Doctor and Pt unhappy when asked about CII regimen

[Maromei]

Hi everyone, I am looking for some advice on how to approach CII scripts to make things less stress for prescribers, patients, and myself.

I print out PDMP for every CII prescription and fill as they're not early, same physician, same pharmacy, make sense (IR + ER), and low quantity (under #120 preferably but I've filled up to #240). So ~80% of the prescriptions I get are filled with no issue, but the other ~20% are a headache to deal with. I am reluctant to turn away scripts that doesn't fit the above criteria and usually call the prescriber to find diagnosis code and goal of care to see if prescriber have plans to decrease patient opioid use for the high quantity ones (if so, I'll document and dispense so physician can conduct slow taper). However, this is a very time consuming process and often results in yelling and threats from pt and/or prescriber. I'm getting discouraged and sometimes just feel like turning the patients away to save the headaches. What am I doing right, what am I doing wrong, am I spending too much time on the CII's?

Scenarios 1:

A young pt (30's) gets morphine ER 30 mg #90, morphine IR 30 mg #360, methylphenidate 10 mg #180, Tramadol #240 (fairly recent addition), Soma #90 monthly. There was recent changes which increased the quantity of IR and decreased ER (due to insurance issue per patient). Patient stated he's been on regimen for 3-4 years due to herniated disk and is using the methylphenidate to help him stay awake after taking morphine.​

What are everyone's thoughts of using a stimulant to stay awake due to high opioid use? Could the patient's dose of morphine be decreased just enough to ease the pain but not knock him out? Is it reasonable to call prescriber suggesting slow taper down citing CDC guideline caution against chronic daily opioid use > 90 MME/day and request a script for narcan to go along with everything. If it makes a difference, prescriber is an anesthesiologist/pain specialist with probation in the past due to refilling norco w/o properly assessing pt.

Scenario 2:

Pt fills oxycodone 30mg #360 and norco 10/325mg #120 each month. Told pt and prescriber it is duplication of therapy and requested one of the IR's be switched to ER. The physician's reason for prescribing two IR's was that pt's copay was too high ($200-$300 range for 60 pills of hysingla/zohydro/oxycontin), but pt was happy to pay ~$170 cash for 360 counts of oxycodone 30. The agreement then is that I fill the oxycodone for #120, file the norco away, and the prescriber will send in a different ER script the next day. The pharmacist staffing the next day called me up the following afternoon to inform me that he refused the oxycodone 80 mg ER TID b/c oxycodone IR was filled the previous day but he filled the norco #120 which made pt and prescriber both happy.​

Was I in the wrong for requesting one of two IR's to be switched to an ER for better pain coverage? Are there any good reasons to give two IR opioids at such high quantities at a time?

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[Charcoales]

Sorry we're out of stock

 

[Digsbe]

Patient 1 needs dose decreases, the use of methylphenidate to "keep someone awake" due to high opioid use is extremely unsafe, not indicated, and the therapy should be decrease opiate use and stop methylphenidate. The patient is basically stating they are at high risk of overdose due to being able to not stay awake without amphetamines. Knowing that's the indication it may be illegal to fill given it's not necessarily for a "valid" or indicated medical purpose. I'd also recommend changing the Soma to Flexeril or something else.

For patient 2 you weren't in the wrong. They should be on the ER and then an IR, two IR's isn't the safest option. Oxycodone 80 ER TID is a pretty hefty dose to start on ER though...

 

[steveysmith54]

How do you find space in Your Pharmacy to keep all that cII inventory ?

 

[PharmacistFl12]

Hi everyone, I am looking for some advice on how to approach CII scripts to make things less stress for prescribers, patients, and myself.

I hope these are not real examples. There's no chance a customer at my pharmacy will receive both Norco and Oxycodone together. 9 out of 10 Pharmacist will not fill that time of duplication in therapy. You cannot be on 2 shorting acting narcotics, especially when one is more potent than the other. This is an automatic rejection at my pharmacy and I guarantee you no supervisor or manager will question your decision.

 

[owlegrad]

Hi everyone, I am looking for some advice on how to approach CII scripts to make things less stress for prescribers, patients, and myself.

Scenarios 1:

​

Scenario 2:

​

​

I used to see Scenario 1 so much at CVS (in FL). I had so many people cuss me out about that. I didn't budge though. It is NOT appropriate, hard stop. Usually they would have a benzo thrown in for good measure on top. I recall a nurse in particular cussing me out in the drive through window about how I was pretending to be a doctor and it not being my place to question the almighty physician blah blah blah. You learn to tune it out (or just lie and say you are out of stock).

Scenario 2 is even worse than scenario 1 IMO. You would never be able to convince me that they are not diverting one or both. I wouldn't have filled either one and would let the patient know they will need to find a new pharmacy. FWIW I think the second pharmacist made the worst possible decision in that situation - they could have either filled the ER or nothing but filling the IR is an unbelievably boneheaded choice. Is that the usual pharmacist who normally fills that combo? Perhaps they get a kickback from the patient or have some kind of cognitive dissidence where they have convinced themselves that it is an appropriate therapy.

 

[Maromei]

Sorry we're out of stock

Unfortunately that won't work, all the regulars know we can order all meds (including CII's) for next day delivery

And if I turn them away, they'll probably have a really hard time filling any where else. I prefer bringing the issue up to the provider and give them the option of slow taper down (as in I want to see a decrease in quantity next month, or find another pharmacy) instead of refusing fill and have patient go into withdrawal. However, it usually doesn't happen that way and the physicians are just annoyed that I'm interfering with a regimen that they've perfected over the years...

It's getting to the point where I'm seriously debating just either fill or don't fill instead of going though all that. It takes out an extremely large chunk of my time, nothing get's changed, and everyone just end up hating me for it 🙁

Patient 1 needs dose decreases, the use of methylphenidate to "keep someone awake" due to high opioid use is extremely unsafe, not indicated, and the therapy should be decrease opiate use and stop methylphenidate. The patient is basically stating they are at high risk of overdose due to being able to not stay awake without amphetamines. Knowing that's the indication it may be illegal to fill given it's not necessarily for a "valid" or indicated medical purpose. I'd also recommend changing the Soma to Flexeril or something else.

For patient 2 you weren't in the wrong. They should be on the ER and then an IR, two IR's isn't the safest option. Oxycodone 80 ER TID is a pretty hefty dose to start on ER though...

For 1, patient stated he failed all the other options including flexeril, baclofen, etc. In hindsight, I probably shouldn't have given out the Soma.. I left an extensive note to the next pharmacist to hopefully not fill the morphine's and methylphenidate until spoken w/ physician on Monday.

Patient 2..........I really don't know what to think. My tech called me that day and I asked that they verify dosing w/ doctor and to perhaps change to at least Q12H, but I guess the other pharmacist didn't agree. I'm a new grad though and look really young, so to have an older pharmacist discount my decision means I'll have a lot of trouble getting the physician to change anything in the future. And the physician is one that writes a lot of questionable CII combinations... Do you have any recommendations on how to approach the physician? I'm sure it'll be frustrating to the patient and prescriber to have one pharmacist say one thing and the next pharmacist say the complete opposite.

How do you find space in Your Pharmacy to keep all that cII inventory ?

We actually don't keep that many on hand, just a couple bottles of each. We just order more the day before each prescription is due to be filled. Most of our patients are regulars.

I used to see Scenario 1 so much at CVS (in FL). I had so many people cuss me out about that. I didn't budge though. It is NOT appropriate, hard stop. Usually they would have a benzo thrown in for good measure on top. I recall a nurse in particular cussing me out in the drive through window about how I was pretending to be a doctor and it not being my place to question the almighty physician blah blah blah. You learn to tune it out (or just lie and say you are out of stock).

Scenario 2 is even worse than scenario 1 IMO. You would never be able to convince me that they are not diverting one or both. I wouldn't have filled either one and would let the patient know they will need to find a new pharmacy. FWIW I think the second pharmacist made the worst possible decision in that situation - they could have either filled the ER or nothing but filling the IR is an unbelievably boneheaded choice. Is that the usual pharmacist who normally fills that combo? Perhaps they get a kickback from the patient or have some kind of cognitive dissidence where they have convinced themselves that it is an appropriate therapy.

The pharmacist is a relief pharmacist that ended up getting hired (part time I believe) a month or so before me. I think he honestly think he made the best possible choice that resolved the conflict between pharmacy, patient, and physician as he sounded quite excited when he called me up to give me a recap of what he did.. All the other older pharmacists are a lot more lenient with the CII's though so all the patient's just think I'm a jerk, so now some pts call ahead of time to figure out who staffs that day to get their CII's filled.

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Question for everyone, is there ever a place in therapy for two IR's at pretty much near max dose? The only time I've ever filled two IR's was for a cancer patient e-prescribed from an oncology clinic b/c his insurance didn't cover ER.

 

[Charcoales]

I guess just fill it just make sure not early (1 day early maximum) and all narcs from same clinic, dx code is on every rx, and staple pdmp printout to each hardcopy to prove you tried.

 

[radio frequency]

​

I used to see Scenario 1 so much at CVS (in FL). I had so many people cuss me out about that. I didn't budge though. It is NOT appropriate, hard stop. Usually they would have a benzo thrown in for good measure on top. I recall a nurse in particular cussing me out in the drive through window about how I was pretending to be a doctor and it not being my place to question the almighty physician blah blah blah. You learn to tune it out (or just lie and say you are out of stock).

In my experience, medication transfers from Florida have the highest probability of being a total train wreck compared to any other state...

 

[BenJammin]

Unfortunately that won't work, all the regulars know we can order all meds (including CII's) for next day delivery
.

"Sorry, those drugs are on manufacturer backorder. We try ordering every day!"

 

[Sine Cura]

Some state boards (looking at you California) having been looking askance at years and years of chronic opioid fills. In their eyes just getting Dx and checking PDMP means little. No I bet you don't question prescribers' use of atenolol versus other beta blockers but these are controls so it's a more sensitive issue obviously

The best option is not to fill this garbage in the first place so now you are stuck with bad patients and unwanted liability

 

[Rouelle]

And if I turn them away, they'll probably have a really hard time filling any where else.

I think you just answered your own question. If you think that the vast majority of reasonable pharmacists would turn them away, that should speak volumes to you.

 

[Dr Wario]

I have gotten rid of patients like this by a very simple printout of the cdc recommendation to not go over 90 morphine equivalent milligrams per day. I call the doctor, make sure they are aware of the guideline, see what the reason this particular patient is an extraordinary circumstance (ie cancer patient) and give them an aggressive dose reduction schedule (15% of high dose per month). Usually I will get the same speal that I am just a pharmacist and what right do I have to question the almighty doctor, I simply respond that the doctor is not following cdc guideline and thus the DEA gives me the responsibility and requirement to intervene.

This works for the old "regulars", I don't order oxy 30 period so to all new ones that try it, I am legitimately out of stock.

I would like everyone to remember that doctors/prescribers are human too, and as humans it is our nature to find the path of least resistance. Doctors know full well that what they are prescribing in these scenarios is harmful to their patients, but the meds work in the short term so they are called heros and the patient is satisfied and the prescriber gets easy return visits month after month. Long term, the patient has worsening pain that is caused by being on the meds, and is physiologically dependent and addicted to them.

Please find attached link to CDC guidelines on opiate dosing and combinations with other drugs.

https://www.cdc.gov/drugoverdose/pdf/Guidelines_Factsheet-a.pdf

 

[Abby Atwood]

The Norco seems really weird to me. If the patient is actually taking 540 MME of oxycodone, the 40 MME from the Norco isn’t going to do anything. If the provider wants to do an opioid rotation, he could try a transition from oxycodone to morphine. It may reduce MME per day due to cross tolerance, morphine is cheaper, and there is less resale value which decreases risk of diversion.

Opioids are a high risk therapy. Pharmacists shouldn’t be expected to fill without appropriate documentation. For these really troubling scripts, I would ask the providers office for diagnosis codes and most recent chart notes.

 

[Maromei]

I think you just answered your own question. If you think that the vast majority of reasonable pharmacists would turn them away, that should speak volumes to you.

Well, the way I think of it, if it's a patient with addiction problem, then it should be brought to the prescriber's attention to see if patient can be weaned off safely. If it's a legitimate patient with pain that gotten to this high of a dose due to bad prescribing practice over the years, I should still try to get prescriber to wean them off. If it's diversion, there's nothing I can do. But if I turn them away and most pharmacy refuse fill, then the patient might never have the chance to wean off and either have to go to withdrawal or buy off the streets. But my limited experience doing this haven't been too successful, so I'd like to know what everyone's experience is. Is there hope or just a waste of time? Should I spend 30 min on scripts like these to try or is it just a waste of time?

I have gotten rid of patients like this by a very simple printout of the cdc recommendation to not go over 90 morphine equivalent milligrams per day. I call the doctor, make sure they are aware of the guideline, see what the reason this particular patient is an extraordinary circumstance (ie cancer patient) and give them an aggressive dose reduction schedule (15% of high dose per month). Usually I will get the same speal that I am just a pharmacist and what right do I have to question the almighty doctor, I simply respond that the doctor is not following cdc guideline and thus the DEA gives me the responsibility and requirement to intervene.

This works for the old "regulars", I don't order oxy 30 period so to all new ones that try it, I am legitimately out of stock.

Thank you for the advice, I was actually looking at that earlier today and was debating if I should keep it around to fax to physicians. I'm glad to hear it worked for you, I'll give it a try this week.

So you don't do oxycodone at all? IR or ER or both? I know there is a high abuse potential, but what happens if the patient max out on norco, jump straight to methadone/morphine? Hysingla and Zohydro are awfully expensive..

 

[Maromei]

The Norco seems really weird to me. If the patient is actually taking 540 MME of oxycodone, the 40 MME from the Norco isn’t going to do anything. If the provider wants to do an opioid rotation, he could try a transition from oxycodone to morphine. It may reduce MME per day due to cross tolerance, morphine is cheaper, and there is less resale value which decreases risk of diversion.

Opioids are a high risk therapy. Pharmacists shouldn’t be expected to fill without appropriate documentation. For these really troubling scripts, I would ask the providers office for diagnosis codes and most recent chart notes.

Half the time, the diagnosis code is for "lower back pain", which doesn't make me any more comfortable filling than before I call.

 

[Charcoales]

Yeah... I look at profile and pdmp before even taking... if looks like going to be a big hassle... I rarely bother to call or fax md since they always take forever to respond or receptionist goes "yea its ok" like lol wtf, all while pt starts getting aggressive and nonstop calling etc. Love giving them hardcopy after refusing then the real show begins. I just keep saying there is drug interaction that could result in death but most don't seem to care.

 

[PharmacistFl12]

This is not a difficult situation. You do not fill those prescriptions. To do so, would mean overlooking red flags and ignoring your own clinical judgment. Both are big no-nos by the DEA. I personally would reject any c2s scripts from both scenarios and advise them to never fill at any pharmacy from my company. Btw, I'm from Florida and work for a company that got in trouble with DEA multiple times for controls issue.

 

[Abby Atwood]

Half the time, the diagnosis code is for "lower back pain", which doesn't make me any more comfortable filling than before I call.

Ask for chart notes. Most retail pharmacies have a policy requiring verification of patient provider relationship for oxycodone scripts of that strength anyway. Plus, it gives you insight into the providers current plan prior to asking for changes. Pharmacies request most recent chart notes for fills of specialty meds. This should be considered a reasonable request for oxycodone.

 

[Sine Cura]

Sometimes you do get chart notes but you still have to deny. Anyone can "cut and paste" the same chart notes and Dx for every patient

Sometimes the doctor's office actually did a PA for something completely inappropriate but you still have to deny. What does a PA pharmacist know about your local quack docs.

 

[Abby Atwood]

For the next fill, it may be most appropriate for the provider to funnel half of the oxycodone dose into ER and continue IR at half the current dose (15 mg same sig). The patient could be titrated down from there. Adding on 40 MME of IR hydrocodone is not even in the same ball park as adding on 360 MME of ER oxycodone. If the provider had sent over a script for a relatively low dose morphine ER, I wouldn’t be as suspicious. As it is, I’m pretty sure that something really fishy is going on. It definitely doesn’t seem appropriate to increase the patients dose to 900 MME on a whim. I almost feel like he sent over that script to pressure the pharmacy into filling the Norco (or he’s just incompetent).

 

[SClENCE]

If either of these two patients walked into my pharmacy I would tell them that I am not comfortable filling it and just leave it at that.

 

[CetiAlphaFive]

Hi everyone, I am looking for some advice on how to approach CII scripts to make things less stress for prescribers, patients, and myself.

I print out PDMP for every CII prescription and fill as they're not early, same physician, same pharmacy, make sense (IR + ER), and low quantity (under #120 preferably but I've filled up to #240). So ~80% of the prescriptions I get are filled with no issue, but the other ~20% are a headache to deal with. I am reluctant to turn away scripts that doesn't fit the above criteria and usually call the prescriber to find diagnosis code and goal of care to see if prescriber have plans to decrease patient opioid use for the high quantity ones (if so, I'll document and dispense so physician can conduct slow taper). However, this is a very time consuming process and often results in yelling and threats from pt and/or prescriber. I'm getting discouraged and sometimes just feel like turning the patients away to save the headaches. What am I doing right, what am I doing wrong, am I spending too much time on the CII's?

Scenarios 1:

A young pt (30's) gets morphine ER 30 mg #90, morphine IR 30 mg #360, methylphenidate 10 mg #180, Tramadol #240 (fairly recent addition), Soma #90 monthly. There was recent changes which increased the quantity of IR and decreased ER (due to insurance issue per patient). Patient stated he's been on regimen for 3-4 years due to herniated disk and is using the methylphenidate to help him stay awake after taking morphine.​

What are everyone's thoughts of using a stimulant to stay awake due to high opioid use? Could the patient's dose of morphine be decreased just enough to ease the pain but not knock him out? Is it reasonable to call prescriber suggesting slow taper down citing CDC guideline caution against chronic daily opioid use > 90 MME/day and request a script for narcan to go along with everything. If it makes a difference, prescriber is an anesthesiologist/pain specialist with probation in the past due to refilling norco w/o properly assessing pt.

Scenario 2:

Pt fills oxycodone 30mg #360 and norco 10/325mg #120 each month. Told pt and prescriber it is duplication of therapy and requested one of the IR's be switched to ER. The physician's reason for prescribing two IR's was that pt's copay was too high ($200-$300 range for 60 pills of hysingla/zohydro/oxycontin), but pt was happy to pay ~$170 cash for 360 counts of oxycodone 30. The agreement then is that I fill the oxycodone for #120, file the norco away, and the prescriber will send in a different ER script the next day. The pharmacist staffing the next day called me up the following afternoon to inform me that he refused the oxycodone 80 mg ER TID b/c oxycodone IR was filled the previous day but he filled the norco #120 which made pt and prescriber both happy.​

Was I in the wrong for requesting one of two IR's to be switched to an ER for better pain coverage? Are there any good reasons to give two IR opioids at such high quantities at a time?

You are spending waaaaaay too much time on this.

If you're uncomfortable enough to question it and make a thread about it, you already have your answer.

Your concerns about withdrawal and illicit drug use is totally naive and unfounded.

Do you really think your average pain management patient knows where to acquire heroin?

 

[Maromei]

To answer a couple people's question, I don't accept any new patients with these type of problem regimens. These patients aren't new, they're regulars patients that I inherited.

For the next fill, it may be most appropriate for the provider to funnel half of the oxycodone dose into ER and continue IR at half the current dose (15 mg same sig). The patient could be titrated down from there. Adding on 40 MME of IR hydrocodone is not even in the same ball park as adding on 360 MME of ER oxycodone. If the provider had sent over a script for a relatively low dose morphine ER, I wouldn’t be as suspicious. As it is, I’m pretty sure that something really fishy is going on. It definitely doesn’t seem appropriate to increase the patients dose to 900 MME on a whim. I almost feel like he sent over that script to pressure the pharmacy into filling the Norco (or he’s just incompetent).

Thank you, I really appreciate your explanation and advice!

If either of these two patients walked into my pharmacy I would tell them that I am not comfortable filling it and just leave it at that.

If I refuse fill, the patients just keeps coming back until they find a pharmacist that'll fill for them. I prefer to not leave issues like that for my coworkers. But it seems like even if I try to get approval to start taper down, they still end up with same regimen anyways, so it gets pretty discouraging after a while. I'm leaning toward doing the same and just refuse fill now..

You are spending waaaaaay too much time on this.

If you're uncomfortable enough to question it and make a thread about it, you already have your answer.

Your concerns about withdrawal and illicit drug use is totally naive and unfounded.

Do you really think your average pain management patient knows where to acquire heroin?

I think I'm spending too much time on this too, it puts me behind on the rest of the verification 🙁. I have to figure out some way to make the call process more efficient (fax maybe if the patient's not waiting) or stop calling and just do either fill or don't fill.

I created this thread to see what people's experience are on the matter, not exactly for a simple "fill or don't fill" purpose (although I AM curious at whether anyone else will fill it as my coworkers did). I also wanted to see if anyone had successes with getting physicians on board with taper down or is it simply a lost cause. From the looks of the responses on this thread, most people are going with the latter.

What I learned so far is that:
- most people either reject or accept instead of trying to initiate taper (a sentiment that I am starting to agree with.. as playing phone tag with the physicians and calming down aggressive patients take up too much time)
- it's a good idea to ask for chart notes instead of simply diagnosis code + question
- the CDC guideline is a good starting point to prompt prescriber to address the issue (thank you, Dr.Wario, really appreciate it)

In regards to scenario 1, I had concerns regarding high overdose risk (and prescribers never seem to prescribe naloxone with anything), so I refused dispense pending justification from physician. However, I've seen older studies such as http://www.jpsmjournal.com/article/S0885-3924(98)00084-0/fulltext suggesting possible benefit in a subset of patients (terminally ills seem to be the focus). I probably still would not be comfortable with such use, but the topic was interesting and I wanted to see if anyone have any experience regarding such use in either fairly healthy/terminal patients.

In regards to scenario 2, no good reason other than that the other pharmacist was so sure of himself that I wanted some reassurance that I didn't mess up somewhere.

 

[Sine Cura]

Yeah most prescribers are incredibly butthurt when you bring up tapers. Then I file a complaint with their board if they are writing crap far beyond the "usual course of practice" in my area (I see Rx from 5-6 "legitimate" pain management practices) like Dilaudid 8 mg out of "urgent care" to see if anything substantive ever happens. (For example this guy is STILL licensed in Arizona and holds a California license still but he is not dumb enough to write for Dilaudid 8 mg #120 1 PO QID for migraines)

And this guy is apparently famous enough to get the DEA involved (apparently he would write for oxycodone 30 #360 and Soma #540 all the time)

I have had mixed success getting people off oxycodone/APAP and hydrocodone/APAP combos, and switching away from Soma or get nothing filled but most times it is a lost cause.

 

[CetiAlphaFive]

I think you're severely underestimating how much doctors are afraid of confronting patients and upsetting them.

Furthermore, I think pain management as a whole ignores the fact that analgesics relieve psychological pain in addition to physical.

No one seems to want to answer the question, "why does the US use such an extreme amount of pain medicine"

Don't get me wrong, I'd be thrilled to have a staff RPh like you.
Guy just need to restrategize

 

[allantois]

I’ve worked for a pain clinic with a few different providers so I can comment from that side. None of them felt that CDC guidelines applied to them because they considered it for PCP practice only, and then the guidelines state that above 90 MME can be “carefully justified”. Actually, getting calls from the pharmacy upset the doctors infinitely more than Pt’s not being able to fill meds at their regular pharmacy. One physician in particular fumed the whole day when he received a call suggesting he write for Narcan.

In my personal opinion, I think that you as a clinician should just refuse to fill the prescription if you are in uncomfortable with it.

 

[Dr Wario]

I’ve worked for a pain clinic with a few different providers so I can comment from that side. None of them felt that CDC guidelines applied to them because they considered it for PCP practice only, and then the guidelines state that above 90 MME can be “carefully justified”. Actually, getting calls from the pharmacy upset the doctors infinitely more than Pt’s not being able to fill meds at their regular pharmacy. One physician in particular fumed the whole day when he received a call suggesting he write for Narcan.

In my personal opinion, I think that you as a clinician should just refuse to fill the prescription if you are in uncomfortable with it.

LOL CDC guidelines do not apply to them? I know you are rehashing what you have heard from PM providers but that is really quite interesting and telling. As for your second part, basically what you are saying is that providers would rather hear a little whining from their patients that they can't find any pharmacy that has their 360 oxy 30's in stock than have to listen to the annoying pharmacist point out the flaws in their prescribing habits?

 

[CetiAlphaFive]

LOL CDC guidelines do not apply to them? I know you are rehashing what you have heard from PM providers but that is really quite interesting and telling. As for your second part, basically what you are saying is that providers would rather hear a little whining from their patients that they can't find any pharmacy that has their 360 oxy 30's in stock than have to listen to the annoying pharmacist point out the flaws in their prescribing habits?

MDs are accustomed to getting into it with other healthcare professionals, as they see themselves at the top of the food chain.

 

[KimChiSlap]

I saw this Youtube video titled America's Opioid Epidemic.
Although I don't know for certain if the people in it are on opioids, the behavior/symptoms that they exhibits may suggest it to be.

We already have a opioid problem. Other countries dont use them as much as we do in the USA.
Do what you think is right, it is your corresponding responsibility!

 

[allantois]

LOL CDC guidelines do not apply to them? I know you are rehashing what you have heard from PM providers but that is really quite interesting and telling. As for your second part, basically what you are saying is that providers would rather hear a little whining from their patients that they can't find any pharmacy that has their 360 oxy 30's in stock than have to listen to the annoying pharmacist point out the flaws in their prescribing habits?

Don’t shoot the messenger. We had a list of specialty pharmacies to which refer the patients to.

 

[owlegrad]

I assume this is "specialty pharmacies"?

 

[Maromei]

I’ve worked for a pain clinic with a few different providers so I can comment from that side. None of them felt that CDC guidelines applied to them because they considered it for PCP practice only, and then the guidelines state that above 90 MME can be “carefully justified”. Actually, getting calls from the pharmacy upset the doctors infinitely more than Pt’s not being able to fill meds at their regular pharmacy. One physician in particular fumed the whole day when he received a call suggesting he write for Narcan.

In my personal opinion, I think that you as a clinician should just refuse to fill the prescription if you are in uncomfortable with it.

I don't understand why doctors are so offended by the suggestion of providing naloxone along with their prescriptions.

Actually most of our pain doctors have pretty good prescribing practices, PCP's are usually the ones I have more trouble with. Scenario 1 is the only odd one I've seen so far from a pain specialist.

Scenario 2 is from a PCP. The PCP doesn't seem to manage his pain patients well and I really think he should refer them to pain specialists at this point.

I assume this is "specialty pharmacies"?

Do you mean me? No, we're just a small pharmacy. We're poorer side of town though, so that's probably why we get more prescriptions like these. The one's I questioned tend to have some issues getting insurance to cover ER. However, I don't believe insurance coverage issue is a good enough reason to put patient at IR+IR.

 

[5minites2016]

Wow, i would not fill any of these scripts if i were you. Paying cash for oxy is a huge red flag. If you want to keep your license, then you either refuse to fill these scripts or find another job.

 

[grumpyRph]

i want like a legit, well organized undercover research study of how many of these feakin' pain pills get to the streets/diversion. it's just sooooooo obvious sometimes, but we have legit clinics rx these high dose oxy30's.

most of us aren't criminals so we don't know how the black market works right? any insight? because like i know it's dangerous for a patient to be getting this high dose opioid, but i don't think they're actually taking it. but do they take half a pill the day before their urine test at the clinic? wtf is going on. lol

 

[Hulkbuster333]

I'm just curious regarding scenario 2. Was one prn and the other scheduled? Isn't there supposed to be a scheduled pain med and one for breakthrough pain as far as pain management? I mean that is a really high amount I probably would be uncomfortable with it too.

 

[CynicalIntern]

I assume this is "specialty pharmacies"?

I don't want to get into the No True Scotsman argument, but a pharmacy that unquestionably fills high doses of narcotics is not "specialty," it's a "pill mill"

 

[owlegrad]

I don't want to get into the No True Scotsman argument, but a pharmacy that unquestionably fills high doses of narcotics is not "specialty," it's a "pill mill"

I love a good fallacy!

The reason I used the quote marks was to insinuate that a pharmacy filling pain meds isn't really a specialty pharmacy. Obviously that wasn't as clear as I thought it was. 🙂

 

[CynicalIntern]

I love a good fallacy!

The reason I used the quote marks was to insinuate that a pharmacy filling pain meds isn't really a specialty pharmacy. Obviously that wasn't as clear as I thought it was. 🙂

Oh, sorry, I knew you were using it sarcastically. I meant to scroll up to the post above you, but saw specialty pharmacy and my vision went red and mashed reply without fully reading.