This is the sixth article in a series of eight articles by Ilene Robeck, M.D. regarding difficult conversations a primary care provider may have when dealing with patients with chronic pain. This series is meant to be a guide for primary care providers facing these situations.
Difficult situation #6: A patient requests a medication refill earlier than scheduled.
Advice: “No early refills” is usually an important element described in the patient-provider agreement which patients are asked to sign when they start receiving chronic opioid therapy. Commonly, the patient is asked to agree to inform the prescriber of all of the medications they are taking, to keep their regularly scheduled appointments, and to acknowledge that they will receive a prescription for only enough medication to last from one appointment to the next appointment. Patients are often asked to bring their medication with them for each return visit, and visits are scheduled a few days before the prescription expires.
If this is the plan that you have established with your patient can you assume that you will never receive a request for an early medication refill? No. It is very likely that you will still get requests for early refills. This is a problem as each request raises a concern about safety, because it means there is more medication circulating in the community than you had intended. What should you do with these requests? Your first step is to try to determine the reason behind the request for the early refill. Understanding the “why”, will help you address the underlying problem. If you can’t figure out the “why” you may need to consider whether or not you should keep the patient on opioid therapy.
The first consideration is whether the patient has requested an early refill because their pain has not been well-controlled and they have taken their medication more often than prescribed, without consulting with you. If this is the case, after talking with the patient about the safety issues involved in unauthorized dose escalation, you may want to modify their treatment plan. This may mean re-evaluating the formulation of the opioid being used, exploring other non-opiate pain management options, and re-assessing the patient’s functional status.
Requests for an early refill may reflect that the patient has some cognitive impairment. The patient may have forgotten how to take their medication, or have misplaced their medication. If there is evidence of cognitive decline the patient may require extra help or supervision in order to take their medication safely. This is especially a worry with older adults who often take multiple medications, but have trouble recognizing the differences between them. Finding a reliable family member or friend who can help set up a weekly pill box may help, along with using teaching tools that clearly identify which medication is which.
It is important to inquire whether the patient is sharing their medication with other people. Although this is unsafe and reflects poor judgment, the patient may feel that they are trying to help someone else.
The most worrisome possibility is that the medication is being diverted in some way, and is being used for unintended purposes by people for whom it has not been prescribed. It is important to ask the patient how and where they will store their medication when it is prescribed, and ask how the plan is working at return visits. If the medication is not kept securely there is an endless possibility of ways it could fall into the wrong hands. A pattern of requests for early refills, with no good explanation, poses a safety risk that indicates that this patient may not be an appropriate candidate for opioids.