Dentistry: Scope of practice out of state prescribing.

[acetylcoa2]

Just looking for some general feedback or recommendation on course of action:

Today, I had a dentist call in acyclovir from a state that is 2500miles+ away from my state. I asked what strength and she did not know. She said whatever it was previously. I asked whats the directions and she did not know either and said whatever it was previously. And she gave a couple refills as well.

From the patient's history this has been prescribed from general practitioners not dentists and patient is routinely on the medication monthly. Acyclovir is FDA approved for genital herpes. Based on these facts, I called dentist back to confirm if this is dental related or not and if this is a current patient of the dentist.

Dentist seemed very defensive and basically said this is for cold sores and it is been working for patient. Dentist also said she is seeing the patient and this is for current dental treatment (which she is calling from a state 2500+ miles away!).

I feel like the dentist is not being honest. I don't believe the patient is picking up this medication in one state and then flying 5+ hours on an airplane to get dental treatment from this dentist. What would you guys do? I'm almost feeling like I need to call the board of dentistry.

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[steveysmith54]

According to Medscape it's also for cold sores, not just genital herpes... I'd ask when the last dental appointment is, document the interaction with the dentist and move on.. would be better if you also had the rx faxed to you, but it's not a bit deal . bigger fish to fry....

 

[WVUPharm2007]

I expect the dental people to invade our forum any second now.

 

[Rouelle]

I have a strange sense of deja vu

 

[owlegrad]

You think this is some kind of shady acyclovir clinic?

Perhaps the dentist just moved out of state. Perhaps the patient used to live in the state the dentist is in. Perhaps the dentist is a friend from college who happened to have seen the patient's teeth one time. Who cares?

 

[BidingMyTime]

Yes, didn't we just have this same discussion just a couple of weeks ago.

I understand your concerns OP, but honestly, assuming that you have a limited amount of time (as is the case with 98% of working pharmacist), I'm pretty sure you have more pressing concerns. Just document that you verified with the dentist that it's being treated for dental issues. Is the dentist lying? Maybe, maybe not, you have no way to know, but it's quite conceivable that they are telling the truth. I'm also pretty sure that your state board and the DEA have a limited amount of time and more pressing issues than to try to figure out whether or not this dentist is lying.

 

[steveysmith54]

I think there is a 50 percent chance the med is used for genital herpres and 50 percent chance it's for cold sore.... I'd proly bet on cold sores, I think that's a more common occurrence...I believe something like 85 percent of the population is infected with that virus... doesn't take a clinical genious to diagnose that condition. If a dentist decides to treat cold sores, id just let them... not like they are treating enlarged prostate... id proly be upset with you too.... sometimes you just have to take things at face value, you are not a detective... I suppose you can ask to examine the pt's genitals to see signs of herpres, but I wouldn't recommend it bc I think we already have a thread abt a pharmacist who asks for pts to undress, I don't think it worked out too well for him

 

[WVUPharm2007]

Is probably 100% for genital herpes. I don't really care if dentists want to play pretend physician. Just as long as the insurance company can't come back and audit. Acyclovir, plausible deniability. Whatever. Birth control...lipitor...viagra...just...no. I don't have time to deal with their trifling nonsense. I let it boil down to payment.

 

[Digsbe]

I'd assume it's for a cold sore or oral herpes. However, with them not knowing the strength or dosing I would have them clarify and probably ask the indication if it wasn't done by a dentist in the past. That's just being sloppy.

 

[RxPreceptor]

I have a strange sense of deja vu

If anything, you'll get some entertainment from reading through this one:
Oral Herpes, Within a Dentist's scope?

 

[Apotheker2015]

You think this is some kind of shady acyclovir clinic?

Perhaps the dentist just moved out of state. Perhaps the patient used to live in the state the dentist is in. Perhaps the dentist is a friend from college who happened to have seen the patient's teeth one time. Who cares?

It's an acyclovir pill mill... Those are starting to pop up. I'd PDMP the hell out of that. Wait... You can't...

 

[CetiAlphaFive]

I'm not touching this one.

LOL

 

[TanMan]

If you really doubt the patient has oral herpes and don't want to fill the rx, there's two ways to verify that it is oral and not genital herpes:
1. Ask the patient to open their mouth (probably not the best thing and would you know what to look for)
2. Ask the dentist to send you pictures of the pathology. We frequently take intraoral photos of pathology and its in our charts. With all the hassle of doing that, the patient might just go to another pharmacy who will fill it w/o question.

 

[steveysmith54]

If you really doubt the patient has oral herpes and don't want to fill the rx, there's two ways to verify that it is oral and not genital herpes:
1. Ask the patient to open their mouth (probably not the best thing and would you know what to look for)
2. Ask the dentist to send you pictures of the pathology. We frequently take intraoral photos of pathology and its in our charts. With all the hassle of doing that, the patient might just go to another pharmacy who will fill it w/o question.

Although it sounds like you know what you are talking about from a clinical point of view, I believe your suggestion falls outside the scope of our practice as pharmacists.... As I mentioned before, medication in question is not a controlled substance anywhere on planet earth, you have to take certain things at face value , i wouldn't waste another second of my time on this matter.

 

[CetiAlphaFive]

Although it sounds like you know what you are talking about from a clinical point of view, I believe your suggestion falls outside the scope of our practice as pharmacists.... As I mentioned before, medication in question is not a controlled substance anywhere on planet earth, you have to take certain things at face value , i wouldn't waste another second of my time on this matter.

Who needs integrity, right?

We've got metrics to meet and Masters to please

 

[steveysmith54]

Who needs integrity, right?

We've got metrics to meet and Masters to please

That's all true, but so is not being trained to look at pathology picture and look into a patient's mouth to diagnose.... you can argue that perhaps these tasks are "common sense", but I don't like to stick my nose (no pun intended) in that...

 

[CetiAlphaFive]

That's all true, but so is not being trained to look at pathology picture and look into a patient's mouth to diagnose.... you can argue that perhaps these tasks are "common sense", but I don't like to stick my nose (no pun intended) in that...

We're not MDs trained in pain management either, but we still ask for diagnosis codes, right?

We're not trying to interpret the theoretical photos, just challenge the theoretical DDS; if he can't produce them, they don't exist.

 

[steveysmith54]

We're not MDs trained in pain management either, but we still ask for diagnosis codes, right?

We're not trying to interpret the theoretical photos, just challenge the theoretical DDS; if he can't produce them, they don't exist.

There is a difference between asking for an icd-10 diagnosis for a spinal stenosis/ disc herniation AND trying to diagnose it yourself by looking at MRI. Anyone can google an ICD diagnose code, having one given to you by a doctor's secretary means nothing... you are trusting another healthcare professional to provide you with the accurate diagnosis and you can evaluate the therapy based on that information. You are correct that we are not trained pain specialists, but we are def taught pain management treatment algorithms and protocols... however, we are def not taught what was suggested by the dentist

 

[CetiAlphaFive]

There is a difference between asking for an icd-10 diagnosis for a spinal stenosis/ disc herniation AND trying to diagnose it yourself by looking at MRI. Anyone can google an ICD diagnose code, having one given to you by a doctor's secretary means nothing... you are trusting another healthcare professional to provide you with the accurate diagnosis and you can evaluate the therapy based on that information. You are correct that we are not trained pain specialists, but we are def taught pain management treatment algorithms and protocols... however, we are def not taught what was suggested by the dentist

U rite, u rite

 

[Apotheker2015]

Just looking for some general feedback or recommendation on course of action:

Today, I had a dentist call in acyclovir from a state that is 2500miles+ away from my state. I asked what strength and she did not know. She said whatever it was previously. I asked whats the directions and she did not know either and said whatever it was previously. And she gave a couple refills as well.

From the patient's history this has been prescribed from general practitioners not dentists and patient is routinely on the medication monthly. Acyclovir is FDA approved for genital herpes. Based on these facts, I called dentist back to confirm if this is dental related or not and if this is a current patient of the dentist.

Dentist seemed very defensive and basically said this is for cold sores and it is been working for patient. Dentist also said she is seeing the patient and this is for current dental treatment (which she is calling from a state 2500+ miles away!).

I feel like the dentist is not being honest. I don't believe the patient is picking up this medication in one state and then flying 5+ hours on an airplane to get dental treatment from this dentist. What would you guys do? I'm almost feeling like I need to call the board of dentistry.

I have to apologize here. I cracked a joke at the expense of your question. The fact that you came to this forum seeking advice makes it valid. You might be new to pharmacy or life. - I don't know- I am new to pharmacy but certainly not new to life.
Here are my issues with having had to answer that phone call. I would have nipped it in the bud right away. I work at a very busy store. So a dentist, unfamiliar to you, called from a state 2500 miles away to give you a verbal prescription for a drug that falls on a grey area and possibly outside of the dentists scope of practice.
Issue #1 - The least the dentist can do is have the courtesy to give you all the elements of a prescription; including exact drug strength and directions. -Same as before??? If she doesn't know what those were, how can she be sure that those are clinically appropriate at this time?
Issue #2 - The dentist got defensive which confirms her erroneous but common belief that her license rules your pharmacist license.
Issue# 3 - It sounds like you acquiesced to fill that prescription and simply do not realize that you have the final word. The system is set up for you to be the final verification step. You either bless it or not. They can call the prescription in elsewhere if that works better for them, too.

Again, I work at a very busy store and have no time for nonsense. Sure, the script falls on a grey area but the real issue here is the prescriber did not even give you a real script. Thus, had that been an e-script, it would have read:

September 2nd, 2017

John Smith

Acyclovir (same strength as prescribed by other providers on this patient's fill history)
Sig: (same directions as prescribed by other providers on this patient's fill history)

HUH???? That's where the line is. They either have a script to give you or not.

 

[Digsbe]

Although it sounds like you know what you are talking about from a clinical point of view, I believe your suggestion falls outside the scope of our practice as pharmacists.... As I mentioned before, medication in question is not a controlled substance anywhere on planet earth, you have to take certain things at face value , i wouldn't waste another second of my time on this matter.

At the same time though it's illegal for a dentist in nearly all states to my knowledge to deviate from their legal scope of practice. Say the patient was somehow harmed and decides to have a lawsuit. Your name is on that rx and most practice standards/laws mandate us doing a DUR. Acyclovir is nothing to bat an eye about but there is still liability and legality in the game.

 

[Zynx]

Regarding that one phone call from a state 2500+ miles away (which the dentist may have just been temporarily out of state for a variety of reasons).
Tell them you notice that they are calling from far away, and are just double checking there is a valid patient-prescriber relationship. Ask if she maintains current medical records on the patient - document the response, and I believe you are covered. All you need is a "yes" - you've now CYA. Or a "No," in which case, its not getting filled.
This was obviously a concern that you noted, but apparently did not ask the question.

If she needs help with dosing/duration of acyclovir for cold sores, we can also provide that. Different from what the patient has been taking? There are a variety of reasons - maybe they found TID rather than BID for chronic suppression helps prevent recurrence for that patient. I would keep the prescription the same as the patient been taking unless it looks obviously out of whack.

 

[Rockinacoustic]

I have no issue with a prescriber not knowing the dosing of something they write for rarely and soliciting my help. We're the drug expert. Own it.

 

[CetiAlphaFive]

I have no issue with a prescriber not knowing the dosing of something they write for rarely and soliciting my help. We're the drug expert. Own it.

How do you accept payment or bill them?

 

[owlegrad]

How do you accept payment or bill them?

Same way they bill for OTC advice I am sure.

 

[Sine Cura]

I would contact the board of dentistry in the state in which the dentist practices and get further clarification. In my limited experience (3 years of "practice"), when you encounter people who play fast and loose with their prescribing privileges (e.g., violate controlled substance prescription laws) or even practice outside of their license (like a dentist writing random **** for themselves or friends and family for non-dental purposes), it is not a one off and their behavior is left unchecked because their licensing board, who has the power to apply disciplinary action, never gave them a "courtesy visit" to put their ass in line or fine. How is the licensing board supposed to know if no one informs them?

As an example, in California aiding and abetting the unlicensed practice of any "healing arts" profession is subject to criminal penalty and I'm sure there are similar regulations in other states, so why would you want to get involved in that because of some idiot who can't even take the time to prepare a script.

 

[Dred Pirate]

I have no issue with a prescriber not knowing the dosing of something they write for rarely and soliciting my help. We're the drug expert. Own it.

I know it is not the same thing, but in a hospital, I give dosing recommendations multiple times per day - and this is stuff (antibiotics, pressors, intubation drugs) that they order a lot. I am sure if you ask, they could come up with a reasonable dose, but they often say "Hey, give drug xx" and trust me. Heck today I told them how to give TPA in a PE arrest (three MD's in room and none knew the dose)

 

[BJNCNC]

I would fill the prescription an move on. Stop wasting everyone's time.


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