Walgreens Expands Its “Good Faith Dispensing” Policy

Presciption drugs and stethoscopeIn April 2013, Walgreens Pharmacy notified health care providers across the country of its revised policy for the dispensing of controlled substances.

The letter cited every pharmacist’s corresponding responsibility, along with physicians, to ensure that every prescription for a controlled substance “must be issued for a legitimate medical purpose.”

The letter said Walgreen’s pharmacists would start taking additional steps when verifying certain prescriptions for controlled substances. MMS has heard from several physicians inquiring about this policy.

Walgreens’ policy states: “Our pharmacists are required to take additional steps when verifying certain prescriptions for controlled substances. This verification process may, at times, require the pharmacist to contact you … information requested may vary, potential questions could include information about the diagnosis, ICD-9 code, expected length of therapy and previous medications/therapies tried and failed.”

According to an FAQ provided to the New Hampshire State Medical Society, Walgreens has emphasized that this new policy should not mean calls to prescribers on every, or even most, prescriptions for controlled substances.

Why did this happen?

Over the past few years, the Drug Enforcement Agency (DEA) has increasingly been looking at the problem of narcotics abuse in this country. While the DEA has investigated and prosecuted individual prescribers of prescription narcotics and synthetic opiates, the DEA is also looking at the distributors and dispensers of these prescription drugs.

The DEA has also been visiting states nationwide and presenting an intense power point lecture to help train pharmacists and remind them of their corresponding duty under federal regulations to ensure that each prescription for a controlled substance is issued for a legitimate medical purpose by each individual prescriber.

In response, Walgreens revised its policy on good faith dispensing of controlled substances, using in part “red flags” as determined by the DEA. Walgreens wants its pharmacists to be comfortable when they fill a prescription for controlled substances and the policy lays out suggestions on how to assure that the prescription is legitimate.

Where do things stand?

MMS has worked closely with the AMA in sharing information and gaining a perspective of this problem on the national scale.  The AMA, along with the national medical societies for family physicians, emergency physicians, anesthesiologists, and osteopathic physicians have been part of broad medicine-pharmacy meetings convened by the National Association of Boards of Pharmacy, with Walgreens, CVS, the National Association of Chain Drug Stores, National Community Pharmacy Association, PhRMA, DEA and other groups to identify “red flags” that stakeholders agree would warrant some sort of further review.  It is anticipated that this set will be reviewed by the stakeholders in Spring 2015.

Red Flags of Illicit Use, Doctor Shopping, and Diversion of Controlled Substances

For Physicians

  • Symptoms incompatible with reported injury
  • History of problems with no medical records
  • Patient reports being from out of town
  • Multiple accidents
  • Insistence on drug of choice
  • Requests drugs by their street names, e.g. “blues” “Ms”
  • Loss of prescription or medications
  • Failure to provide or go for medical testing
  • Taking more medicine than directed
  • Requests medicine refills early
  • Use medicines from multiple physicians or filled at multiple pharmacies (as seen on the Prescription Monitoring Program)
  • Use of medicines prescribed for others
  • Use medicines in combination with alcohol
  • Paying in cash or sometimes uses insurance and other times cash

For Pharmacists

  • Prescriptions for large quantities of a “cocktail” or “holy trinity” of opioids, benzodiazepines, and carisoprodol
  • Diagnosis of lower lumbar pain. DEA testified that 90 percent of the pill mill doctors use lower lumbar pain as a diagnosis code
  • Pattern prescribing. Prescriptions for the same drugs, the same quantities, coming in from the same doctor
  • Shared addresses by customers presenting prescriptions on the same day
  • Customers going to the pharmacy counter with dilated pupils and difficulty concentrating
  • Unusual physical distance between the doctor, the patient, and the pharmacy
  • Patients paying in cash or sometimes uses insurance and other times cash
  • Prescriptions done in a “factory-like” manner – no reason to prescribe 15mg and 30 mg oxycodone because 30mg tablets are scored down the middle
  • Use medicines from multiple physicians or filled at multiple pharmacies (as seen on the Prescription Monitoring Program)
  • Inordinately large quantity of controlled substance prescribed
  • Prescriptions refilled at inconsistent intervals based on quantity
  • Use of street drug name by either the patient or the prescriber
  • Suspicion of forged or altered prescription
  • Suspicion of forged or altered identification or refusal to provide

What should you, the prescriber do?

If you or your patients have difficulties filling prescriptions for controlled substances at any pharmacy please contact the MMS Physician Practice Resource Center at (781)434-7702 or pprc@mms.org.

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