Amphetamine Dosing

[FarmD711]

Most of the references I have found seem to indicate that total doses of Adderall > 60 mg/day aren't really any more effective than 60 mg would be.

We have started receiving prescriptions for 80 mg, 120 mg, even up to 240 mg/day at my pharmacy.

I'm wondering what rationale or process other pharmacists follow in terms of verifying appropriateness. I have turned away several patients with 240 mg/day Rxs, saying I need to speak with a Dr first. They always take the prescription back and don't want to wait. Several of them have filled them at other stores in the chain (obviously without that pharmacist verifying, because it was after hours). Am I being too careful? Is 120 mg or 240 mg/day reasonable? Two of these particular patients used no insurance so that was another red flag for me but apparently not for the other pharmacist.

---

Members don't see this ad.

 

[zelman]

One of two situations: diversion or terrible doctor. It is entirely possible that these patients' doctors slowly escalated their doses of a substance upon which they became progressively more dependent to the point of needing an obscene dose. It's like an addict on 1g of diazepam a day: it's not an appropriate dose, but taking them down to 10 mg TID will cause a seizure.

 

[FarmD711]

I'm uncomfortable with this particular doctor anyway, but I feel like a blanket refusal to fill any Rx for >60 or 80 mg/day is not necessarily the right course of action. It's a tough balance between satisfying the DEA and the patient (should there be patients out there who truly need that type of dose).

 

[klaurent02]

Looks like some patients trying to stretch out their prescriptions.

 

[Wheresmyaricept]

I actually know of a girl on a crazy high dose like this because she is a rapid metabolizer. These people probably aren't.

 

[StellargalS]

I actually know of a girl on a crazy high dose like this because she is a rapid metabolizer. These people probably aren't.

What kind of assay will provide the appropriate objective data for routine clinical practice?

 

[zelman]

What kind of assay will provide the appropriate objective data for routine clinical practice?

It's not so simple. The blood levels will vary based on 3 factors. Absorption is controlled by gastric pH, metabolism is controlled by CYP2D6 and elimination is controlled by urinary pH. I don't know that the evaluation of all of these should be "routine".

 

[FarmD711]

It's not so simple. The blood levels will vary based on 3 factors. Absorption is controlled by gastric pH, metabolism is controlled by CYP2D6 and elimination is controlled by urinary pH. I don't know that the evaluation of all of these should be "routine".

Then how should a community pharmacist proceed when presented with a prescription for 240 mg/day of Adderall.

 

[npage148]

Then how should a community pharmacist proceed when presented with a prescription for 240 mg/day of Adderall.

Call the Dea.

 

[Wheresmyaricept]

Call the Dea.

This.

 

[Muse600]

I've seen one...about 180mg/day...took 2-3 weeks to hear back from the md (who's been seeing the pt for years) said pt is really just intolerant to lower doses

I'm relatively new, but I've been using judgment call with the usual cues: new pt? cash pt? address closer to other pharmacies? state Rx drug monitoring show polypharmacy? doctor far away? pt's appearance? asking for specific manufacturer? 45 y'old loud surfer dude trying to befriend me any way possible? I'm not a tough/intimidating looking dude, but if I ask some of the basic questions & make direct eye contact, I also read their body language to see if they're trying to slip a fast one by me (ie. keep looking down because they know they're doing something wrong? very tense until I say I can or can't fill it? staring back at me aggressively to see if I'm lying about having it in stock?)

 

[FarmD711]

I've seen one...about 180mg/day...took 2-3 weeks to hear back from the md (who's been seeing the pt for years) said pt is really just intolerant to lower doses

I'm relatively new, but I've been using judgment call with the usual cues: new pt? cash pt? address closer to other pharmacies? state Rx drug monitoring show polypharmacy? doctor far away? pt's appearance? asking for specific manufacturer? 45 y'old loud surfer dude trying to befriend me any way possible? I'm not a tough/intimidating looking dude, but if I ask some of the basic questions & make direct eye contact, I also read their body language to see if they're trying to slip a fast one by me (ie. keep looking down because they know they're doing something wrong? very tense until I say I can or can't fill it? staring back at me aggressively to see if I'm lying about having it in stock?)

But is intolerance to lower doses really a therapeutic justification for a dose like that? I had another one today for 180 mg/day. Drs nurse told me just to have them fill it where they normally fill it if I'm not comfortable with it. He has picked it up a few times at other nearby stores in the chain and reacted very badly to me telling him I'm not comfortable with it and won't fill it.

It seems alot of the nearby stores in my chain and other pharmacists in my store don't have a problem with dosing like this. Maybe it's alert fatigue, they feel too busy to care...I don't know. Noone else seems to be questioning doses >80 mg and it makes it harder for me because the patients keep saying "the other guy fills it no problem". That's not gonna make me change my mind, but am I being too strict with this?

 

[KidPharmD]

Wouldn't fill it.
When I did retail full time, I was perfectly okay with another pharmacist filling something I wasn't comfortable. Then it becomes between the doctor, the patient, and that pharmacist and isn't my problem anymore.
"The other guy fills it..." is never a good reason to fill something. The other guy could be an idiot, reckless, or non-existant.
This is what it would take for me to fill it... A patient who has been documented (same doc) to fail pretty much everything else, ability to check a CSMD on the patient everytime, fills at my store (or one of my chain) everytime, never more than 2 days early, agreement from the doctor to write a case report "Extremely high dose mixed amphetamine salts is safe in effective in an adult with ADHD resistant to other therapies." - With my name first.

If you aren't positive you are okay with this, remember if this patient has a seizure or an MI and its due to excessive adderall, the family will include you in the lawsuit.

 

[All4MyDaughter]

Then how should a community pharmacist proceed when presented with a prescription for 240 mg/day of Adderall.

Look at RX history.
Talk to the patient.
Call the doctor.
Go from there.

 

[pharmacy7424]

Call the Dea.

I'm not sure why anybody would want to attract DEA attention to themselves...what good could come of it? You are not playing cop as a pharmacist

Just tell them you don't have it in stock and to go somewhere else

 

[FarmD711]

Look at RX history.
Talk to the patient.
Call the doctor.
Go from there.

This would be my typical thought process. I guess what I'm struggling with is what possible therapeutic justification for 180-240 mg of adderall per day would be acceptable?

 

[All4MyDaughter]

This would be my typical thought process. I guess what I'm struggling with is what possible therapeutic justification for 180-240 mg of adderall per day would be acceptable?

I guess I'd just see what the prescriber said and see if it sounds reasonable?

 

[Muse600]

But is intolerance to lower doses really a therapeutic justification for a dose like that? I had another one today for 180 mg/day. Drs nurse told me just to have them fill it where they normally fill it if I'm not comfortable with it. He has picked it up a few times at other nearby stores in the chain and reacted very badly to me telling him I'm not comfortable with it and won't fill it.

It seems alot of the nearby stores in my chain and other pharmacists in my store don't have a problem with dosing like this. Maybe it's alert fatigue, they feel too busy to care...I don't know. Noone else seems to be questioning doses >80 mg and it makes it harder for me because the patients keep saying "the other guy fills it no problem". That's not gonna make me change my mind, but am I being too strict with this?

again - in my limited experience (as other posters have stated), at that point in time the discussion with the doctor is the therapeutic justification, and documentation is important.

but it sounds like there might be an element you and I both share: we lack balls

honestly, some of being a pharmacist is just having balls. If you don't feel comfortable filling it, put on your PO'd vin diesel face, and give him a very stern explanation. Let him get upset, but stand your ground. If you're new, you'll do it a few times and get better at it.

 

[FarmD711]

again - in my limited experience (as other posters have stated), at that point in time the discussion with the doctor is the therapeutic justification, and documentation is important.

but it sounds like there might be an element you and I both share: we lack balls

honestly, some of being a pharmacist is just having balls. If you don't feel comfortable filling it, put on your PO'd vin diesel face, and give him a very stern explanation. Let him get upset, but stand your ground. If you're new, you'll do it a few times and get better at it.

This is exactly what I've done. Both the Dr and the patient are saying that this makes me unreasonable because they've never had a problem before with any other pharmacist. And this is true. It has been filled for years (180-240 mg/day) by other stores in my chain nearby. They were all out of stock so he came to me. I have no problem telling him I"m not going to fill it. I have no problem even saying as a blanket statement that I'm not going to fill any amphetamine Rxs over 80 mg/day. I'm just wondering how other RPhs have handled this, am I being unreasonable, and is there any therapeutic justification for dosing of amphetamines that high.

 

[RealityRx]

I'm just wondering how other RPhs have handled this, am I being unreasonable, and is there any therapeutic justification for dosing of amphetamines that high.

"I'm so sorry, ma'am. I'd love to be able to fill this for you, but I only have 23 pills left in stock until the next delivery. I'll give them to you, but then it cancels out the rest of your rx and you'll have to have it written again. I mean, I will, if that's ok with you..."

Works every single time. Keeps everyone happy.

 

[Muse600]

This is exactly what I've done. Both the Dr and the patient are saying that this makes me unreasonable because they've neve
that
r had a problem before with any other pharmacist. And this is true. It has been filled for years (180-240 mg/day) by other stores in my chain nearby. They were all out of stock so he came to me. I have no problem telling him I"m not going to fill it. I have no problem even saying as a blanket statement that I'm not going to fill any amphetamine Rxs over 80 mg/day. I'm just wondering how other RPhs have handled this, am I being unreasonable, and is there any therapeutic justification for dosing of amphetamines that high.

This is exactly what I've done. Both the Dr and the patient are saying that this makes me unreasonable because they've never had a problem before with any other pharmacist. And this is true. It has been filled for years (180-240 mg/day) by other stores in my chain nearby. They were all out of stock so he came to me. I have no problem telling him I"m not going to fill it. I have no problem even saying as a blanket statement that I'm not going to fill any amphetamine Rxs over 80 mg/day. I'm just wondering how other RPhs have handled this, am I being unreasonable, and is there any therapeutic justification for dosing of amphetamines that high.

(again, in my very limited experience!) I think you did well - this now sets the precedent for you and keeps the riff-raff off of your shift. The druggies are going to to keep pushing until they get what they want, but if you stand your ground, they will just give up on you and go to another pharmacy. I once floated to a different store, saw the same doctor shopper as I saw from a different store. All it took was for him to look at me, utter a comment under his breath, and walk right back out.

And if you think about it - you have the upper hand. They want what you have...and what you have has strict rules and regulations surrounding it. Starting a fight with you, or being rude to you isn't going to make it any more likely that you're going to fill it. And in the end, it's your license to protect...your #1 obligation is to the board of pharmacy that licenses you...

however, IMHO, the reality of it is that the stores I've floated to, MOST places have a standard answer of "we don't have it...we can't get it...it's on backorder...we only send out our order once/month, can you wait?"

 

[PikminOC]

Most of the references I have found seem to indicate that total doses of Adderall > 60 mg/day aren't really any more effective than 60 mg would be.

We have started receiving prescriptions for 80 mg, 120 mg, even up to 240 mg/day at my pharmacy.

I'm wondering what rationale or process other pharmacists follow in terms of verifying appropriateness. I have turned away several patients with 240 mg/day Rxs, saying I need to speak with a Dr first. They always take the prescription back and don't want to wait. Several of them have filled them at other stores in the chain (obviously without that pharmacist verifying, because it was after hours). Am I being too careful? Is 120 mg or 240 mg/day reasonable? Two of these particular patients used no insurance so that was another red flag for me but apparently not for the other pharmacist.

Calling the doc is a good idea. Someone had forged my scrips. The person sent my scrip to have them make more and write whatever medications they wanted.
There are some situations such as bariatric surgery where the increases in doses are needed for absorption. But then I just switch to Daytrana.

 

[PikminOC]

I've seen one...about 180mg/day...took 2-3 weeks to hear back from the md (who's been seeing the pt for years) said pt is really just intolerant to lower doses

I'm relatively new, but I've been using judgment call with the usual cues: new pt? cash pt? address closer to other pharmacies? state Rx drug monitoring show polypharmacy? doctor far away? pt's appearance? asking for specific manufacturer? 45 y'old loud surfer dude trying to befriend me any way possible? I'm not a tough/intimidating looking dude, but if I ask some of the basic questions & make direct eye contact, I also read their body language to see if they're trying to slip a fast one by me (ie. keep looking down because they know they're doing something wrong? very tense until I say I can or can't fill it? staring back at me aggressively to see if I'm lying about having it in stock?)

This is good. Especially checking the Rx monitoring program. I don't get a chance to check it on all my patients so I appreciate it when a pharmacist lets me know. I don't get annoyed with pharmacists. We are all working together!

 

[BidingMyTime]

I'm just wondering how other RPhs have handled this, am I being unreasonable, and is there any therapeutic justification for dosing of amphetamines that high.

People are individuals, and there is always going to be some 1 in a billion exception to the rule. Personally, I have never seen a dose of amphetamine that high...if I did, I would be calling the doctor. I have filled RX's of extremely unusually dosing after getting valid justification/evidence from the prescriber. I wouldn't blanket say I would never fill that dosage, especially when the patient has been on that dosage--but I would have to investigate before filling. Don't be afraid to talk to the patient, don't be afraid to call the prescriber. Usually after talking to them, it will be obvious if its a prescription you should or shouldn't fill.

 

[D1CE K]

That high of a dose and their just abusing. That euphoria.

 

[DustinfromCA]

Vyvanse 140mg (70mg am, 70mg afternoon) for a young child? Previously only 70mg. Call and verify and fill? Or is it reasonable to refuse to fill such a high dose for a pediatric patient? I personally have never seen such big jump in dose.. usually 10-20mg dose increase per script. Very odd. And over max dose.

I always wonder how much liability we as pharmacists have when something goes awry but you took all the proper steps to verify the correct dosage.

 

[PikminOC]

Vacation dosing?

 

[ldiot]

I wouldn't use a blanket statement such as "I'll never fill a dose over 60mg/day" because you have unique situations but I WOULD refuse all CIIs from a particular doctor if many of their scripts are like this because you have then established a trend.

 

[Old Timer]

Pharmacist: I don't feel comfortable filling this
Doctor: Nobody else has a problem
Pharmacist: Then they should have no trouble getting it filled elsewhere.

I don't give a F**K what anyone says. If my gut says no, then it's no. Unless they have some data to backup giving this dosage, I would refuse. If there are multiple patients from the same doctor then definitely refuse and report the precriber to the DEA and the state.

Any doctor prescribing a dose that is higher than the usual maximum dose should have a reasonable explanation they should be willing to share with you. Sometime in the late 90's I received an RX from the local cancer hospital for MS-Contin 100 mg 18 tablets every 12 hours. Called the MD and it turned out the patient had end stage metastatic (Bone, Brain & liver) prostate cancer and was a serious heroin user. There was no way 15 pr 30 mg of Morphine was going to help this guy so I filled it. But it was a one off and the prescriber a reasonable explanation he was willing to share.

 

[Dr Wario]

Luckily or unluckily for us (depending on how you see it) we max out on almost every CII category every month so scripts like this are very simple. It really does not matter if it is legit or not, the fact of the matter is that giving someone this many pills will make it so we don't have drug for our regular customers who also get many non-controlled substances (thus letting us order more CIIs) so we don't have it in stock "for them".