The Bottom Line: Physicians responsibly prescribe medicine like opioids to manage patients’ pain, but new cstd pharmacy rules designed to prevent excessive opioid use allow pharmacists to question the legitimacy of those prescriptions. Some physicians fear pharmacists’ increased scrutiny crosses the line into the practice of medicine.
Physicians are questioning whether some Texas pharmacists are overstepping bounds by using a new rule to second-guess whether a doctor’s prescription is appropriate.
Physicians have authority to prescribe medicine in Texas. It’s part of the responsibility of being a licensed physician: Diagnose the patient’s condition to determine with him or her what type of treatment is needed, and prescribe it.
Some physicians must prescribe strong medications like opioids to manage patients’ pain, but Texas State Board of Pharmacy (TSBP) rules give pharmacists a list of 19 “red flag” factors intended to weed out illicit prescribing and stop inappropriate dispensing of medications. In some cases, the rules have caused delays in patient care, limits on prescriptions, and demands for more medical information before the pharmacists fill the prescriptions.
Waco otolaryngologist Charles Guy, DO, says a pharmacy recently rejected his patient’s prescription for pain medicine because it exceeded the pharmacy’s corporate dosage limit for opioids. Dr. Guy was forced to adjust the prescription dosage before the pharmacy would fill the prescription.
“I let them know that I thought it was ridiculous, and they’re telling me how to prescribe medicine to my patient,” Dr. Guy told Texas Medicine magazine. “Having them reach out if there is a true concern and a valid concern, I think, is a better relationship than setting a policy system-wide [that’s] not really thinking about the patient or the physician-patient relationship, or even the pharmacy-patient relationship.”
The new pharmacy policies were created out of concern over the nation’s opioid epidemic. Some state medical organizations and retail corporations that operate pharmacies are developing their own policies to combat the problem. Some new rules are based on the Centers for Disease Control and Prevention’s Guideline for Prescribing Opioids for Chronic Pain, a set of recommendations to reduce people’s misuse, abuse, or overdose from these drugs.
However, do the new rules go too far? Some physicians say they strain the physician-pharmacist relationship. For example, TSBP’s red flag rules — implemented earlier this year — say a pharmacist must make “every reasonable effort to prevent inappropriate dispensing due to fraudulent, forged, invalid, or medically inappropriate prescriptions.” The Texas Medical Association helped mitigate the scope of the rules with its input during the board’s comment period but remains concerned about many aspects of the final version.
The American Medical Association (AMA) also responded to a similar overreaching red flag policy instituted by a national retail corporation. AMA CEO and Executive Vice President James Madara, MD, disagrees with the “one-size-fits-all corporate policy implemented rather than a patient-centered understanding of the complexities surrounding pain.” He said, “Having the corporate entity determine what is — and is not — acceptable clinical practice is deeply troubling.”
Texas Medicine magazine reports the Texas Medical Board has received complaints about pharmacists or others changing physicians’ lawful and valid prescriptions. Texas Medical Board President Sherif Z. Zaafran, MD, said TMB has the authority to investigate complaints and ensure any new policy does not supersede state law.
“We want to make sure at the end of this whole process of reviewing this, that whatever statement is put out by different regulatory agencies, that that very clearly gives the pharmacist the protection that they need, that they are not being forced by another entity to be practicing beyond the scope of their specific license in dispensing medications appropriately,” Dr. Zaafran said.
In the end, physicians say they want to manage prescriptions safely and in the best interest of their patients. Doing so, they say, is their obligation and responsibility — part of the practice of medicine.
TMA is the largest state medical society in the nation, representing more than 52,000 physician and medical student members. It is located in Austin and has 110 component county medical societies around the state. TMA’s key objective since 1853 is to improve the health of all Texans.
