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Doctor told the patient to open Adderall XR capsules...

Discussion in 'Pharmacy' started by mydogatemysuboxone27, Aug 8, 2018.

  1. mydogatemysuboxone27

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    OK so backstory here: The patient was switched to Adderall XR 20mg from Vyvanse.. the doctor seven days in decided to raise the dose to 30mg. Instead of sending over Adderall XR 30mg, she sent over 10mg instead and told him to take both. I told the doctor I wouldn't fill the 10mg script after just filling the 20mg, and told her if she'd like to send over 30mg (since that is the actual dose she wanted him at) I would be able to fill that for the patient. She agreed and sent that over.

    The patient comes in and told me the doctor told him to use the 20mg capsules and to open the 30mg capsules and split the contents into 3, find empty capsules and use 1/3rd of the contents in the empty capsule to get the 30mg dosage. I was first a bit shocked that was even a suggestion but cautioned the patient not to do that because there's no guarantee he's getting the correct dosage, especially because it's a time released medication.

    I'm still a bit shocked that a doctor would suggest that to a patient. I'm planning on following up with the prescriber tomorrow but has anyone heard of a physician suggesting that before?:shrug:
     
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  3. Doktor_dud3

    Doktor_dud3 CPhT, Pre-Pharmacy

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    That's crazy. The only thing I can think of is he maybe didn't want the patient to have extra Adderall lying around? But even then they would have a bunch of the thirty mg caps left over at the end of the month. Definitely weird.
     
  4. owlegrad

    owlegrad Uncontrollable Sarcasm Machine
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    Uh it is weird. Stupid even.

    I am referring of course to the fact you would fill the 30mg script but not the 10mg. :p

    But kidding aside, yeah splitting capsules is just stupid. No way they will get the right dose. Probably not the right kinetics either, although that would depend on the mechanism of how the ER properties are formulated obviously.
     
  5. Old Timer

    Old Timer SDN Advisor
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    This could easily be cured by you filling the 10 mg capsule, especially since you were willing to dispense the 30 mg. No matter how much alcohol I consume while on vacation, I still can't come up with a rational reason for what you did.....
     
  6. wagrxm2000

    wagrxm2000 Do not respond to this
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    The real question is why didn't the patient just put the split 30 mg into the 20 mg capsule or even better open the 20 mg capsule and put half in a full 20 mg capsule?????

    Actually it's why didn't you fill the 10 mg?
     
    #5 wagrxm2000, Aug 8, 2018
    Last edited: Aug 8, 2018
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  7. CetiAlphaFive

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    Let me guess: the physician graduated medical school when Hall and Oates first album came out
     
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  8. croquemonsieur

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    why didn't you fill the 10's??? this is why i don't tell people i'm a pharmacist...
     
  9. 3boooda

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    Why you didnot wanna dispense the 10mg rx? You made it more complicated for the patient to use total of 30mg
     
  10. wucool33

    wucool33 New Member
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    Yeah this is kinda stupid on your part. I can’t think of any logical reason for you not filling the 10mg. I suppose if you were worried the patient will have 7 extra capsules of 10mg at the end of the month, you could have just asked the doctor to send over a script for 21 caps (if you are going to be really anal about it).
     
  11. tlh908

    tlh908 Senior Member
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    Threads like this give me hope. If this pharmacist is my competition for a job I should be good during the saturation.
     
  12. Dred Pirate

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    come on man - you make us all look stupid - fill the 10- document appropriately -

    PS - I had this one patient (who had OCD) take 2 mg of prozac - I figured he meant 20 - nope - takes the capsules and split into 10 x 2 mg piles and took 2mg a day
     
  13. Dr Wario

    Dr Wario Hey you! Want to try this pill?
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    Wouldn't it be so much easier to use liquid at that point?
     
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  14. P2P_puhleez

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    This is what happens when you're unreasonably and overly cautious about controlled substances.
     
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  15. CetiAlphaFive

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    What exactly happened?

    OP looked a little funny in the eyes of SDN and possibly the MD?
     
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  16. pencilandpen

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    why cant you open the capsules? the capsules in just a shell, its the tiny little pulvules in the capsules that has the delayed release mechanism
     
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  17. Lnsean

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    Wtf wouldn't you fill the 10mg? You spoke to the doctor...he wanted the patient on 30mg...if he
    You can open the capsule. It clearly says so in the package insert. I've dispensed this a few times that way...with words like "sprinkle content of capsule" or "open capsule" in the sig. Like the other poster said above, it's the beads that are time-released...not the shell...this is basic stuff really if you think about it. All you had to do was look at that giant package insert that is folded into a tiny square and glued on top of every freaking Adderall XR bottle...open it up and skim over the Dosage and Administration section. As for how the patient is splitting it, that's not really of your concern.

    Also, I'm not sure why you would have a problem with dispensing the 10mg along with the 20mg if you already talked to the doctor and they wanted 30mg? 10+20 = 30mg...you know?

    I hate to sound like an ass, but you handled this very poorly and really made us all look bad.
     
    #16 Lnsean, Aug 9, 2018
    Last edited: Aug 9, 2018
  18. Lnsean

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    You can open them. It says so in the package insert.
     
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  19. Lnsean

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    Seriously, I don't even know OP and his post made me mad. How can you be such a freaking robot and not use your head to think? Jesus christ...talk about making mountains out of molehills.
     
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  20. CetiAlphaFive

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    I don't think you understood the issue with what they are doing after they open it
     
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  21. Lnsean

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    I don;t think you read OP's post. He specifically said it was an issue of opening the capsule and having the time-release mechanism being messed up...which is not true at all. I understand most people don't know that you can open these capsules. Which is fine. The thing to do is to tell the doctor that he would call back after double checking the mechanism. Instead, OP thought he was being smart and clever and a know-it-all when he was the one that was ignorant.
     
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  22. grumpyRph

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    the only thing i can think of is maybe the OP was stressed and made a weird judgement call...maybe OP would think, ok the patient will just throw away the 20's and start fresh with the 30's..... along the lines of 2 wrongs don't make a right. OP didn't anticipate the doctor having these bizarre instructions to split the capsules.
     
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  23. giga

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    Even if they somehow screw up splitting the 30 mg into 10 mg doses, it's probably not that big of a deal. This isn't a narrow therapeutic index drug, and if they end up taking anything between 20-50 mg they'll be fine, especially if they have already been on the 20 mg/day for awhile. It's not ideal, but not unsafe. But I also echo everyone else's comment that not dispensing the 10 mg capsules makes no sense at all. You created this completely unnecessary situation. And as already mentioned, time release mechanism isn't impacted by opening the capsule (or by taking two capsules simultaneously).
     
  24. giga

    Pharmacist U.S. Public Health Service 10+ Year Member

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    Who throws away perfectly good adderall?
     
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  25. owlegrad

    owlegrad Uncontrollable Sarcasm Machine
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    If the doctor doesn’t want the 20 mg to go to waste why not instruct the patient to take one and a half capsules of what they already have?
     
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  26. giga

    Pharmacist U.S. Public Health Service 10+ Year Member

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    that actually would be easier than trying to split the 30 mg capsules into thirds... honestly, both prescriber and pharmacist in this situation don't seem to be the brightest.
     
  27. JST416

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    Thank god I work in hospital and dont deal with this or the public
     
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  28. RxVampire

    RxVampire PharmDruggist
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    C'mon don't you want to deal with some who thinks do that type of scenarios? often involving engineered dose form design or odd tablet shape?
    Had once MD using Xarelto 20mg tablet & instructing patient to somehow cut an asymmetrical (yet very artistic) tablet to get a 15mg dose, you know to save some money...FML (Not FluoroMethoLone abbreviation)
     
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  29. JST416

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    Haha...havnt heard that yet but I do here some crazy stories from my friends
     
  30. JST416

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    *hear....i'll correct myself before the here, hear, their, they're everywhere people do
     
  31. wagrxm2000

    wagrxm2000 Do not respond to this
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    They're's an edit button.
     
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  32. JST416

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    well...too late
     
  33. JST416

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    thats a lot of theyr's's
     
  34. PolarPop

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    I think if I remember right the problem with this is that some of the beads in the XR capsule are actually IR and some are XR. So unless your patient can pick which beads are which and keep the ratio right, they are going to get a different effect than if they just got the whole capsule.
     
  35. mydogatemysuboxone27

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    Alright that's a lot of responses, I appreciate the feedback. If I would've known the patient would have been instructed to open up the 30mg capsules to divide the contents into three I would've just filled the 10mg capsules. That wasn't explained to me and the prescriber asked me to delete the 10mg script after the 30mg came in so I couldn't go back. I originally thought it would be better for him to get a single dose from one pill then take two considering he takes 5 other meds and admits to me he can't keep track of everything he takes.

    I'm not perfect, nor do I have a complex that I must be right or I'm a know-it-all, etc. I made a decision that I thought was right and the patient was good with that decision. I will take everything into consideration the next time a situation like this arises and maybe ask one more question to the provider to see if I can get all the information.
     
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  36. CetiAlphaFive

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    You're right again.

    When the OP said
    They obviously were not talking about a patient dividing the contents of a capsule into thirds.

    Maybe we can get video proof of what OP said.
     
  37. Lnsean

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    He clearly said it was because of the time released and judging from the comments here...only one other person knew that you could open these Adderall XR capsules. The point i'm trying to make was that he told the patient the wrong information...the time release mechanism isn't affected by opening the capsule. As for how the patient is dividing it...that's non of OP's business unless it was written on the script. OP was clearly in the wrong here for denying the 10mg script and for incorrectly counseling the patient.
     
  38. wagrxm2000

    wagrxm2000 Do not respond to this
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    No one's perfect, it takes awhile to experience every type of situation that might occur. I think you now know what to do if this occurrs again. (No one is ever going to throw away their Adderall)
     
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  39. wagrxm2000

    wagrxm2000 Do not respond to this
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    Not looking to argue but are you certain all the beads are the same?

    I honestly do not know the answer.
     
  40. Lnsean

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    You can argue...we're all here to debate and argue. Just don't stalk people and follow them into the other forums like you did previously.
     
  41. wagrxm2000

    wagrxm2000 Do not respond to this
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    First, I don't want to argue. Not everything I post is meant to get a reaction out of someone. You do need to get over this following you thing though.

    I just want to know if that's true? Are they all the same or different beads.
     
  42. Lnsean

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    Why post if you don't want a reaction? Does it make you nervous or something? What's the point of posting if you tell people they can't respond to it...like anyone is going to listen. You're too naive and silly. IF you post, expect people to comment.
     
  43. wagrxm2000

    wagrxm2000 Do not respond to this
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    Oh my goodness, nevermind. I posted I didn't want to argue because I didn't want this to happen. I was simply curious.

    Just forget I asked the question
     
  44. owlegrad

    owlegrad Uncontrollable Sarcasm Machine
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    Check the package insert under dosage and administration. :)
     
  45. wagrxm2000

    wagrxm2000 Do not respond to this
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    There's a reason why I want someone to answer the question.
     
  46. owlegrad

    owlegrad Uncontrollable Sarcasm Machine
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    It says they may be opened but do not divide the contents of the capsule. I take that to mean they are not all identical, although it does not expressly state that.
     
  47. wagrxm2000

    wagrxm2000 Do not respond to this
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    Yeah I just wanted to throw that into someone's face haha.

    It's a little less satisfying now.

    It does state there are different beads later on. It's under description. Based on that, I wouldn't recommend opening the capsule unless you plan on taking everything, definitely not dividing it.

    Anyways, all but two people are in the wrong, the OP and the other person knows who they are.
     
    #46 wagrxm2000, Aug 10, 2018
    Last edited: Aug 10, 2018
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  48. P2P_puhleez

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    This is correct - there are two types of beads. It's in the FDA approved medication guide for Adderall XR.

    Sent from my Pixel using SDN mobile
     
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  49. Dred Pirate

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    yup - but he insisted it didn't work - obviously the placebo effect in full force - I figured it wouldn't hurt him
     
  50. rx1983

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    My suggestion is stop finding reasons NOT to fill prescriptions and instead find ways to help the patient. Too many pharmacists do this and don't realize they're in the customer service business.
     
  51. owlegrad

    owlegrad Uncontrollable Sarcasm Machine
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    Customer service but also health care. On top of that you have the rediculous amount of regulatory burden as a barrier to actually providing good customer service.

    Although I actually agree with your basic premise. It’s amazing how once you earn that Pharm.D. “helping people” no longer seems to be your driving force...
     
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