It's not in stock: Community pharmacists' decision-making and communication when refusing to dispense controlled...

Pharmacists play a vital role in ensuring that controlled substances (CS) are used safely and appropriately and may refuse to dispense a CS prescription as part of this responsibility. Such decisions, while often appropriate, can have unintended consequences for patients. Despite this, little is known about how pharmacists navigate CS dispensing decisions and how they communicate refusals to patients.

To qualitatively describe pharmacists' decision-making process and communication strategies when declining CS prescriptions.

Semi-structured interviews were conducted with 11 pharmacists recruited from the Texas State Board of Pharmacy Registry between March 2023 and April 2024. Data were analyzed using Braune and Clarke's thematic analysis approach.

Patient characteristics, professional values, practice environment, prescribing clinician relationships, regulatory oversight, stigma, safety concerns, and gaps in training were identified as important contextual influences on decision-making. Participants also described employing risk management practices to mitigate perceived dispensing risks, including verifying prescriptions and conducting due diligence, seeking external guidance, and documenting patient interactions. Three strategies for communicating denial were identified: transparent and constructive denial, tactful evasive responses, and deceptive denial. Additionally, employer policies were noted to play a role in guiding how pharmacists implemented risk management practices and communicated refusals to patients.

Pharmacists' decisions to decline CS prescriptions are complex and influenced by multiple contextual and risk management considerations that require balancing professional judgment, regulatory responsibilities, and patient-centered care. Future research is needed to better understand how these factors shape dispensing decisions and to inform interventions that support safe dispensing practices and optimal patient care.