Limiting Pharmacist Discretion

Or Pharmacists Aren't Auxiliary Doctors Anymore

I believe it’s time we stopped treating the people who dispense your prescriptions as medical professional. We should revoke the discretion given to pharmacists not to fill facially valid scripts (certainly electronic scripts) unless the computer flags a dangerous drug interaction, the pmp flags doctor shopping or the script seems to clearly contain a mistake1. The involvement of the medication dispenser as more than a glorified clerk and pill counter in filling prescriptions is a holdover from the days when the pharmacist functioned as something of a hybrid between a nurse-practitioner and sole clearinghouse for all a patient’s medications.

None of these roles for a pharmacist make sense anymore. Patients now fill prescriptions at whatever pharmacy is most convenient with no guarantee that any one pharmacy chain let alone pharmacist will process all their prescriptions2. Yes, pharmacists can access your other prescriptions via prescription monitoring programs (PMPs) but so can your doctors making your doctors, with their greater information about you, in a better position to check for dangerous interactions. Any advantage possessed by the pharmacist as a result of their narrow focus on drugs combined with the breadth of the drugs they are familiar with has been undercut by software that can automatically flag potentially dangerous interactions.

While having a second set of eyes glance over the prescription is valuable (especially running software that flags interactions with the other prescriptions listed in the patient’s PMP record) pharmacists aren’t the best way to implement such a system3. However, even if inertia means we keep employing the pharmacist in this capacity that doesn’t justify giving they discretion to refuse to fill valid prescriptions absent some indication of outright physician mistake or dangerous drug interaction unknown to them. Given this kind of discretion to pharmacists offers no benefits I can see and imposes substantial costs.

For instance, this discretion frequently ends up with pharmacists refusing to fill prescriptions explicitly because the patient is uninsured patients (happened to my father just this week) and I suspect it happens for more frequently without being explicitly acknowledged. I’ve also seen just how much more difficult this discretion makes it for acquaintances who look poor or non-white to get their prescriptions filled. Furthermore, while not quite as bad as the situation with Plan B some pharmacists judgmentally decide they disapprove of certain kinds of prescriptions, e.g. opiate maintenance therapy, and make it particularly difficult to get such prescriptions filled. One might think pharmacists might at least need a good reason to refuse to fill a prescription but apparently the law says they can do so for any reason at all.

One might think this kind of discretion is necessary to reduce prescription forgery and attempts to circumvent doctor shopping prohibitions. However, the former problem is quickly being rendered obsolete with electronic prescriptions and even when we are talking about paper prescriptions refusing to fill facially valid prescriptions just sends the prescription forger out looking for a pharmacy that doesn’t care or tacitly accepts the practice to make more money. Refusing to fill the prescription covers that pharmacist’s ass or makes them feel good but doesn’t stop the drug seeking patient from filling their script. Likely, a much bigger dent in prescription forgery and related activities would be made if reputable pharmacies filled facially valid scripts after carefully checking IDs but, when suspicious, reached out to contact that patient’s prescribing physicians.

While the drug addicts will always find some pharmacy which will fill a valid script4 the same can’t be said about patients in genuine need of their medications. Poor working parents don’t have the free time or money to drive all over town trying to get their prescription filled and they don’t have the drug abuser’s contacts letting them know where they should go nor the desperate driving need of the addict.

Horribly, despite the fact that exercising this discretion seems to be primarily a harm it appears that pharmacists can refuse to dispense controlled substances for any reason. Though if the patient is disabled (as many chronic pain patients are) this may create a cause of action.

  1. And if when asked the customer, taken as their word, indicates the doctor knew it was unusual in that way they still have to dispense 
  2. For instance, when I get a prescription from a doctor I usually just fill it at whatever pharmacy is next door to that doctor so I don’t have to call an additional Lyft. 
  3. Have the prescribing physician run the software to flag interactions using the same PMP data the pharmacist would use plus information from the patient’s records. Rather than having pharmacists be the second pair of eyes to look at the prescription require that each prescription also be run past someone with nurse or pharmacist training by the doctor (via an online service if they lack office staff). 
  4. Among addicts there are standard percentages of the prescription given in exchange for lending money to spring it from the pharmacy prescription or driving them around to pharmacies to get it filled)