Crazy hydrocodone Quantities!!

[CardinalGirl210]

---

Members do not see this ad.

I am a new pharmacist so I'm still learning some things and trying to learn how to tailor my message to patients and MDs without getting yelled at. I got a script for Hydrocodone 10/325 for #180 take 1 or 2 q4h as needed for pain. No insurance. MD's office is right by the store I was floating at, but patient fills all the way on the other side of town at another store within my company. She also had an RX for alprazolam #90 from the same MD. I thought the Norco RX was crazy - #180 and it's only a 15 days supply. I called the MD's office and asked for a diagnosis code and asked why she's getting such a large quantity that only lasts 15 days. The medical assistant was like oh yeah I guess it should be #240 for 30 days. MD was unavailable to come to the phone of course. I told the patient I didn't have enough to fill it and she wasn't upset. I filled her xanax and gave her daughter some candy and she left in a pleasant mood.

How do you more experienced pharmacist handle it when you get a C2 or other controlled substance for a ridiculous quantity or ridiculous dosing? Specifically, what do you ask the MDs and what do you tell the patients?

 

[Momus]

I am still filling a bunch of norco #240-360/30 days supply, 12 tab/day on a monthly basis. It's pretty common...

 

[farmadiazepine]

540 pills of methadone every 30 days. I just shrug my shoulders and say "Damn, it feels good to be a gangster."

 

[Gombrich12]

Start turning away Norco scripts for #180 qty and see how fast corporate shows up. Yea we have a corresponding responsibility alright, it's to the shareholders.

 

[Estrace]

Ridiculous.....I don't fill anything over #120/30 days supply. I just tell the patient that I'm not comfortable filling their script.

 

[Old Timer]

What is the maximum daily dose of Hydrocodone? Why would you fill a script for more than that?

 

[zelman]

Hydrocodone is not a potent analgesic. Your CYP450-2D6 enzymes convert it to hydromorphone, which is. There is a decent chance that this patient has a genetic variation that explains the need for high doses. But there's also a decent chance that they're selling them. Either the doctor or patient is doing their job poorly, but there's no way to know which with your resources. I typically would fill it as long as it isn't early.

 

[Wheresmyaricept]

Some people don't have insurance. And some people develop a tolerance to opioids which requires a higher dose. She obviously has a history of the medication, always fills it at the same chain, and it's from the same doctor. As long as she isn't doctor shopping or pharmacy shopping according to the PMP then I wouldn't mind. 180 is a common number for severe acute pain, but they should probably be on a long acting agent too. The issue is those are more expensive, and with no insurance the only option is cheap acute meds.

 

[Ackj]

Another thing that always gets me is q4h =/= 6 doses. Most people have to sleep for at least 4-6 hours, so that 4am dose probably isn't needed. I do see a few rx that are q4h mdd 5 (or 10, instead of 12).

 

[Old Timer]

Hydrocodone is not a potent analgesic. Your CYP450-2D6 enzymes convert it to hydromorphone, which is. There is a decent chance that this patient has a genetic variation that explains the need for high doses. But there's also a decent chance that they're selling them. Either the doctor or patient is doing their job poorly, but there's no way to know which with your resources. I typically would fill it as long as it isn't early.

Still, is there a maximum dose of Hyrocodone? If so, would you exceed it? Under what circumstances? How would you document it?

 

[Dr Wario]

Still, is there a maximum dose of Hyrocodone? If so, would you exceed it? Under what circumstances? How would you document it?

I don't know of a max dose of hydrocodone, but I do know there is a max order amount from cardinal every month.

 

[Wheresmyaricept]

Still, is there a maximum dose of Hyrocodone? If so, would you exceed it? Under what circumstances? How would you document it?

There is no therapeutic max dose of any opioid. The max dose is limited by the adverse effects.

 

[Old Timer]

There is no therapeutic max dose of any opioid. The max dose is limited by the adverse effects.

Is that what the PI says?

 

[KidPharmD]

Is that what the PI says?

Lexi-Comp lists doses limited by Acetaminophen exposure.
However, it doesn't really matter. Pharmacists should know that opiates are limited by their side effects, all except one can have tolerance develop. I do not understand why any pharmacist would automatically assume that this patient is not legitimately in pain just because it looks like a lot to them. Is it the best opiate choice - Absoltely not. At this point of pain management - unless the patient doesn't usually need this much, is the time for a long acting opiate and a breakthrough medicine.

To OP: A good test it to suggest that you can make a recommendation to her doctor that would allow her to achieve pain control with many fewer pills a day. A refusal would be a much more likely to be a flag to me. Also, if she says she doesn't take it that much, you can check her story against refill history and any controlled database.

Also, you apparently lied to the patient because you didn't want to express your actual concern. No wonder we aren't the most trusted profession anymore.

 

[ExpressMaiL]

I am a new pharmacist so I'm still learning some things and trying to learn how to tailor my message to patients and MDs without getting yelled at. I got a script for Hydrocodone 10/325 for #180 take 1 or 2 q4h as needed for pain. No insurance. MD's office is right by the store I was floating at, but patient fills all the way on the other side of town at another store within my company. She also had an RX for alprazolam #90 from the same MD. I thought the Norco RX was crazy - #180 and it's only a 15 days supply. I called the MD's office and asked for a diagnosis code and asked why she's getting such a large quantity that only lasts 15 days. The medical assistant was like oh yeah I guess it should be #240 for 30 days. MD was unavailable to come to the phone of course. I told the patient I didn't have enough to fill it and she wasn't upset. I filled her xanax and gave her daughter some candy and she left in a pleasant mood.

How do you more experienced pharmacist handle it when you get a C2 or other controlled substance for a ridiculous quantity or ridiculous dosing? Specifically, what do you ask the MDs and what do you tell the patients?

You're going to eventually learn about following your company's p&p and the importance of documentation. I have seen "crazy" doses; but it's easier for me to say that since I work with pain/palliative patients.

 

[BenJammin]

Still, is there a maximum dose of Hyrocodone? If so, would you exceed it? Under what circumstances? How would you document it?

For a norco prescription, everything you're asking is irrelevant.

 

[SpartanLaser]

Still, is there a maximum dose of Hyrocodone? If so, would you exceed it? Under what circumstances? How would you document it?

You should be asking yourself what is the max dose of APAP first lol.....

 

[BidingMyTime]

It's fair to question that prescription, but its not uncommon to see prescriptions like that. It's not an ideal pain treatment, but many people do that because of price issues or side effect/allergy issues. It's fair to ask the dr for a diagnosis, and to also talk to the patient about better treatment options (SR morphine, Oxycontin, possibly methadone.), or if she's being treated by a family doctor, talk to her about seeing a pain specialist or other specialist for her type of pain. But, since she is uninsured, her options are probably limited due to cost, which is why she is on such a high dose of hydrocodone. Now if there are other issues (you didn't mention any), like you check your states registry and find out she really does have insurance, or her prescriber has a questionable history, etc......well then you have the right to refuse to dispense a prescription, just be sure to carefully document your reasons. But if everything seems legit, there is no reason not to fill that prescription.

 

[CardinalGirl210]

It's fair to question that prescription, but its not uncommon to see prescriptions like that. It's not an ideal pain treatment, but many people do that because of price issues or side effect/allergy issues. It's fair to ask the dr for a diagnosis, and to also talk to the patient about better treatment options (SR morphine, Oxycontin, possibly methadone.), or if she's being treated by a family doctor, talk to her about seeing a pain specialist or other specialist for her type of pain. But, since she is uninsured, her options are probably limited due to cost, which is why she is on such a high dose of hydrocodone. Now if there are other issues (you didn't mention any), like you check your states registry and find out she really does have insurance, or her prescriber has a questionable history, etc......well then you have the right to refuse to dispense a prescription, just be sure to carefully document your reasons. But if everything seems legit, there is no reason not to fill that prescription.

Very helpful answer - thanks a lot!

 

[Old Timer]

According to the PI:

The usual adult dosage is one tablet every four to six hours as needed for pain. The total daily dosage should not exceed 6 tablets.

When dispensing dosages above this you should, to protect yourself, have some documentation. I have seen many crazy prescriptions written. I once had a prescription from a local cancer hospital for MS Contin 1800 mg q12. I questioned the doctor only to find out the patient was a heroin addict so higher dosages were required. Call made, documentation obtained, patient's record noted and rx dispensed.

My point is whenever you dispense anything outside of the standard recommended dose, you should document what you did and why you did it. I'm not saying to blanket decline because as has been pointed out in reality there is no max dose from a clinical POV. The legal issues may be different. But I also note that death due to prescription drug abuse are on the rise and I don't want to be party to that.

Gather all of the information, have a discussion with the patient and make an informed and documented decision.

Personally, I would discuss with the doctor and the patient the danger of taking almost 4GM of acetaminophen every day along with 120mg of hydrocodone daily. It would appear this is really not optimal therapy. He should be referred to a "real" pain management doctor as opposed to the quack on the corner who hangs out a shingle that says pain management. I might fill it once or twice but if this was from a GP, I probably would not fill this on an ongoing basis.

 

[Lnsean]

Lexi-Comp lists doses limited by Acetaminophen exposure.
However, it doesn't really matter. Pharmacists should know that opiates are limited by their side effects, all except one can have tolerance develop. I do not understand why any pharmacist would automatically assume that this patient is not legitimately in pain just because it looks like a lot to them. Is it the best opiate choice - Absoltely not. At this point of pain management - unless the patient doesn't usually need this much, is the time for a long acting opiate and a breakthrough medicine.

To OP: A good test it to suggest that you can make a recommendation to her doctor that would allow her to achieve pain control with many fewer pills a day. A refusal would be a much more likely to be a flag to me. Also, if she says she doesn't take it that much, you can check her story against refill history and any controlled database.

Also, you apparently lied to the patient because you didn't want to express your actual concern. No wonder we aren't the most trusted profession anymore.

This is really bad advice. You are ultimate liable if something does go wrong if you're dispensing such high quantities. Saying stuff like "oh well it doesn't have a max dose limit" isn't legal ground to stand on. Sure, technically there is no dose max, but is it common dosage? Is it usual in your daily practice to dispense #540 pills of norco? The lawyers are going to go after you and the company because that's where they money is, and they'll dig deep enough to sue you for negligence and other sht.

If you decide to fill these amounts, you had better start documenting stuff. Cover your ass.

 

[BenJammin]

Why are you guys dispensing high amounts of norco anyway? It's a C2!

 

[zelman]

Why are you guys dispensing high amounts of norco anyway? It's a C2!

Well, you see, there's something called a "prescription"...

 

[BenJammin]

Well, you see, there's something called a "prescription"...

And there's also something called the DEA, the Controlled Substances Act, and a duty to dispensed controlled substances for legitimate medical uses.

 

[wagrxm2000]

Remember even if you document a conversation, you are still liable if anything happens to the patient. Counseling does not protect you. While there aren't really max doses of opiates there are naive opiod recommendations. If a patient comes in with oxycontin 60 mg and there is no documentation of ever being on it, calling the doctor is not an excuse to dispense.

 

[KidPharmD]

This is really bad advice. You are ultimate liable if something does go wrong if you're dispensing such high quantities. Saying stuff like "oh well it doesn't have a max dose limit" isn't legal ground to stand on. Sure, technically there is no dose max, but is it common dosage? Is it usual in your daily practice to dispense #540 pills of norco? The lawyers are going to go after you and the company because that's where they money is, and they'll dig deep enough to sue you for negligence and other sht.

If you decide to fill these amounts, you had better start documenting stuff. Cover your ass.

What bad advice did I give? I answered a question about the max dose of Hydrocodone/APAP. Practicing pharmacy always worried about whether or not you will be legally liable for something "going wrong" is a horrible way to practice. I also gave the OP some advice on what I would do in this situation. I didn't tell the OP to ignore the large amounts, in fact I would always question these kinds of prescriptions, but that doesn't make the amount a default reason to refuse to fill the Rx. Also, you should always document your reasons for filling a prescription out of the ordinary.

Yes, I have dispensed this much norco (30days with these directions is #360). I can actually remember the patient's name. This was pre-C2 and the patient had metastatic cancer with very labile bone pain and would need anywhere from 6-12 tablets a day. After about 9 months of this (and some progression) I convinced the MD to switch to MS Contin and MSIR because she was using 12 more consistently.

 

[zelman]

And there's also something called the DEA, the Controlled Substances Act, and a duty to dispensed controlled substances for legitimate medical uses.

I know. And that's why a prescription for #10 Lomotil and #540 Norco both deserve the same type of scrutiny. Insinuating improper activity based on schedule and quantity is a very close-minded approach.

 

[ChalupaBatman86]

I would demand evidence of a loose stool before dispensing the Lomotil, can't be too careful.

 

[Lnsean]

What bad advice did I give? I answered a question about the max dose of Hydrocodone/APAP. Practicing pharmacy always worried about whether or not you will be legally liable for something "going wrong" is a horrible way to practice. I also gave the OP some advice on what I would do in this situation. I didn't tell the OP to ignore the large amounts, in fact I would always question these kinds of prescriptions, but that doesn't make the amount a default reason to refuse to fill the Rx. Also, you should always document your reasons for filling a prescription out of the ordinary.

Yes, I have dispensed this much norco (30days with these directions is #360). I can actually remember the patient's name. This was pre-C2 and the patient had metastatic cancer with very labile bone pain and would need anywhere from 6-12 tablets a day. After about 9 months of this (and some progression) I convinced the MD to switch to MS Contin and MSIR because she was using 12 more consistently.

Refer to OldTimer's post for reference. I don't want to beat a dead horse over and over again. It appears there are pharmacist at either extremes: those that are too clinically focused without common sense and those that are too suspicious.

I was merely referring to the fact that you solely rely on clinical judgement to address the situation, which is scary. Even if the script makes clinical sense, you have to ask yourself "is this common dosage? Would an average pharmacist in the normal course of his/her duty question this script?"

Obviously, the Walgreens pharmacists in Florida who were dispensing 200-500 oxys didn't think it was a problem. Did they lose their license? Who knows, but you don't want to be caught in this situation and your best defense was "well oxys don't have max limits." I'm sure they didn't think anything "wrong" would happen either...up until the DEA showed up at their doors.

As for metastatic cancer patients, I've had patients with fake cancer dx's so....

 

[SClENCE]

There may not be a max dosage for hydrocodone but you could calculate day supply based on the max dose of Tylenol. The problem is the day supply based on the max dose of tylenol is greater then the day supply based on the sig. So even when the doctor verifies it do you base the day supply based on the sig, max dose of tylenol, or refuse it due to dosage?

Even if it's a cancer patient are you putting yourself at risk by dispensing over the max daily dose of Tylenol?