It’s not well known among the public, but a key role of the pharmacist is to make sure that medications are prescribed appropriately. This means providing not only the right drug and dosage for a particular patient, but also the right doctor.
The general term is “scope of practice” and it is best illustrated by an extreme example – the prescription authority of a veterinarian. A veterinarian has the authority to dispense pain medications to animals. However, this power would not allow them to prescribe Oxycontin to their niece, since humans are outside their scope of practice. A pharmacist would also be suspicious if the vet wrote for Ritalin (a drug for ADHD), even if it were for a dog.
This is a normal role for pharmacists – questioning whether a prescription drug is being used appropriately and prescribed within a doctor’s area of expertise. But it’s not always so clear.
A recent article in the New England Journal of Medicine (NEJM) defines abusive prescribing as when a physician overprescribes analgesics, either in excessive quantities or in a form more powerful than necessary. The clearest example of this is the so-called "pill mills," clinics that operated specifically to write as many prescriptions for narcotics as they can get away with – a kind of storefront for opioid addicts.
Pharmacies do have a responsibility under their license (pharmacies are licensed by the DEA to handle narcotics, just as doctors are) to oversee the use of controlled substances and to make sure they are being prescribed responsibly – a difficult task. No one wants to make a false accusation or deny patients narcotics when they truly need them. The pharmacist writing for the NEJM described how they managed it:
We identified high-risk prescribers by benchmarking them against others on several parameters. We used data from submitted prescriptions from March 2010 through January 2012 for hydrocodone, oxycodone, alprazolam, methadone, and carisoprodol. Prescribers were compared with others in the same geographic region who had the same listed specialty. The first parameters were the volume of prescriptions for high-risk drugs and the proportion of the prescriber's prescriptions that were for such drugs, as compared with the volume and proportion for others in the same specialty and region; the thresholds for suspicion were set at the 98th percentile for volume and the 95th percentile for proportion.
Other indicators there might be a problem were the age of patients and whether or not they paid cash – two known risk factors for addiction. Finally, the chain requested interviews with doctors who were deemed suspicious because of their ranking on the factors above.
By talking directly to doctors who appeared to be overprescribing, the pharmacist could evaluate the types of patients the practice was seeing and hear about any unusual justifications for the high levels of pain medications being prescribed.
What Can Be Done?
Pharmacies do not have police powers and are not in the business of regulating doctors. In the article cited, data was collected chain-wide on almost a million doctors. They found 42 who were of the greatest concern. Of those, five physicians agreed to talk to the pharmacy representative and showed good reasons why they were prescribing high levels of pain medications. These doctors had a scope of practice that included the treatment of chronic pain.
The 37 remaining doctors either didn’t respond, lawyered up, or weren’t able to justify the high levels of narcotics prescribed.
The only recourse for the pharmacy chain was to impose the threat they mentioned when first contacting the doctors – the chain would refuse to fill any narcotics from those physicians. Not exactly an arrest, but it illustrates the gray area in which pharmacies function. It is the duty of a pharmacist to make sure drugs are dispensed appropriately, but there is no mechanism of enforcement other than to deny service.
The article doesn’t state whether the information gathered by the chain was referred to the DEA for enforcement. The DEA does have the ability to track physicians and examine their prescribing habits, but they don’t always have the resources to act. In some ways, the DEA relies on pharmacies to nip problems in the bud, since a pharmacy is directly in the supply chain for drugs that end up on the streets.
The solution offered in the NEJM article is to make prescribing patterns transparent – not just across one chain (as in this example) but state and nationwide. Doing so will assure that any narcotic prescription can be tracked, and if a pattern of overprescribing emerges, enforcement can be swift and sure. After all, pharmacists don’t want to be cast in the role of policemen.