Analyzing Colorado Pharmacist 2014 Disciplinary Actions: Controlled Substances, Red Flags and Pharmacist Corresponding Responsibility

Baer Law recently completed an analysis of thirty-three (33) separate 2014 disciplinary cases against Colorado pharmacists by the Colorado State Board of Pharmacy (Board).

Certain cases, especially those involving controlled substance dispensing errors and pharmacists dispensing controlled substances when no valid patient-prescriber relationship existed, should be of particular interest to all licensed Colorado pharmacists.

Out of the thirty-three cases analyzed, twenty-four (24) letters of admonition were issued to pharmacists. A letter of admonition is a public reprimand issued to a pharmacist in the form of an actual letter or as part of a stipulation, which is an agreement between the Board and the pharmacist prior to a formal hearing. With a stipulation, both parties agree to facts, sanctions and the terms and conditions for continued practice, if applicable. Though a stipulation resolves the case both a letter of admonition and stipulation are public records.

Of the twenty-four letters of admonition issued to pharmacists in 2014, Baer Law identified eleven cases involving controlled substances.

In some instances, the pharmacist dispensed the wrong controlled substance medication as cited by the Board. In these cases, the pharmacist:

  • “Performed the initial interpretation on an order for Fentanyl 25 mcg transdermal patches but dispensed fentanyl 75 mug patches;”
  • “Performed the initial interpretation and final evaluation on an order for Fiorinal/Codeine #3 which was dispensed as butalbital/acetaminophen/caffiene/codeine;”
  • “Performed the initial interpretation on a prescription of Butalbital/ASA/Caf when the order was written for Butalbital/ASA/Caf/Codeine;”
  • “Performed the initial interpretation on an order for MS Contin 30mg, but dispensed morphine sulfate ER 100mg tablets;”
  • “Admittedly dispensed a prescription with 20 tablets of methadone 5mg on an order for 720 methadone 10mg tablets;”
  • “Performed the initial interpretation on an order for Oxycontin 15mg tablets which was dispensed with oxycodone 15mg immediate release tablets.”

In another case, the pharmacist was cited for filling “a prescription for Adderall 20mg tablets, a schedule II controlled substance, before the filling date authorized by the prescriber.”

In the last four cases, pharmacists were cited for dispensing controlled substances when no valid patient-prescriber relationship existed or when a pharmacist dispensed controlled substances after an out-of-state prescriber had lost his license to prescribe controlled substances.

In the first case, multiple pharmacists, and their pharmacy, were disciplined for performing the initial interpretation on controlled substance orders for oxycodone, Soma, and Xanax after it was later determined during a routine Board inspection that:

  • No valid preexisting patient-prescriber relationship existed between an out-of-state prescriber and a patient residing in Colorado and
  • At the time these orders were dispensed, the out-of-state prescriber was prohibited from prescribing any Schedule II-IV controlled substances.

In another case that was previously cited on the Baer Law Blog, Pharmacists Must Ensure Prescription Orders are Issued for a Legitimate Medical Purpose by an Authorized Prescriber and Have a Recognized Medical Utility or Application, a pharmacy manager was disciplined after her pharmacy filled orders for controlled substances for patients of a California based prescribing practitioner who the pharmacist mistakenly believed, after investigation, had a valid, pre-existing patient-practitioner relationship with the patients.

The final four cases should be a learning experience for all pharmacists as the disciplinary actions may have been avoided had the pharmacists involved exercised corresponding responsibility and proactively identified certain “red flags” that could have assisted them in identifying prescriptions that are not legitimate.

As previously discussed on the Baer Law Blog, Corresponding Responsibility: A Pharmacist’s Obligation to Understand, pharmacists must exercise sound professional judgment with determining the legitimacy of a controlled substance prescription. When a pharmacist is presented with a doubtful, questionable or suspicious prescription, the law does not require a pharmacist to dispense the prescription. On the contrary, a pharmacist who deliberately ignores a questionable prescription when there is reason to believe the prescription was not issued for a legitimate medical purpose may be prosecuted along with the prescribing physician for knowing and intentionally distributing controlled substances.

All pharmacists should be able to identify certain “red flags” that could assist in identifying prescriptions that are not legitimate.

Common red flags include but are not limited to:

  • Pattern prescribing (i.e. prescriptions for the same drugs and the same quantities from the same doctors);
  • Irregularities on the face of the prescription itself;
  • Nervous patient demeanor;
  • Multiple or duplicative therapies (i.e. Oxycontin and MS Contin);
  • Prescribing of combinations or “cocktails” of frequent abused controlled substances;
  • Geographic anomalies;
  • Shared Addresses;
  • Filling a larger percentage of cash prescriptions;
  • Customers with the same diagnosis code from the same doctor;
  • Prescriptions written that are not consistent with their area of specialty;
  • Prescriptions for medications with no logical connection to diagnosis or treatment;
  • Consistent requests for early refills; and
  • (Re)filling prescriptions of patients or doctors located hundreds of miles away

While there are no clear and concise answers or guidelines, a pharmacist should always exercise his or her independent judgment when determining whether a prescription was issued for a legitimate medical purpose by a prescriber in their normal course of professional practice. Failure to do so could result in disciplinary action by the Board.