A Pharmacist Discusses Being 'Red Flagged'

Tony asked

I received a script from my doctor for 75, Norco 5/325. My directions were to take one tablet by mouth three times a day or as needed. So, if I took it only 3 times a day, it would last 25 days. A medical assistant at my doctor's office who hands out the script argued with me over this... that it should have lasted 30 days. Long story short, I have been flagged by DEA, and I have to make my meds last 30 days on the dot. Advice?

Answer

Situations like this can certainly be difficult, and unfortunately, are often simply the result of some sort of miscommunication.

Let's first discuss your prescription, which was for:

• Norco (hydrocodone; acetaminophen) 5/325mg
• Quantity 75
• Directions: The one tablet by mouth three times a day or as needed.

Clearly, based on the directions, this prescription would be for a 25 day supply.

However, and this is an important point, oftentimes doctors will specify a day supply on a prescription as a note to the pharmacy and patient, especially when the day-supply doesn't exactly match the prescribed directions.

Here is an example of a prescription showing this common practice:

The intent of a prescription like this is to give the patient some flexibility with dosing. The prescriber is allowing you to take up to three per day, but, not necessarily on a daily basis.

Now, I don't know what the intent of the prescriber was in your situation, but it is possible they intended something like this for you. Nevertheless, this should certainly be discussed to avoid situations like yours.

A key point about the 'day-supply' of a prescription, is that it doesn't need to exactly match up with the prescribed directions if the prescriber specifies a different one. As mentioned, it is fairly common practice for a doctor to specifically note a day supply on a controlled substance prescription, or to direct the pharmacy to hold you to a specific pick-up day.

If your pharmacy input your prescription in as a 30 day supply (even though that doesn't match up with quantity and respective directions), that is the day supply that will not only be transmitted to your insurance company but also to your state's (California) controlled substance prescription monitoring program, which is known as CURES (Controlled Substance Utilization Review and Evaluation System).

DEA Red-Flagging

It is important to note that the DEA doesn't 'red flag' individuals in matters like these because all controlled substance monitoring programs are run by the individual states.^[1] This is stated specifically on their website:

Q: Does the Drug Enforcement Administration (DEA) oversee PDMPs?
A: The DEA is not involved with the administration of any state PDMP.

The DEA, a medical review board or local law enforcement could certainly gain access to the records in a given state monitoring program if the situation necessitates it, however.^[2] Some states require a warrant to access a database while others do not.

Nevertheless, third-party access to a state-controlled substance monitoring program database generally only occurs in substantial cases of abuse, diversion, or misuse, as well as to investigate the potential illegal sales/distribution of prescriptions (e.g.  'pill mills').^[3]

It is highly unlikely that you are being tracked by the DEA or are 'red-flagged' by them based on what you described.

State Controlled Substance Monitoring Programs

Even state monitoring programs don't necessarily 'flag' someone in cases like yours (a miscommunication on the day supply of one prescription). The programs are in place to record the prescription fill history of an individual in a central, easily accessible database for review.

Before these programs were in place, aside from insurance companies sharing information, controlled substance fill history was not shared between pharmacies (except in the same chain).

The program your state (California) uses (CURES) is actually rather advanced and does have 'Patient Alerts' though. The system will provide an alert to users (e.g. prescribers, dispensers, etc...) about an individual in the following cases:^[4]

• If they are prescribed more than 90 morphine milligram equivalents per day.
• If they have obtained prescriptions from 6 or more prescribers or 6 or more pharmacies during the last 6 months.
• If they are currently prescribed more than 40 morphine milligram equivalents of methadone daily.
• If they are currently prescribed opioids for more than 90 consecutive days.
• If they are currently prescribed both a benzodiazepine and opioid.

None of the above alerts apply to your situation.

Additionally, most other state controlled substance monitoring programs do not have alerts.

Now, the CURES system does allow messaging between prescribers and dispensers and additionally, allows for doctors to notate a compact agreement for a specific patient.

A compact is essentially a treatment exclusivity agreement, so in this sense, if your doctor has inputted a 'compact' for you, this would be flagged to other prescribers (but again, you aren't 'flagged' as a drug abuser).

Your pharmacy and/or doctor may in all likelihood have some sort of internal messaging system, with documentation regarding your fill history, but this information wouldn't be loaded into some sort of state or federal database.

Final Words

To summarize all of the above, you likely aren't 'red-flagged' by the DEA or even in your states drug monitoring program (CURES for California) since the concept of a 'red-flag' doesn't really exist in cases like this.

Federal agencies and local law enforcement could theoretically access your fill history (they may need a warrant depending on the state) but in your situation, trying to fill a 30-day supply prescription after 25 days (due to a miscommunication), this would be highly unlikely.

You may be 'flagged' in the CURES system as having a compact, or exclusive practitioner treatment agreement, but this isn't the same as being flagged as a controlled substance 'doctor shopper' or abuser.

The most likely scenario is that your pharmacy or doctor has some sort of internal memo regarding this issue with Norco.

Your best bet would be to discuss the situation with your doctor and pharmacy to try to clear up any miscommunication.