The refill request was for a muscle relaxant, one with significant potential for addiction. I opened the patient’s chart to see when it has last been filled. I had approved a refill 25 days prior. This request was 5 days early.
Early requests are not entirely unusual, as patients are often afraid that waiting to the last minute can result in them running out of medications. A pattern of early refills can indicate a problem so I decided to log into the state controlled substance database to view the patient’s prescription history. It seemed that he had consistently been filling the medications 3-5 days ahead of the due date. I decided to investigate further.
I scrolled back through the online history and saw something that made my heart sink. The database showed that 2 months earlier the patient had filled the medication at two different pharmacies one day apart. If this was true, the patient was abusing the medication.
I could not believe it. This patient was one of my favorites, our interactions had been consistently enjoyable, often with interesting conversation. (He is a passionate and hard working man and we have much in common.) The thought that he might have been abusing his medication, that I might be forced to confront him and possibly dismiss him from the practice filled me with dread. Unfortunately, the evidence on my computer screen was hard to ignore.
I called my receptionist over and asked her to call each of the pharmacies to confirm that they had indeed filled the medications on the dates indicated. A few minutes later she handed me a note. Both pharmacies had confirmed the refills.
I wondered how to address this with the patient. The evidence was pretty clear but something just didn't feel right. I wondered if my unease was more about the possibility that I had been deceived than it was about the patient’s circumstance. I decided that I did not need to be confrontational immediately, that I would give the patient a chance to explain.
I called him on the phone and he answered immediately. “I received your refill request,” I told him, “but it was a few days early.” I went on, “ So I checked the state database to review your history, and according to them, you refilled the medication twice in January only a day apart, on the 16th and 17th.”
“Doc, there’s no way. I didn’t get two prescriptions. Let me call the pharmacies!” He was adamant, yet not defensive. I told him that I would not be able to fill the medications without him coming to the office, as we would have to address the issue and I would need to document it in the record. As much as I wanted to trust him it would be a mistake to assume that the pharmacies were at fault. I told him he would need to sign a controlled substance agreement and that his practice of using different pharmacies based on his work schedule would need to end.
He did not argue at all. “Of course, I understand. I will come in tomorrow!”
I received a text from him within a few minutes, saying he had just called and only one of the pharmacies had confirmed a refill. The state database must be wrong.
I decided to call the pharmacies myself. The first pharmacist came on the line right away and looked up the patient’s medication history. She read off the record for the date in question. “We show a prescription on January 26th that was deleted. The patient never received the medication.”
I was so relieved! The patient had been telling the truth! (When it comes to controlled medications this does not often happen.) I called the patient back and gave him the news. I told him I could refill his medications but that it would need to be on the due date, that I could not refill the medications early. He was in total agreement.
When I hung up the phone I breathed a sigh of relief. I had dodged a bullet. There was a time not so long ago when I would have assumed the worst and been more confrontational. If I had done that, a relationship might have been lost. Giving him the benefit of the doubt had made all the difference.
-Bart