This Should Never Happen

One of my long-time patients had a problem last week. I prescribe buprenorphine/naloxone 8/2mg tablets, 2 per day for a total of 16mg for her. She’s been in recovery from opioid use disorder for over six years. She keeps her appointments with me, takes her medication as prescribed and is doing well, despite some recent mid-life stresses.

Unfortunately, while walking her dog, she fell. She had immediate leg pain but thought it was only a pulled muscle or tendon. She wasn’t keen on going to the emergency department, so she waited a few days and saw her primary care doctor. The doctor ordered an X-ray of her leg which showed a femur (thigh bone) fracture. She sent her to the hospital right away and the orthopedic surgeon admitted her.

She had surgical repair the next morning, with the placement of an intramedullary rod down the length of the femur, held in place with screws. She was sent home that night and her surgeon prescribed oxycodone and some other medications.

So far so good.

But when her significant other went to pick up her medication at the pharmacy, the pharmacist refused to fill the oxycodone. The only explanation she provided was that she felt uncomfortable dispensing it because she knew this patient was prescribed Suboxone by me.

This pharmacist didn’t call me, though. I knew nothing about all of this until the patient called my after-hours number to explain the situation. The patient said she’d already contacted her surgeon, who had called the pharmacist to ask her to fill his prescription, but she still refused.

No problem, I told the patient, after getting her description of what happened. I’ll call the pharmacist, explain the situation, and describe our treatment plan.

Ordinarily I would continue the patient’s dose of buprenorphine/naloxone at 16mg per day, or perhaps drop the dose down to 4mg per day while she was taking the oxycodone, but she had missed her usual buprenorphine/naloxone for the last two days, what with going to her primary care doctor, then the hospital, then having surgery. So, I told the patient to stay off the buprenorphine/naloxone until she no longer needed the oxycodone, and then we would re-start the buprenorphine.

I didn’t think I’d have any problem explaining our plan to the pharmacist.

I was wrong.

This pharmacist was frosty from the start. She wasn’t rude, but she wasn’t friendly.

I started by saying, “Hi this is Dr. Burson and I’m calling about patient X. She’s just had surgery on her leg and his surgeon sent a prescription for oxycodone. I have been treating this patient for years for opioid use disorder and we have worked out a plan for pain control post- op and we…”

“I have the right not to fill this prescription.”

Caught off guard and only halfway through my explanation, I stopped. “Uh, what?”

“I have the right to refuse to fill this prescription. After all, it’s my license on the line too.”

“I don’t know what that means. But I can tell you that I am an Addiction Medicine specialist and I’m telling you it is OK to dispense this medication and we have a plan in place for her significant other to hold the pill bottle…”

“This patient has been on Suboxone for many years.”

“Yes, I know. If you will look at your records, I’m the one prescribing it.”

“I don’t feel I should fill the oxycodone.”

Like a light switch turning on, I felt suddenly angry. My tone changed. My voice raised, I said, “SHE BROKE ….  HER LEG!” I could see my husband glancing at me, knowing me well enough to see I was about to get salty.

“Ma’am I am aware of that…”

“It is unethical for you to refuse to fill this prescription! Don’t you know that just because someone has the disease of opioid use disorder, you can’t deny them pain medication to treat painful acute conditions like a broken bone??”

“I have already spoken to her surgeon and explained I don’t feel I should fill this opioid prescription.”

“And what did he say?”

“He wants me to fill it, but I told him I would not.”

We went back and forth in that vein for a few minutes, until I saw it was futile to talk further.

“What is your name?”

She gave it to me as I wrote it down with hands shaking with anger.

It was getting late on a Friday night, and the surgeon had to send my patient’s oxycodone to another pharmacy. They were about to close for the night, so she couldn’t send her significant other to pick up her prescription until the next morning.

This patient went over twelve hours, fresh out of surgery, without the pain medication that her surgeon prescribed, and that an addiction medicine doctor (me), who knew the patient very well also agreed she needed, all because a pharmacist was worried about her license if she filled it.

I wanted to report this pharmacist to the North Carolina Board of Pharmacy but after I cooled down, I changed my mind. For whatever reason, she was afraid. She needed information and education. For whatever reason, I couldn’t provide this. She was more likely to listen to another pharmacist. Thankfully, I’m acquainted with a pharmacist who works with the North Carolina Association of Pharmacists. She is knowledgeable about MOUD and part of her job is educating pharmacists. I emailed her and asked if she’d be willing to help. She said yes, of course, and I sent her the contact information.

I felt angry I couldn’t help my patient, and that she had to wait on her pain medication.

This didn’t happen in the rural community where I work at an opioid treatment program. It happened where I have my own practice, where I see patients with opioid use disorder. My office-based practice is in an upscale community known to be progressive. It’s a bedroom community close to an urban area. If it can happen in this location, it can happen anywhere.

My patient is doing well, and her leg is healing. This is the most important thing.

But denial of appropriate medication for acute pain should not happen to this patient or anyone else.