ED Prescribing Tricks

[docB]

There are some tricks to writing prescriptions to ED patients. They often have no insurance and little money. If they do have insurance even the pharmacists don’t know what will be covered by their plan.

Here are some things I do to try to avoid the dreaded call from the pharmacy that usually is a request to provide an alternate med for a patient seen by your partner three days ago. In that situation invariably no one has any idea what the patient is being treated for or what drug would be covered so it turns into a nightmare.

Bear in mind that these are just things I do which by no means = correct things to do.

-I practically never write for Augmentin. I only give it for bites. It’s expensive. Plans hate it because they want everyone to write for amox. Insurance company executives wake up in cold sweats every night with nightmares that they covered Augmentin for an otitis. I use either amox or something else.

-For antiemetics if the patient has no money and no insurance I wright for phenergan and I write for both the pills and the suppositories. I explain that if they can’t hold down the pills they should go the other way. I like Zofran, especially the chewables, but they’re pricy. 30 cost ~$100 in my area. I write for 5 or 10 and give 2 refills. I tell the patient that way they won’t buy a bunch that just go bad in their medicine cabinets. Medicaid restricts Zofran to 17 a month in my state anyway. That always sucks with the hyperemesis gravadarum patients. “I out of my Zofran and here in the ER to get admitted for the reat of the month again!” Damn Medicaid.

-I offer patients Bicillin injections in the ED. I tell them “It’ll hurt like hell but you won’t have to fill a prescription or worry about keeping up with the pills.” I don’t push them on it but I offer it.

-Putting people on a respiratory quinalone is a real crap shoot. I get lots of calls about how Levaquin isn’t covered and I need to switch it to Cipro. I explain that Cipro doesn’t work for respiratory but you’re fighting the bureaucracy so it’s hopeless. If I have to send someone out on a respiratory quinolone I write 3 scripts, 1 for Levaquin, 1 for Avalox and 1 for Gatiflox. I then write on the scripts “Fill whichever one of these will be covered by your plan.” I show them the scripts and explain the plan. Don’t try this with stupid people or they might fill all three.

-If you put someone on Pyridium for their UTI you’ve gotta tell them it will turn their urine orange. If you don’t you’ll just see them again the next day for their orange pee.

More as I think of them.

[highdesert]

All good suggestions.

I have something that I do that works well... I prescribe narcotics only in multiples of a specific number (nope, not posting it here). It isn't 10. I prescribe anxiolytics only in multiples of another number. If I, or any of my partners receive a call along the lines of "did you prescribe X amount of Vicodin?", it's generally easy to know if I did or not without pulling up their chart. It is *always* a multiple of my fixed number. So, no, I did not prescribe 20 Vicodins to so and so...

[Apollyon]

Originally Posted by highdesert

All good suggestions.

I have something that I do that works well... I prescribe narcotics only in multiples of a specific number (nope, not posting it here). It isn't 10. I prescribe anxiolytics only in multiples of another number. If I, or any of my partners receive a call along the lines of "did you prescribe X amount of Vicodin?", it's generally easy to know if I did or not without pulling up their chart. It is *always* a multiple of my fixed number. So, no, I did not prescribe 20 Vicodins to so and so...

I'll tell anyone - I always write for an odd number, and usually prime - so there's NO question. 11, 13, 17, and 19 are your buddies.

[waterski232002]

Instead of respiratory quinolones for CAP, I write for doxycycline when I know a patient will have problems paying for the antibiotics. Doxy is dirt cheap.

[GeneralVeers]

When I write for an antibiotic, AND a narcotic to someone who is suspicious for drug seeking, I always write: "Pharmacist, only fill vicodin with penicillin".

Every time I do that I get a call, because the patient only wants to fill the vicodin.

[docB]

Originally Posted by waterski232002

Instead of respiratory quinolones for CAP, I write for doxycycline when I know a patient will have problems paying for the antibiotics. Doxy is dirt cheap.

Yeah I don't write for those often but when I do for one reason or another I do the 3 Rx thing.

[FoughtFyr]

For the seekers oxaprozin. The "ox" means it must be related to oxycodone and hey, you are treating their pain!



- H

[southerndoc]

Originally Posted by GeneralVeers

When I write for an antibiotic, AND a narcotic to someone who is suspicious for drug seeking, I always write: "Pharmacist, only fill vicodin with penicillin".

Every time I do that I get a call, because the patient only wants to fill the vicodin.

Nice, I love it! I'll have to remember that one!

[DropkickMurphy]

Originally Posted by FoughtFyr

For the seekers oxaprozin. The "ox" means it must be related to oxycodone and hey, you are treating their pain!



- H

I've yet to figure out the attraction to narcotics abuse(I know why they abuse them, I just don't understand it)......the one time I was given Oxycontin (by a oral surgeon after a wisdom tooth extraction) I spent the entire night watching the ceiling rotating behind a stationary fan and trying not to hurl while desperately clinging to the carpet to control the vertigo......

[GeneralVeers]

Originally Posted by DropkickMurphy

I've yet to figure out the attraction to narcotics abuse(I know why they abuse them, I just don't understand it)......the one time I was given Oxycontin (by a oral surgeon after a wisdom tooth extraction) I spent the entire night watching the ceiling rotating behind a stationary fan and trying not to hurl while desperately clinging to the carpet to control the vertigo......

A crusty old attending I worked with at St. Francis in Indianapolis used to prescribe Dilobid to drug seekers. It's essentially an old non-steroidal drug, but all the seekers thought they were getting Dilaudid.

[bartleby]

1. Those asking for "The pain medicine that starts with a 'D'", get dolobid (say "duhlawbid") instead of dilaudid. By the time they figure it out, they're staring incredulously at the bottle while their irritated nasal mucosa is getting some of that sweet, sweet NSAID loving from those crushed & snorted tablets.

2. Simple is better for the elderly who have moderate to severe pain. Percocet gives too much oxycodone and not enough tylenol for what most eldelry need. Instead, have them take the max dose of tylenol 'round the clock (1,000mg q6h) and half to one 5mg tablet of plain oxycodone q4-6h. If they're getting the right dose of tylenol they will have a lower narcotic med requirement.

2a. Anybody (esp over 40) who gets more than one or two days worth of a narcotic gets a script or specific instruction for a stool softener. An ounce of colace is worth a pound of manual rectal disimpaction.

2b. NSAIDs are ideally avoided in the elderly. If they must be used, suggest no more than OTC dosing.

[NinerNiner999]

I liked Zofran until I found out just how much it really was:

Tablets (Zofran)
4 mg (10): $223.08
8 mg (10): $365.53
24 mg (10): $1008.41

[sdn1977]

Great thread!

Those of us who work with you usually know your tricks......

That's Dolobid - not Dilobid....still used sometimes....not often

Yeah - I've seen only fill vicodin w/ antibiox...but, no can do - if they want the vicodin, I fill it.....can't do otherwise, sorry.....to give you some comfort though....they usually come back 3 days later with a rip roaring infection & no pain pills

I LOVE it when you give me a choice....quinolone, proton-pump inhib, whatever....I run them all & give the pt the best price...but I can only do that if you give me the option. The best way to do this is to write all of them on the same rx & specifiy for me to fill only the least expensive of the choices - otherwise, separate rxs can be taken around - although, who wants extra Protonix????

The attraction to abuse....not always for the individual's own use - often for the street value of the drug - it beats working in McD's! Vicodin in some neighborhoods runs $1-$8/tab...

Pyridium - doesn't need an rx - tell them to buy Azo or generic - its 95mg - take 2 & is available in most grocery stores & drug stores 24h/d without rx - less expensive than me....oh - & it permanently stains contact lenses - be sure to tell them that - orange urine is just messy & stressful.....stained contact lenses is expensive!

Steroid decreases.....don't make it so complicated the pt doesn't get it....especially when you've referred them to their pulmonologist, rheumatologist, etc....make it simple because they will surely get it mixed up (or their son, daughter, spouse)!!!

Don't write for the most expenisve inhalers - albuterol & separate steroids - most combinations don't fly unless they have good insurance.

If you can - give the spacer in the hospital - few insurances pay for spacers.

Check what your PA wrote - especially if he/she is new....we get most of our crazy orders from new PA's who are writing for you.

It doesn't matter if you write for me to label in spanish, russian, mandarin, etc.....it gets labeled in english unless the pharmacist who is dispensing speaks that language - so be sure you have educated your pt thru an interpreter or yourself, because you can't be sure we will label it in any other language than english.

Assume your pt won't bring in the rx - their child, spouse, friend, SO, whomever will bring it to me...so I often don't get the chance to educate. Be sure to highlight the big areas - drowsiness, ETHO/metronidazole, food, etc...

Please, please, please...if your dose for a child is out of the norm...please note that you are aware. That is the ONLY time I will insist to speak with you......over 30 years...I'm running 50/50 on dosing errors in children (with the exception of pediatricians..)...so if you are writing for an unusual dose - make a note of the pts wt/bsa & note that you are aware of the the unusual dose & acknowledge you want it to be as you've written - then I won't call.

Thanks for making my life better!!!!! I'll try to think of more as you all post.....(I really hope you don't dread my call -when I do part-time as a hospital pharmacist you're all really nice ).

[DropkickMurphy]

Originally Posted by GeneralVeers

A crusty old attending I worked with at St. Francis in Indianapolis used to prescribe Dilobid to drug seekers. It's essentially an old non-steroidal drug, but all the seekers thought they were getting Dilaudid.

Which attending.....I think I may know who you are talking about.....PM me if you prefer....

[beyond all hope]

Doxy, Bactrim and Amox are all good antibiotics and very cheap. Doxy works for mild pneumonias, Bactrim works for mild sinusitis.

Azithromycin is now generic! If you write for a Z-pack make certain the pharmacy will consider generics (different for every state).

Penicillin works just as well as Clinda in the mouth, much cheaper, less C. Diff (doesn't cover Staph so not for skin)

When I'm giving a long course of antibiotics (esp Clinda) to anyone I consider giving Lactobacillus or just tell them to eat yogurt with active cultures to prevent Abx diarrhea or C. Diff. Any female on a long course of Abx, esp DM, gets a single dose of Diflucan at the end to prevent candida.

Not a big fan of Bicillin - painful, dangerous if anaphylaxes, and Pen VK is cheap.

If I have an poor asthmatic who needs Advair I order 2 puffs from the pharmacy and then give the rest to the patient. Agree with spacers - give in ED.

If I'm really in a bind with a sick asthmatic that won't fill prescriptions I'll order 300 mg PO prednisone, give the patient 100 now and have him take the other 4 tabs home to take daily - 10 cents/pill to prevent a potentially life-threatening relapse. You'll get some funny looks for that one and maybe a call from the pharmacy.

If you have a tooth that you think is a seeker, do a block with a long-acting anesthetic (which you can bill for) and give them Tylenol. Headaches get antiemetics and Tylenol.

Any other seekers, if you really think they're abusing, make up a BS pseudomedical reason that you can't give them narcs (Sir, I'd love to give you Vicodin, but it will worsen your constipation, which will make your abdominal condition worse...I'd like to give you Morphine for your chest pain but it can cause an unsafe drop in your blood pressure...I'd like to give you Dilaudid but it could mask signs of serious injury, etc.) Once you make it clear they're not going to get narcs, they stomp out, and you have time to treat people with real medical problems.

[DrQuinn]

Good tips for all.......

Don't forget "I can't give you demerol, I dont' want to give you serotonin syndrome...."

Dolobid looks like it would work, I perused the pharmacopeia while on the crapper once in my M3 year and ran across it on accident, I thought I had found the gold-mine....

Reglan/Benadryl Rx to go for migraines/headaches.

Trazodone for sleep/insomnia (after warned about priapism)

Instead of writing for Clinda 300 mg, I have heard from pharmacists that it is cheaper to go for 2 po tabs of 150..........

Q

[a_ditchdoc]

Originally Posted by NinerNiner999

I liked Zofran until I found out just how much it really was:

Tablets (Zofran)
4 mg (10): $223.08
8 mg (10): $365.53
24 mg (10): $1008.41

The PICU at Columbia Presbyterian uses only Zofran for nausea, they do not consider anything else. I looked it up on the web and saw that it can cost up to $100 per dose. It is nice that the kids get the best antiemetic possible with the least side effects, but Jeez... $300 per day for prophylactic Rx of nausea?

[GeneralVeers]

Originally Posted by DropkickMurphy

Which attending.....I think I may know who you are talking about.....PM me if you prefer....

I'll give you a hint, his name starts with K, and he is hard of hearing.

He's my role-model for the ornery, but caring ED physician. If you see him, tell him I said hi.

[DropkickMurphy]

Originally Posted by GeneralVeers

I'll give you a hint, his name starts with K, and he is hard of hearing.

He's my role-model for the ornery, but caring ED physician. If you see him, tell him I said hi.

I think we're thinking of the same person. Unfortunately I don't get over to Indy much anymore......

[edinOH]

Percogesic:

APAP/Phenyltoloxamine

It is my friend.

That and atarax.

"Ma'am, it isn't XanaX, it's AtaraX. They're similar, but different. They both will help you sleep. You really should follow up with your physician next week if you want more Xanax."

[GeneralVeers]

I love it when I prescribe an NSAID and patients say "Will it make me sleepy?"

I always answer: "Yes, that could happen. Just be very careful not to drive or work right after taking your Dolobid, as it could be dangerous"

[basementbeastie]

for those times when a opiod *is* indicated....i always type the # prescribed into our computerized DC instructions....very easy to check when the pharmacy calls asking about the script for PERCOCET DISPENSE # 190!

[gree0411]

Someone who has a longer attention span than I do needs to compile a list of all of these tidbits of information to keep in our pockets while on shift.

[mikecwru]

Originally Posted by basementbeastie

for those times when a opiod *is* indicated....i always type the # prescribed into our computerized DC instructions....very easy to check when the pharmacy calls asking about the script for PERCOCET DISPENSE # 190!

We rarely get calls like this, I'm assuming because our rxs are computerized and it writes the # out as well (disp #10 (TEN))

mike

[basementbeastie]

Originally Posted by mikecwru

We rarely get calls like this, I'm assuming because our rxs are computerized and it writes the # out as well (disp #10 (TEN))

mike

while at the mothership we have to hand write scripts; our 'community' ED does have computer printed scripts......

[Apollyon]

Originally Posted by basementbeastie

while at the mothership we have to hand write scripts; our 'community' ED does have computer printed scripts......

On the handwritten for controlled substances, I do Arabic numbers (1, 2, 3, etc), spell it out, and Roman numerals.

[Flopotomist]

I hope some marketing guru from a pharm. company is reading this... if they name the next aspririn/caffeine pill "Morphaline" or "Darvoclet" they could make a KILLING.

[basementbeastie]

Originally Posted by Apollyon

On the handwritten for controlled substances, I do Arabic numbers (1, 2, 3, etc), spell it out, and Roman numerals.

i do something like --> disp: #3 (three)

i have fielded many a call for scripts written by interns, etc for outrageous # of percs....

[basementbeastie]

Originally Posted by basementbeastie

i do something like --> disp: #3 (three)

i have fielded many a call for scripts written by interns, etc for outrageous # of percs....

these were, of course, fradulent....

[bulgethetwine]

With apologies to those posts that I edited, paraphrased, missed, or didn't include for my own silly reasons, here is a summary of the advice on this thread so far:

Antibiotics

For penicillin coverage, unless you’re dealing with a bite, use amoxicillin.

Penicillin works just as well as Clinda in the mouth, much cheaper, less C. Diff (doesn't cover Staph so not for skin)

Azithromycin is now generic! If you write for a Z-pack make certain the pharmacy will consider generics (different for every state).

Consider Bicillin injections in the ED. I tell them “It’ll hurt like hell but you won’t have to fill a prescription or worry about keeping up with the pills.” I don’t push them on it but I offer it…

When giving a long course of antibiotics (esp Clinda), consider giving Lactobacillus or just tell them to eat yogurt with active cultures to prevent Abx diarrhea or C. Diff.

Females on long course Abx (esp DM) – give a single dose of Diflucan to prevent candida.

Since levaquin is expensive and cipro doesn’t work for resp, consider writing 3 scripts, 1 for Levaquin, 1 for Avalox and 1 for Gatiflox. Then write on the scripts “Fill whichever one of these will be covered by your plan.” I show them the scripts and explain the plan. Don’t try this with stupid people or they might fill all three.

Doxy, Bactrim and Amox are all good antibiotics and very cheap. Doxy works for mild pneumonias, Bactrim works for mild sinusitis.

If you put someone on Pyridium for their UTI you’ve gotta tell them it will turn their urine orange. If you don’t you’ll just see them again the next day for their orange pee.

Antiemetics

Phenergan is an inexpensive anti-emetic, and consider writing for both the pills and the suppositories. If you must prefer the more expensive zofran (chewable?) consider writing for 5 or 10 at a time with 2 refills – that way they won’t buy a bunch that just go bad in their medicine cabinets.

Price of zofran:

4 mg (10): $223.08
8 mg (10): $365.53
24 mg (10): $1008.41

Asthma meds

If I'm really in a bind with a sick asthmatic that won't fill prescriptions I'll order 300 mg PO prednisone, give the patient 100 now and have him take the other 4 tabs home to take daily - 10 cents/pill to prevent a potentially life-threatening relapse. You'll get some funny looks for that one and maybe a call from the pharmacy.

Steroid decreases.....don't make it so complicated the pt doesn't get it....especially when you've referred them to their pulmonologist, rheumatologist, etc....make it simple because they will surely get it mixed up (or their son, daughter, spouse)!!!

Don't write for the most expenisve inhalers - albuterol & separate steroids - most combinations don't fly unless they have good insurance.

If you can - give the spacer in the hospital - few insurances pay for spacers.

Pain Meds

Prescribe narcotics in a particular “code”: I use prime numbers – others have a secret “multiple” so they can know in an instant if their script has been doctored.

For drug seekers: oxaprozin - The "ox" means it must be related to oxycodone and hey, you are treating their pain!

Some suggested “Dilobid” – essentially an old non-steroidal.

Simple is better for the elderly who have moderate to severe pain. Percocet gives too much oxycodone and not enough tylenol for what most eldelry need. Instead, have them take the max dose of tylenol 'round the clock (1,000mg q6h) and half to one 5mg tablet of plain oxycodone q4-6h. If they're getting the right dose of tylenol they will have a lower narcotic med requirement.

Anybody (esp over 40) who gets more than one or two days worth of a narcotic gets a script or specific instruction for a stool softener. An ounce of colace is worth a pound of manual rectal disimpaction.

NSAIDs are ideally avoided in the elderly. If they must be used, suggest no more than OTC dosing.

If you have a tooth that you think is a seeker, do a block with a long-acting anesthetic (which you can bill for) and give them Tylenol. Headaches get antiemetics and Tylenol.

Any other seekers, if you really think they're abusing, make up a BS pseudomedical reason that you can't give them narcs (Sir, I'd love to give you Vicodin, but it will worsen your constipation, which will make your abdominal condition worse...I'd like to give you Morphine for your chest pain but it can cause an unsafe drop in your blood pressure...I'd like to give you Dilaudid but it could mask signs of serious injury, etc.) Once you make it clear they're not going to get narcs, they stomp out, and you have time to treat people with real medical problems.

Don't forget "I can't give you demerol, I don’t want to give you serotonin syndrome...."

Reglan/Benadryl Rx to go for migraines/headaches.

Trazodone for sleep/insomnia (after warned about priapism)

Percogesic: APAP/Phenyltoloxamine

Atarax has utility for some here, too.

Other words from a Farmy not included above:

I LOVE it when you give me a choice....quinolone, proton-pump inhib, whatever....I run them all & give the pt the best price...but I can only do that if you give me the option. The best way to do this is to write all of them on the same rx & specifiy for me to fill only the least expensive of the choices - otherwise, separate rxs can be taken around - although, who wants extra Protonix????

Pyridium - doesn't need an rx - tell them to buy Azo or generic - its 95mg - take 2 & is available in most grocery stores & drug stores 24h/d without rx - less expensive than me....oh - & it permanently stains contact lenses - be sure to tell them that - orange urine is just messy & stressful.....stained contact lenses is expensive!

It doesn't matter if you write for me to label in spanish, russian, mandarin, etc.....it gets labeled in english unless the pharmacist who is dispensing speaks that language - so be sure you have educated your pt thru an interpreter or yourself, because you can't be sure we will label it in any other language than english.

Assume your pt won't bring in the rx - their child, spouse, friend, SO, whomever will bring it to me...so I often don't get the chance to educate. Be sure to highlight the big areas - drowsiness, ETHO/metronidazole, food, etc...

Please, please, please...if your dose for a child is out of the norm...please note that you are aware. That is the ONLY time I will insist to speak with you......over 30 years...I'm running 50/50 on dosing errors in children (with the exception of pediatricians..)...so if you are writing for an unusual dose - make a note of the pts wt/bsa & note that you are aware of the the unusual dose & acknowledge you want it to be as you've written - then I won't call.

[gree0411]

[QUOTE=bulgethetwine;4301040]With apologies to those posts that I edited, paraphrased, missed, or didn't include for my own silly reasons, here is a summary of the advice on this thread so far:

Thanks. That is an awesome summary. Try to edit and update it as more people post.

[GeneralVeers]

That summary should be a sticky. All interns should have to read that.

[DropkickMurphy]

Originally Posted by GeneralVeers

That summary should be a sticky. All interns should have to read that.

If you can - give the spacer in the hospital - few insurances pay for spacers.

I buy a box of them whenever I can so I can donate them to patients I see in the ER as an RT that can't afford them. They aren't THAT expensive before you figure in the hospital's markup.

[Flopotomist]

Originally Posted by DropkickMurphy

I buy a box of them whenever I can so I can donate them to patients I see in the ER as an RT that can't afford them. They aren't THAT expensive before you figure in the hospital's markup.

isn't that what toilet paper tubes are for?

[Febrifuge]

Originally Posted by GeneralVeers

When I write for an antibiotic, AND a narcotic to someone who is suspicious for drug seeking, I always write: "Pharmacist, only fill vicodin with penicillin".

Every time I do that I get a call, because the patient only wants to fill the vicodin.

I took a call once from a very on-the-ball pharmacist who noticed the pt was filling just the narcs. When I asked the staff doc, he was like, "hey, the pharmacist should do what they think is right." No soup for that guy.

[dilated]

Originally Posted by NinerNiner999

I liked Zofran until I found out just how much it really was:

Tablets (Zofran)
4 mg (10): $223.08

Zofran is set to go generic this year, right? Anybody know when the price ought to become reasonable?

[Dimoak]

Originally Posted by dilated

Zofran is set to go generic this year, right? Anybody know when the price ought to become reasonable?

According to a Canadian online pharmacy:

4mg Ondansetron HCl Tabs #10 = $64.99 (US)
8mg Ondansetron HCl Tabs #10 = $86.99 (US)

This pharmacy normally sells 4mgs and 8mgs of the same # as Zofran for $146.99 and $209.99 respectively, so we can probably expect the generics to cost a little less than 50% of what Zofran is in the US as well.

[Doczilla]

Originally Posted by dilated

Zofran is set to go generic this year, right? Anybody know when the price ought to become reasonable?

I picked up 2 4mg vials of the IV form for my EMS kit and it ran me $2.60.

'zilla

[EctopicFetus]

the Zofran ODT is still expensive,

[docB]

WalMart has a list of drugs that they'll fill for $4. I prescribe heavily off that list now.

[edinOH]

Love zofran ODT.

Works great but too damned expensive.