a small town in western Kentucky. I would occasionally get HCTZ and Lopressor prescriptions from a prescriber. The name on the top of the Rx blank stated “Dr.John Smith.” There was no designation after the name, so I filled these several times before I was made aware that the prescriber was a dentist. The techs where I was working said the dentist “helped out” the local docs by treating hypertension when he saw it in his office.
These prescriptions were illegal in that they were outside the scope of practice of the prescriber. Dentists are not trained to diagnose or treat hypertension. And pharmacists who fill the prescriptions can get into a LOT of trouble. (see below)
There are two basic types of illegal prescriptions.
The first is the forged, altered or unlawfully possessed prescription. KRS 217.214 addresses this in Kentucky. When a pharmacist has a reasonable suspicion that a presented prescription is forged, altered or unlawfully possessed, the pharmacist MAY retain the prescription. I capitalized “MAY” because the pharmacist makes the decision whether or not to seize and retain. The main consideration here is the pharmacist’s safety—if retaining may compromise safety, the pharmacist can return the prescription to the customer. First and foremost, keep yourself safe in these situations. (in an extreme case, if you feel that not filling an obviously forged Rx would endanger you, fill it. As long as you don’t have a handful of these Rxs in your files, the Board is unlikely to sanction your action)
Let us take a moment and define “reasonable.” If another pharmacist with similar education, skills, and experience would consider the likelihood of forgery or alteration to the same degree you do, you are acting reasonably. Another way to look at it is to view it under the legal phrase “more likely than not.” If you believe—not 100% but at least 51%–that more likely than not that an Rx is forged, you may seize and retain. Seizing and retaining under reasonable circumstances and belief cannot result in liability, even if it turns out the Rx was legitimate.
The second type of illegal prescription is the inappropriately prescribed medication. The scenario at the beginning of this blog is a perfect example. Here are some more provided to me by Kentucky Drug Control:
-A dentist prescribing large prescriptions of narcotics for his mother (he was taking them)
–An APRN prescribing alprazolam with multiple refills (pharmacists fill these scripts all the time, uggh)
– An APRN without a CAPA-CS (left practice,they terminated her CAPA-CS, she kept writing controls)
-A doctor prescribing himself Ambien
-A PA calling himself in Ambien under doctor’s name
-A dentist requiring patients bring in their controlled substance prescriptions for him to keep and dispense as needed from office (he is in prison)
-Several cases of providers calling in medication for “patients” and picking it up themselves for “some reason” HUGE RED FLAG
-Lots of cookie cutter prescribing or “no-exam” Don’t be afraid to ask the patient if anyone took medical history/performed medical exam and what their diagnosis is!
-OB/GYN prescribing to men
-A pediatrician prescribing to ADD meds to adults
-A psychiatrist prescribing Lortab/alprazolam/carisoprodol combinations
-Stolen blanks from an orthopedists in L-ville and pharmacists keep filling the month of Xanax 2 mg rx they wrote, no questions asked- RED FLAG!!!
-Lots of cases where the provider fails to KASPER patient prior to prescribing controlled substance
100s of promethazine w/cod scripts (>300ml) from docs states away for made up patients and person picking up lives in another state – all forgeries and Rph fill them all the time
Let me add anorexiant prescriptions where the patient does not meet the manufacturer or legal BMI requirement. (In my previous blog on Controlled Substance issues, I already touched on postdated CS Rxs)
When a prescriber writes an inappropriate prescription, too many of us ignore this and fill it. What I thought was a problem of the past is quite prevalent today, and these Rxs lead to a number of lawsuits every year.
What the pharmacist should do is two things: 1) retain the prescription or return it to the patient after writing on the face of the blank the reason that the prescription is inappropriate, then contact the prescriber and explain; and 2)if the prescriber persists in writing these Rxs, report the prescriber to the appropriate administrative board and/or Drug Control.
If problems arise from these prescriptions being filled, the pharmacist should expect the punishment from the Board to be of greater degree than for a misfill or other error emanating from a legitimate prescription. Is a jury or the Board going to just look askance because the prescription was inappropriate and illegal? Hardly. Under the doctrine of corresponding responsibility, if not already established as a principal duty, a pharmacist should know the prescriber at the very least well enough to determine the legitimacy of the prescription written. What kind of prescriber? What is the scope of practice? Does this Rx fit within that scope? are the questions you must ask.
One of the many dangers here is that malpractice insurance does not cover “criminal acts” and insurers consider filling illegal prescriptions a criminal act. So, if you fill digoxin for a patient with CHF and the prescription comes from a dentist, and then the patient suffers harm from the drug, the award or settlement to the patient (or family) from the ensuing lawsuit will come from the wallet in your back pocket.
But a lawsuit may not be your biggest worry. The Board of Pharmacy can sanction you for the harm to the patient under KRS 315.121. The Board has the right to revoke your license for life and they have shown that they are not afraid to use this right. And it does not stop there. The Board can provide evidence of filling an illegal prescription to the state attorney general’s office. Since filling an illegal prescription is considered to be a criminal act in itself, you can then be prosecuted by the AG.
Prescribers writing inappropriate/illegal prescriptions is more prevalent today than most of us think. As pharmacists, we need to be aware of the ability of a prescriber and what he/she can actually legally prescribe. The consequences of failing to do this can be devastating to a career.