Emergency supply

[BidingMyTime]

Under the legal provisions behind giving emergency supplies it is still illegal to give out controlled substances. Regardless of refill request or not pharmacists cannot give emergency controlled medications the same way they can for non-controlled. It's all subject to professional judgement which can be regulated by the board.

It depends on the state, IL law is vague and allows ES of any maintenance medicine (even if controlled), oxycodone or any pain medicine would not qualify, phenobarbital for seizures would.

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[BidingMyTime]

Denying a refill request isn't a vindictive punishment for the patient as some are painting. I can list a few common situations:

1. Post hospitalization discharge med script. A hospitalist or other exclusively inpatient provider initiates a new medication while patient is hospitalized and gives patient a script for varying length of time based upon provider comfort. After discharge the clinical relationship is terminated and responsibility is shifted to the outpatient doctor. The inpatient doctor will usually not refill as they aren't following pertinent labs or able to gauge symptomatic relief. It is up to the patient and outpt provider to decide if it should be continued and new long term script should be written.

2. Pt is on long term DM or HTN meds. There are certain clinical standards of care that must be met ie foot exam, eye exam, UA that must be done yearly and documented. These measures are going to be tied to reimbursements in the near future. Having finite limits "force" patients to return to office for re-eval to make sure things aren't progressing and patient is compliant.

3. The patient is partly responsible for knowing their med situation. Once they fill their last refill at the very least they should make an appt or call for a new script. It should never be a surprise to run out of a chronic med. The compliant ones are good about this. The noncompliant ones aren't and the last thing I want to do is give a non compliant patient a longer leash without coming into the office for education/discussion.

Thank you for explaining this, I am amazed a the number of pharmacists who've said they would give an ES after a refill was expressly denied by a physician. I have never met a pharmacist in real life who would do this. The sole idea of an ES is to make sure the patient does not go without a life maintenance drug solely because the physician can't be reached. Once the physician has been reached and has denied refills, then it would be illegal to give an ES.

 

[BidingMyTime]

Birth control

and there are pharmacists who really give out BC as an ES? BC is not a maintenance drug. Not to mention, Plan B can be bought without a prescription if they are unable to avoid a pregnancy-likely situation until their doctors office opens up.

 

[zelman]

and there are pharmacists who really give out BC as an ES? BC is not a maintenance drug. Not to mention, Plan B can be bought without a prescription if they are unable to avoid a pregnancy-likely situation until their doctors office opens up.

If someone has been on a med for 5 years with no dose changes and your option are A: bet that it'll be approved tomorrow and B: have them yell and scream and cry for 40 minutes, it seems reasonable to me.

 

[BidingMyTime]

If someone has been on a med for 5 years with no dose changes and your option are A: bet that it'll be approved tomorrow and B: have them yell and scream and cry for 40 minutes, it seems reasonable to me.

You need to be more assertive, let them throw a temper tantrum like a 2-year-old if they want, and then completely ignore in (if they start doing anything threatening or damaging, call the police.) Very few people are going to throw a temper tantrum....unless you are acting wishy-washy and they think they can sway you. I just tell people firmly & politely, "federal/state law does not allow me to do that. You need to call your dr." Just remember, the people who are willing to throw a fit for 40 minutes, will be the 1st one to sue you if anything goes wrong (they will blame you for their cervical cancer, because if only you hadn't given them that month of BCP, they would have been forced to go to the doctor and get their pap.) I've seen a couple of people sit quietly in my pharmacy's waiting room for over 2 hours, waiting for the next pharmacist to come on duty so they could give their sob story to them, but no one has ever harassed me for even 5 minutes, much less 40 minutes, because I make it crystal clear that what they want me to do is not allowed by law, and that I won't be breaking the law.

 

[zelman]

You need to be more assertive, let them throw a temper tantrum like a 2-year-old if they want, and then completely ignore in (if they start doing anything threatening or damaging, call the police.) Very few people are going to throw a temper tantrum....unless you are acting wishy-washy and they think they can sway you. I just tell people firmly & politely, "federal/state law does not allow me to do that. You need to call your dr." Just remember, the people who are willing to throw a fit for 40 minutes, will be the 1st one to sue you if anything goes wrong (they will blame you for their cervical cancer, because if only you hadn't given them that month of BCP, they would have been forced to go to the doctor and get their pap.) I've seen a couple of people sit quietly in my pharmacy's waiting room for over 2 hours, waiting for the next pharmacist to come on duty so they could give their sob story to them, but no one has ever harassed me for even 5 minutes, much less 40 minutes, because I make it crystal clear that what they want me to do is not allowed by law, and that I won't be breaking the law.

Don't get me wrong: I do not often do this. I'm just saying it has happened, and that's probably why the 30 day was mentioned.

 

[KidPharmD]

I have been trying to find the minutes from the board meetings, but the gist of the two cases, is that the pharmacists loaned more than they were allowed to which resulted in patient harm from one and potential for patient harm on the other (warfarin interaction). Both had actions against their licenses already. Both had physicians complain to the board, and both were old enough to surrender their license and not have to worry too much.

 

[Nguyen]

nope, at walmart we do not dispense an emergency supply if the doctor denies the refill request. but to be honest in reality even after youve dispensed an emergency supply the doctor can still deny the request (this is assuming that it took days for the denial to be received) so...

 

[confettiflyer]

and there are pharmacists who really give out BC as an ES? BC is not a maintenance drug. Not to mention, Plan B can be bought without a prescription if they are unable to avoid a pregnancy-likely situation until their doctors office opens up.

BC isn't exclusively used for pregnancy prevention.

 

[confettiflyer]

nope, at walmart we do not dispense an emergency supply if the doctor denies the refill request. but to be honest in reality even after youve dispensed an emergency supply the doctor can still deny the request (this is assuming that it took days for the denial to be received) so...

Right, but the information at the time you dispensed the ES was appropriate for the action. So you're describing two entirely different scenarios.

 

[Lnsean]

guys...it's 7 days of celexa...chill out. the intent was good. professionally speaking, it was the right thing to do with SSRIs unless maybe prozac.

 

[Lnsean]

I have been trying to find the minutes from the board meetings, but the gist of the two cases, is that the pharmacists loaned more than they were allowed to which resulted in patient harm from one and potential for patient harm on the other (warfarin interaction). Both had actions against their licenses already. Both had physicians complain to the board, and both were old enough to surrender their license and not have to worry too much.

he said she said isn't evidence

 

[eagles22]

guys...it's 7 days of celexa...chill out. the intent was good. professionally speaking, it was the right thing to do with SSRIs unless maybe prozac.

There's a lot of things a pharmacist could do with good intentions that violate the law or could harm the patient. Bottom line is there was a no not dispense order placed by the doctor that was violated. That is hard to defend should anything go wrong.

 

[Lnsean]

There's a lot of things a pharmacist could do with good intentions that violate the law or could harm the patient. Bottom line is there was a no not dispense order placed by the doctor that was violated. That is hard to defend should anything go wrong.

students without practical experience shouldn't really comment on these real life scenarios...I think OP is seeking advices from real practitioners...but do carry on.

 

[KidPharmD]

guys...it's 7 days of celexa...chill out. the intent was good. professionally speaking, it was the right thing to do with SSRIs unless maybe prozac.

I would pose that you cannot justify an illegal action as a professional action if there is a legal alternative.

he said she said isn't evidence

I wasn't intending to provide solid evidence or case law, just a relation of a relavent situation.

students without practical experience shouldn't really comment on these real life scenarios...I think OP is seeking advices from real practitioners...but do carry on.

The OP asked if a pharmacist was "allowed" to dispense the loaner supply. I would say this is a question of legality, not practical experience. A student with an appropriate knowledge of the letter of the law is just as qualified as an experienced pharmacist to answer this question. I knew a lot more about the letter of the law off the top of my head as a student right after my law class than I do now. Also, this is "Student Doctor"

 

[Lnsean]

I would pose that you cannot justify an illegal action as a professional action if there is a legal alternative.



I wasn't intending to provide solid evidence or case law, just a relation of a relavent situation.



The OP asked if a pharmacist was "allowed" to dispense the loaner supply. I would say this is a question of legality, not practical experience. A student with an appropriate knowledge of the letter of the law is just as qualified as an experienced pharmacist to answer this question. I knew a lot more about the letter of the law off the top of my head as a student right after my law class than I do now. Also, this is "Student Doctor"

see, every scenario in life isn't going to fit into those rules and laws that are in the books. that is why you went to school and are paid highly...to use your judgement. I can train a monkey to follow treatment guidelines and rules.

If it was just a matter of legality, then that should be easy...all OP has to do is look up his/her state's laws, not hocus pocus "he said she said" stuff online.

 

[Aznfarmerboi]

There's a lot of things a pharmacist could do with good intentions that violate the law or could harm the patient. Bottom line is there was a no not dispense order placed by the doctor that was violated. That is hard to defend should anything go wrong.

Not really.

... because that is why we went to pharmacy school which give us competency to understand what can or can not harm the patient. And from experience, I would give it to any of my regulars that need to find a new doctor for many reasons including,

... home bound and can not find somebody to help them go to the doctor,

could not make an appointment or have to wait to see another doctor because doctors are not accepting Medicaid/ Medicare anymore.

A doctor posted many valid reasons why the med is not refilled for other reasons...

etc.

If I give 7 days worth of Celexa to a regular patient of mines, he would not experience any side effects and will either get a new script or wont get anymore.

Anybody who can not see through that is probably a student or somebody or just recently graduated. Or think that his job is to count pills and dispense.

There are bigger things to fry...

 

[Lnsean]

Not really.

... because that is why we went to pharmacy school which give us the minimal competence to understand what can or can not harm the patient. And from experience, I would give it to any of my regulars that need to find a new doctor for many reasons including,

... home bound and can not find somebody to help them go to the doctor,

could not make an appointment or have to wait a while to see another doctor because doctors are not accepting Medicaid/ Medicare anymore.

etc.

If I give 7 days worth of Celexa to a regular patient of mines, he would not experience any side effects and will either get a new script or wont get anymore.

Anybody who can not see through that is probably somebody who is a student or somebody who just recently graduated. Or think that his job is to count pills and dispense.

There are bigger things to fry...

You're going to get downvoted because you have common sense and logic. These other people don't understand that while you can be taught what an SSRI is in school...you can't be taught clinical judgement and decision making.

 

[KidPharmD]

then that should be easy...all OP has to do is look up his/her state's laws, not hocus pocus "he said she said" stuff online.

Usually people have not been taught/ don't know how to search their state laws for information so they come here for an easier answer.

As previous posts from the OP have implied he is practicing in California, the relavent section is the California Business and Professions Code Chapter 9, Article 3, Section 4064.

In summary, california designates the requirements for legally providing an emergency refill as the prescriber being "unavailable to authorize the refill," and not refilling "might interrupt the patient's ongoing care and have a significant adverse effect on the patient's well-being"

The law does not designate a specific days supply, so you could assume an entire refill could be provided. However this particular situation would not meet the first test, as the prescriber was available and denied the request. California also requires you to inform the prescriber, for which I can't imagine this doc would be happy about.

As for what I would do (assuming this is a compliant patient), I would first call the new doc to authorize a new refill. That has always worked for me in the past for maintenance medications like this. If for some reason I had been turned down by both the past and future physician for a script... I would have a really hard time justifying the loaning of a medication. There is the option to refer to an urgent care or ED, but that isn't ideal and it would probably depend on the specific patient.

As a side note - this isn't reddit... there isn't a "downvote"

 

[owlegrad]

Always charming to characterize an opposing viewpoint as lacking "common sense and logic".

I have a hard time imagining a scenario in which I would loan in direct violation of the physician's order NOT to refill a med. The patient can go to an urgent care center or get a new prescription/doctor. All this talk about it being a professional decision sounds gratifying and all, but I doubt any states have pharmacy practice laws so liberal as to allow this, so what we are really talking about it is, "would you break the law and do this for a patient?". I mostly likely would not.

 

[Lnsean]

Always charming to characterize an opposing viewpoint as lacking "common sense and logic".

I have a hard time imagining a scenario in which I would loan in direct violation of the physician's order NOT to refill a med. The patient can go to an urgent care center or get a new prescription/doctor. All this talk about it being a professional decision sounds gratifying and all, but I doubt any states have pharmacy practice laws so liberal as to allow this, so what we are really talking about it is, "would you break the law and do this for a patient?". I mostly likely would not.

Yea...such confidence on making a statement like that without looking up each state's laws. You know what's worst than someone characterizing an opposing viewpoint as lacking common sense? Someone who thinks they know what they're talking about.

 

[Lnsean]

Usually people have not been taught/ don't know how to search their state laws for information so they come here for an easier answer.

As previous posts from the OP have implied he is practicing in California, the relavent section is the California Business and Professions Code Chapter 9, Article 3, Section 4064.

In summary, california designates the requirements for legally providing an emergency refill as the prescriber being "unavailable to authorize the refill," and not refilling "might interrupt the patient's ongoing care and have a significant adverse effect on the patient's well-being"

The law does not designate a specific days supply, so you could assume an entire refill could be provided. However this particular situation would not meet the first test, as the prescriber was available and denied the request. California also requires you to inform the prescriber, for which I can't imagine this doc would be happy about.

As for what I would do (assuming this is a compliant patient), I would first call the new doc to authorize a new refill. That has always worked for me in the past for maintenance medications like this. If for some reason I had been turned down by both the past and future physician for a script... I would have a really hard time justifying the loaning of a medication. There is the option to refer to an urgent care or ED, but that isn't ideal and it would probably depend on the specific patient.

As a side note - this isn't reddit... there isn't a "downvote"

Well there we go. We have OP"s answer then. She's going to lose a lot of sleep tonight.

 

[confettiflyer]

On a side note, some of you n00bs don't seem to understand how discourse goes on SDN. Jusssayin'

 

[owlegrad]

Yea...such confidence on making a statement like that without looking up each state's laws. You know what's worst than someone characterizing an opposing viewpoint as lacking common sense? Someone who thinks they know what they're talking about.

BRB let me go read 50 states pharmacy practice laws so I can have an informed opinion.

 

[zelman]

BRB let me go read 50 states pharmacy practice laws so I can have an informed opinion.

Don't forget DC, Guam and Puerto Rico.

 

[Lnsean]

BRB let me go read 50 states pharmacy practice laws so I can have an informed opinion.

You wouldn't have to if you didn't try to pass your opinions off as facts.

 

[bananaface]

What state allows for a 30 days supply? Why would anyone give that many?

In Oregon it is indefinite and hairy. The law says you can take care of the pt until they have time to establish with a new provider if their doctor dies. (Not the situation above, but kind of interesting.) It could be months. No one can touch controlled substances (obviously) and billing insurance would be a big liability. In reality, unless one is super remote, the patient can likely establish with a provider reasonably quickly. My take is that if there is a walk in clinic, a new provider is available.

In the case above, I would not advance any tabs because the prescription was denied. If they need a new rx the new provider could prescribe an interim supply or the patient could be seen at the walk in clinic for an interim rx.

Part of not messing with psych meds is following the outgoing PCPs directive. If they say no more refills, the patient should not get any tabs pursuant to that providers prior orders.

 

[KidPharmD]

As we all live in different states with what appears to be very different laws on the subject, I have decided to take a little time to actually compile each state's section on emergency refills if such is authorized in their pharmacy practice act. I have about 10 done so far, so I should be able to post the results here in a few days time.

That being said, so far the inability to contact the original prescriber does seem to be a very consistent requirement of these sections of law. In this situation I do believe we are talking about "would you be willing to potentially break the law for a patient." I can honestly say that I can imagine no circumstance where I would be willing to put my license in jeopardy for a patient in a community pharmacy. My family, and my ability to support them, is more important than helping a patient that let his Rx run out.

 

[npage148]

Especially when there's always an ER the patient can go to

 

[owlegrad]

You wouldn't have to if you didn't try to pass your opinions off as facts.

My statement was "I doubt...". So I admit in the premise I could be wrong.

Anyway, haven't you heard "Never let facts stand in the way of a food story"?

 

[Lnsean]

Especially when there's always an ER the patient can go to

lmao..this guy.

 

[Lnsean]

As we all live in different states with what appears to be very different laws on the subject, I have decided to take a little time to actually compile each state's section on emergency refills if such is authorized in their pharmacy practice act. I have about 10 done so far, so I should be able to post the results here in a few days time.

That being said, so far the inability to contact the original prescriber does seem to be a very consistent requirement of these sections of law. In this situation I do believe we are talking about "would you be willing to potentially break the law for a patient." I can honestly say that I can imagine no circumstance where I would be willing to put my license in jeopardy for a patient in a community pharmacy. My family, and my ability to support them, is more important than helping a patient that let his Rx run out.

That is of course your prerogative. I just came in to say that it is no big deal. OP isn't going to get in trouble. There are really bigger things to worry about.

 

[Lnsean]

My statement was "I doubt...". So I admit in the premise I could be wrong.

Anyway, haven't you heard "Never let facts stand in the way of a food story"?

Yea, you can never go wrong with that. Make a bold statement but with enough ambiguity so that you don't have to back up anything you say. Smart move. How could anyone call you out on anything in the future? I feel ill-prepared for prime time internet arguments. Apparently, this is the big leagues now.

My apologies...do carry on people.

 

[KidPharmD]

That is of course your prerogative. I just came in to say that it is no big deal. OP isn't going to get in trouble. There are really bigger things to worry about.

As we are talking about facts and opinions, what you should say is that you BELIEVE that it is no big deal, and you do not think the OP will get in trouble. As he is likely violating his pharmacy practice act (a.k.a. the law), the fact is that there is the potential for him to get in trouble.

 

[Ackj]

Anyway, haven't you heard "Never let facts stand in the way of a food story"?

I haven't heard that, but what were you planning on cooking?

 

[owlegrad]

As we are talking about facts and opinions, what you should say is that you BELIEVE that it is no big deal, and you do not think the OP will get in trouble. As he is likely violating his pharmacy practice act (a.k.a. the law), the fact is that there is the potential for him to get in trouble.

I agree. I am trying to imagine a pharmacist in a hospital deliberately dispensing a medication after a physician's order to stop it. I can't see it happening. It seems like common sense to me (see what I did there? har har) that that would be practicing medicine, not pharmacy. So why would it be ok to do so in a retail pharmacy?