I took my first look at the prescription and the red alert siren from Star Trek started blaring inside my head. Not the handwriting for that doc, not instructions that were anywhere near normal for that opioid, and the patient—sweating profusely despite the cool air– was standing there watching me intently.

“I need to clarify the prescription with the doctor,” I told him.

“Wh-what’s wrong?”
“Just a problem a quick call will resolve,” I reassured him.

(Never, never tell someone what is wrong with a forged prescription. This just educates the person on how to do better next time.)

As soon as I had the doctor’s office on the line, he turned and ran out of the store.

What do you do when faced with a forged prescription, or a prescription that has been altered, or a prescription that is unlawfully possessed?

(A forged prescription is one that has been called in/created/written on a stolen pad by a non-prescriber. For example, this recent spate of phoned-in prometh with codeine prescriptions. An altered prescription is a legitimate prescription that has been changed in some manner to obtain the presenter with more pills, stronger pills, more refills than were intended by the legitimate prescriber. For example, I once had an Rx for Fiorinal w/ Codeine #12—the patient turned the 1 to a 4 and marked the Rx for 3 refills—the prescriber had made no notation at all on the refill line. An unlawfully possessed prescription is usually a legitimate prescription being presented by someone who should not have had possession. An unlawfully possessed Rx may be a legit Rx for pain that was stolen from the patient.)

Initially, how sure are you that the Rx is forged or altered? Most states have created regulations that provide protection against liability for a wrongful accusation if the pharmacist is reasonably sure that the Rx is not wholly legitimate. “Reasonably sure” is defined as “more likely than not.” So, if you are 50.1% sure that the Rx is forged, you may act without fear of liability.

For some pharmacists, the quick way out is to state that ”we are out of this” and hand the Rx back. This is an acceptable response sometimes, but not always. What this does is simply hand the problem over to a colleague at the next pharmacy down the street. See next paragraph; but if there is no reasonable danger to the pharmacy staff, do not pass along this problem.

The first thing to do, once a reasonable suspicion is aroused, is assess the safety of the pharmacist and other pharmacy personnel before making a decision to seize and retain the prescription. Is the person presenting the prescription also presenting some sort of attitude, demeanor, or even blatantly threatening the staff? Whether or not to act depends on the probability/possibility that confronting the presenter would create peril. If only an iota of such seems likely, then do what is necessary for the safety of the personnel.

One question that arises occasionally: what if refusing to fill the forged Rx creates a danger to pharmacy staff? The answer is, if this danger is reasonable, fill the Rx. Safety first. Follow up by documenting on the Rx why you filled a forgery and then call the police. Boards of pharmacy are unlikely to punish you for doing this. Of course, this should be a one-time occurrence. However, if you have a stack of forgeries you filled because you thought there was a danger in not filling, expect to have a long talk with the Board about staffing and security, as well as punishment.

Reasonable suspicion? Yes. Safe? Yes. Now is the time to decide to seize and retain the prescription or just hand it back to the “patient.” Most states still make this the pharmacist’s decision. So up to this point everything is permissible.
But once the decision to seize is made, everything goes from being “permissible” to “shall” or “must.” Different states look at this is varying ways, but they are very similar.

Now that the seizure of the Rx has been accomplished, the pharmacist needs to determine lack of or legitimacy (not where the forgery or alteration is obvious and blatant—however, again, any iota of doubt needs to be confirmed). Legitimacy should be determined in a reasonable amount of time. If during office hours, this should usually be within a couple of hours. After hours, a few hours to find and confirm with the prescriber. If after hours and the prescriber is unavailable, the next day is not unreasonable. A question that arises: if the prescriber cannot be contacted within a reasonable time, can the patient demand the Rx be given back? If there is some doubt as to legitimacy—the forgery is not obvious and blatant, the answer is “Yes, the patient has the right to get his/her Rx returned.”

(Another question that arises regularly: if you return the Rx to the patient, can you write something on the face of the Rx blank? This is tricky. Facts are OK, opinions are not. For example, you refuse to fill a pain Rx because it is 10 days early. It is fine to write the date and “10 days early” on the Rx. But with suspected forgeries, be more careful. If a note from you arouses a suspicion of forgery from another pharmacist where it would not have arisen otherwise, your protection from liability may be lost.)

Once it is determined that the Rx is forged, altered, or unlawfully possessed, most states now require the authorities be alerted. This was voluntary for years, until the late 1990s-early 2000s when many chains told their pharmacists to just turn away forged or altered Rxs. The reason behind this was that the chains were seeing too many pharmacist-hours spent in court or with the police, an economic and staffing problem. Another issue along the same lines was that some prescribers did not want to deal with the hassle of forged or altered Rxs, so they asked pharmacists not to take action. (Many of the docs did dismiss the patient.) Boards reacted to this, and now it is codified in most states that the police must be called. You must act.

When the police are called, they will confiscate the forgery. Check your employer policies to determine if you should make a copy for store/company records.

As the drug abuse epidemic worsens, pharmacists are faced with a plethora of problems and challenges from unscrupulous people seeking to obtain drugs through illegitimate means. One of our roles—after our safety has been established—as gatekeepers to medications is to act appropriately when faced with these issues.

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