(8-minute read) BUT PROBLEM IS DEEPER — WHOLESALERS ARE CUTTING SUPPLY
In what has emerged as a crisis within a crisis, patients with chronic pain in Alaska are having a harder time getting legitimate pain medication. They are being turned away by pharmacies for the opioids or other controlled substances that keep their pain manageable.
News accounts across the country report that patients who have had their pain medication cut off or drastically reduced are killing themselves because they can’t live with their chronic pain. Those in chronic pain understand this growing health crisis, which is a personal crisis to them.
This problem grew when recent federal legislation attempted to reduce the amount of illegal opioids hitting the streets through pill mills — unscrupulous doctors who flood the market with classified drugs through misuse of the prescription pad.
But in Alaska, it’s been a painful transition for those who rely on controlled pain medication. Pharmacies have been turning them away, to the point where the patients have reached out to the State Pharmacy Board for relief.
In response to these complaints, a letter went out to Alaska’s pharmacists from the Pharmacy Board last week, telling them to follow the law, which is to fill legitimate prescriptions.
The trend toward “refusal to fill” prompted the board to issue specific guidelines and reminders to pharmacists:
- Pharmacists must use reasonable knowledge, skill, and professional judgment when evaluating whether to fill a prescription. Extreme caution should be used when deciding not to fill a prescription. A patient who suddenly discontinues a chronic medication may experience negative health consequences;
- Part of being a licensed healthcare professional is that you put the patient first. This means that if a pharmacist has any concern regarding a prescription, they should attempt to have a professional conversation with the practitioner to resolve those concerns and not simply refuse the prescription. Being a healthcare professional also means that you use your medication expertise during that dialogue in offering advice on potential alternatives, changes in the prescription strength, directions etc. Simply refusing to fill a prescription without trying to resolve the concern may call into question the knowledge, skill or judgment of the pharmacist and may be deemed unprofessional conduct;
- Controlled substance prescriptions are not a “bartering” mechanism. In other words, a pharmacist should not tell a patient that they have refused to fill a prescription and then explain that if they go to a pain specialist to get the same prescription then they will reconsider filling it. Again, this may call into question the knowledge, skill or judgment of the pharmacist;
- Yes, there is an opioid crisis. However, this should in no way alter our professional approach to treatment of patients in end-of-life or palliative care situations. Again, the fundamentals of using our professional judgment, skill and knowledge of treatments plays an integral role in who we are as professionals. Refusing to fill prescriptions for these patients without a solid medical reason may call into question whether the pharmacist is informed of current professional practice in the treatment of these medical cases.
- If a prescription is refused, there should be sound professional reasons for doing so. Each patient is a unique medical case and should be treated independently as such. Making blanket decisions regarding dispensing of controlled substances may call into question the motivation of the pharmacist and how they are using their knowledge, skill or judgment to best serve the public.
The Pharmacy Board further warned that failing to practice pharmacy using reasonable knowledge, skill, competence, and safety for the public could result in disciplinary actions.
The State’s Division of Corporations also sent a similar letter, ordering pharmacies to consult physicians before refusing their patient’s opioid prescriptions.
“Recent federal legislation (21 CFR §1306.04(a)) provides more tools to strike this balance; it does not inhibit practitioners’ ability to prescribe controlled substances to patients,” the letter stated
“State law places the treatment of pain in the prescriber’s hands,” said Sara Chambers, director of the Division of Corporations, Business and Professional Licensing. “The prescribing practitioner has full authority to make a diagnosis and determine the appropriate course of treatment, including dosage and quantity of a controlled substance. The patient’s best interests must come first, and pharmacists are valued partners in the healthcare team; however, they are not prescribers and should not refuse to fill a valid prescription without first consulting the prescribing practitioner.”
PHARMACIES CAUGHT IN THE MIDDLE
After the federal legislation to crack down on the opioid epidemic, wholesalers have begun cutting off the supply to pharmacists.
In Alaska and elsewhere, that has meant that if a wholesaler notices an increase in orders, they can refuse to send them. Alaska pharmacies are finding it increasingly hard to even get the drugs being prescribed by doctors.
But that leads to another problem: If a patient is turned away from one pharmacy, he or she will try another. Those pharmacies may not know the patient or feel comfortable with a new prescription showing up out of the blue. In addition, that new opioid prescription increases the number of opioids that pharmacy is filling, and then the pharmacy could find that it has exceeded the percentage of opioids-to-other-prescriptions, and find itself on the black list with the opioid wholesalers.
This has led some pharmacists to refuse to fill an opioid prescription unless the patient brings all of his or her prescriptions to that pharmacy, in order to balance the ratio required by wholesalers.
The burden, then, is shifted downward to the patient.
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