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 The leading web portal for pharmacy resources, news, education and careers January 22, 2018
Pharmacy Choice - Drugs and Counseling Disease State Management - January 22, 2018

Drugs and Counseling Disease State Management


Drug Diversion of Controlled Substance Prescriptions
by Ken Baker, BS Pharm, JD

On September 11, 2001, terrorists stuck the United States by commandeering four commercial aircraft and flying them into the twin towers in New York and the Pentagon in Washington DC. Two thousand nine hundred and ninety-six people died as a result of these attacks.1 It was a tragedy and lead to two wars, billions of dollars spent, and the deaths of brave soldiers sent to exact justice.

In 2010 over twenty thousand people, more than six times the number of people killed in the 9/11 attack, died from an overdose of prescription drugs. Of that number, almost three quarters were from opioid pain medication.2 According to the Centers for Disease Control and Prevention, prescription drug abuse accounts for more deaths than from heroin and cocaine combined.2,3 The problem of diversion of prescription drugs to non-medical uses is real and growing.

The fight to save lives due to prescription drug abuse and misuse is a war in which pharmacists find themselves in the front line. A prescription for a controlled substance must be written for a "legitimate medical purpose by a practitioner acting in the usual course of professional practice."4 The problem is not just diversion. Pharmacists also have an obligation to those patients who are truly in pain. According to the American Pain Foundation almost twenty-five percent of adult Americans, 20 years old and older, more than 75 million people, will suffer chronic pain.5

There have been reports of patients leaving the pharmacy in pain or in tears after a pharmacist refused to fill a legal and legitimate prescription.6 Pharmacists need to be able to differentiate between legitimate patients and one who intends to divert controlled substances to non-medical use. Pharmacists also need to protect themselves by properly documenting why they did or did not dispense a drug written on a prescription that appears proper on its face. The following are some suggestions of procedures. If properly documented by the pharmacists they may help curb diversion, assuring a proper patient is adequately treated and protect the pharmacist. These are not presented in any particular order of importance. The list is certainly not complete or exhaustive.
  • Use your experience. If you develop a feeling something is unusual about the prescription, the patient or the situation, stop. Once you question a prescription, you cannot fill it until your concerns have been answered and you have documented how you resolved the questions.
  • Use common sense. If the prescription is for a regular patient who appears to be a chronic pain sufferer and who presents a prescription from a local physician who is known and trusted, it is probably a legitimate prescription.
  • You are not required to be perfect or always right, but you do have to resolve each question of ligitimacy.
  • When in doubt talk to the patient and/or the prescriber. Questions may be easily resolved when you have the facts.
  • A prescriber who is actively assisting in diversion of drugs by writing prescriptions that are not for legitimate medical reasons is likely to lie if you call – trust but verify.
  • Review Red Flags that raise questions about the legitimacy of a prescription.7
    • A doctor seems to write all prescriptions for the same drugs and the same quantities indicating patients are not treated according to individual needs;
    • A particular doctor appears to be prescribing primarily controlled substance combinations that are frequently abused and there is little variation;
    • The patient and/or doctor have come from several miles (or states) away;
    • A group of patients have the same addresses and their prescriptions are presented on the same day;
    • The doctor seems to be prescribing a lot of questionable prescriptions for patients who do not appear to be chronic pain sufferers.
    • The quantity and strength of the prescribed medication raises a question;
    • The patient insists on paying cash for expensive medications;
    • Several patients seeing the same doctor present with the same diagnosis code indicating the diagnosis may not be legitimate;
    • A doctor writes prescriptions outside his or her area of practice or specialty;
    • A fraudulent prescription is not a prescription and cannot be filled under any circumstances.
  • Remember a red flag is only that, it raises a question that must be investigated and resolved. People without insurance do pay cash and may suffer chronic pain.
  • White flags are indication that a prescription is legitimate. They may help resolve questions.
  • Overuse of pain medication may be the symptom of a legitimate medical problem, which the pharmacist and physician need to work together with the patient to resolve. It is not necessarily the same as drug diversion for non-medical uses.
Pharmacists have been placed in the middle between those who would divert legitimate, legal drugs for non-medical purposes and real, legitimate pain patients. The pharmacist must be able and willing to work to resolve these questions – say no when necessary and yes when needed.

Ken Baker is a pharmacist and an attorney. He teaches at Midwestern University, Glendale, Arizona, campus and the University of Florida. He consults in the areas of pharmacy error reduction, communication, and risk management. Mr. Baker is an attorney, of counsel, with the Arizona law firm of Renaud Cook Drury Mesaros, PA. Contact Ken Baker at ken@kenbakerconsulting.com.

This articles is not intended as legal advice and should not be used as such. When a legal question arises the pharmacist should consult with an attorney familiar with pharmacy law in his or her state.

  1. Static Brain website, http://www.statisticbrain.com/911-death-statistics/ Last accessed 1/28/2014.
  2. Prevoznik, T, "DEA Perspective: Pharmaceutical Use and Abuse," US DEA, Baton Rouge Pharmacy Diversion Awareness Conference, August 2013 http://www.deadiversion.usdoj.gov/mtgs/pharm_awareness/conf_2013/august_2013/prevoznik.pdf#xml=http://search.deadiversion.usdoj.gov/texis/search/pdfhi.txt?query=er+visits&pr=Prod-static-walk&prox=page&rorder=500&rprox=500&rdfreq=500&rwfreq=500&rlead=500&rdepth=0&sufs=2&order=r&cq=&id=521821bfd last accessed 1/28/2013
  3. Roberts, J, “Report: Prescription Drug Deaths Skyrocket”, FoxNews.com, November 01, 2011 http://www.foxnews.com/health/2011/11/01/prescription-drug-deaths-skyrocket/ Last accessed 1/28/2013
  4. See DEA publication Pharmacists Manual and 21 C.F.R. §1306,
  5. American Pain Foundation 2006 survey on 303 chronic pain sufferers who sought care from their physician and were currently using an opioid to treat their pain. http://www.painmed.org/PatientCenter/Facts_on_Pain.aspx#keyfindings last accessed 1/28/2013.
  6. See, Sullivan, Colleen, My Story: Humiliated by a Pharmacist, 8/5/2013, http://americannewsreport.com/nationalpainreport/my-story-humiliated-by-a-pharmacist-8821166.html last accessed 1/7/2014; Filosa, Gwen, "Walgreens refuse Rx's from local docs, Doctor says pharmacists overstep authority by refusing patients' meds" 4/12/2013; Florida Keys News, http://keysnews.com/node/46864 last accessed 1/7/2013; Segal, Bob, Walgreens' "'secret checklist" reveals controversial new policy on pain pills”, 9/18/2013. http://www.wthr.com/story/23469086/2013/09/18/walgreens-secret-checklist-reveals-controversial-new-policy-on-pain-pills last accessed 1/7/2013,
  7. See for example Quarles and Brady Blog A Pharmacist’s Obligation: Corresponding Responsibility and Red Flags of Diversion, Larry Cote, August 11, 2013; see also DEA Pharmacists Manual


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