Ethical question - Lasix Abuse

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MindOverMatter

MindOverMatter

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I recently came across a strange scenario at work, and would like some opinions.

Have a patient requesting brand Lasix, 1 year supply all at once. While this situation by itself is not a cause for concern, when I looked into the patient's profile I saw that she has requested the same thing for 3 months in a row. Always brand, always a year's supply. She always pays cash.

Our patient notes in the system state that she travels frequently, and routinely loses medication on airlines, etc. which is obviously BS, but she told me the same thing when I questioned her. My assumption is that she must be selling it on some black market, presumably to body builders looking to shed water weight before competition. I filled it for her this once, since I am new at this store and this is my first run-in with her, but I told her that since she is prone to "losing" medication, I would recommend only filling one month's supply in order to save money. She immediately brushed that off and said she doesn't want to come to the pharmacy every month since she travels so much. Sigh.

Anyways, when she returns next month with the same excuse, which I'm sure she will, I will probably turn her down, at least for the year's supply. While it's obviously not a control, and the doctor continually sends a new rx each month (#90 with 3 refills), I'm not comfortable with the thought of supplying some black market scheme.

Am I in the wrong here?
 
You're just doing your job. I'd recommend contacting the physician now, before the patient has a prescription in hand.
 
You're not in the wrong, but I really wouldn't care about it. I would think she is taking it to a foreign country and supplying relatives or selling it. If the MD is ok with it, I would document it and let it go.
 
Not a pharmacist, but seriously, who losses a years worth of Lasix? If you actually lost medication previously, you wouldn't bring more than whatever amount was required for your trip. Paying cash, only buying brand name one year at a time- she's totally a dealer for the BB crowd. Surprised she didn't ask you for 1000 doses of albuterol while she was at it.
 
I agree with the supplying of families in other countries. I have a friend who does this for his family in Egypt since they can't afford the meds there and he has insurance (but he does 90 days at a time). Doctor writes out the scripts he needs, the owner of the pharmacy knows about it and helps out with it. Illegal but morally right.
 
Mad Jack said:
Not a pharmacist, but seriously, who losses a years worth of Lasix? If you actually lost medication previously, you wouldn't bring more than whatever amount was required for your trip. Paying cash, only buying brand name one year at a time- she's totally a dealer for the BB crowd. Surprised she didn't ask you for 1000 doses of albuterol while she was at it.
Click to expand...

sorry for my ignorance... but what is the relationship to albuterol and body building?
 
fauxden said:
sorry for my ignorance... but what is the relationship to albuterol and body building?
Click to expand...
It's used as what they call a thermogenic agent to aid in cutting, which they've used in place of clenbuterol for years. They believe it boosts metabolism and improves performance when taken at high enough doses (we're talking ridiculous doses, 16 mg BID). There were actually some studies that backed this up and showed that athletes were able to gain strength faster while simultaneously losing weight when using albuterol. But due to the high doses required, they need -large- amounts of the stuff, as they run it for three weeks at a time, meaning they'd need a minimum of 269 single dose 2.5 mg units for one cycle, assuming they carefully measured and saved the remainder of each one. Realistically they wouldn't and would just want 300 or more respules. If anyone comes looking for a crazy large supply of albuterol at once, this could very well be the reason.
 
Sparda29 said:
I agree with the supplying of families in other countries. I have a friend who does this for his family in Egypt since they can't afford the meds there and he has insurance (but he does 90 days at a time). Doctor writes out the scripts he needs, the owner of the pharmacy knows about it and helps out with it. Illegal but morally right.
Click to expand...
In most countries, isn't Lasix dirt cheap compared to America even without insurance? With a lot of meds, I can see buying in the states to be an advantage, but Lasix just seems crazy. Not a pharmacist though, so please forgive my ignorance if I'm in the wrong here.
 
Mad Jack said:
In most countries, isn't Lasix dirt cheap compared to America even without insurance? With a lot of meds, I can see buying in the states to be an advantage, but Lasix just seems crazy. Not a pharmacist though, so please forgive my ignorance if I'm in the wrong here.
Click to expand...

Lasix yeah it's pretty cheap, especially the generic. Not sure how much the brand costs though.

But yeah, my friend who I know does this uses it for diabetes, HTN, statins, abx and whatnot.
 
I have had a similar situation come up (though only 3 month supplies, not 1 year!), so I contacted MD, who investigated further. As it turned out, the patient had been Dr. hopping and had hx of bulimia so was using Lasix to purge. I think you are right to be concerned.


MindOverMatter said:
I recently came across a strange scenario at work, and would like some opinions.

Have a patient requesting brand Lasix, 1 year supply all at once. While this situation by itself is not a cause for concern, when I looked into the patient's profile I saw that she has requested the same thing for 3 months in a row. Always brand, always a year's supply. She always pays cash.

Our patient notes in the system state that she travels frequently, and routinely loses medication on airlines, etc. which is obviously BS, but she told me the same thing when I questioned her. My assumption is that she must be selling it on some black market, presumably to body builders looking to shed water weight before competition. I filled it for her this once, since I am new at this store and this is my first run-in with her, but I told her that since she is prone to "losing" medication, I would recommend only filling one month's supply in order to save money. She immediately brushed that off and said she doesn't want to come to the pharmacy every month since she travels so much. Sigh.

Anyways, when she returns next month with the same excuse, which I'm sure she will, I will probably turn her down, at least for the year's supply. While it's obviously not a control, and the doctor continually sends a new rx each month (#90 with 3 refills), I'm not comfortable with the thought of supplying some black market scheme.

Am I in the wrong here?
Click to expand...
 
Gombrich12 said:
You're not in the wrong, but I really wouldn't care about it. I would think she is taking it to a foreign country and supplying relatives or selling it. If the MD is ok with it, I would document it and let it go.
Click to expand...

Even if she was doing this... the prescription is a legal document permitting the Lasix for her own use. If she hasn't provided an updated prescription indicating an increase in dosage, she has no business asking for a year supply three times within the period mentioned by the OP. Donating to a foreign country sounds great, but there are other *legal* means of doing this. There are 340b pharmacies providing medications to individuals at very reduced cost, in addition to charitable pharmacy laws and regulations that can be used. One prescription of Lasix from one person isn't going to help the world...
 
In Pennsylvania, it would be illegal. You should contact the doctor and find out what the heck is going on.
 
Recycled said:
I have had a similar situation come up (though only 3 month supplies, not 1 year!), so I contacted MD, who investigated further. As it turned out, the patient had been Dr. hopping and had hx of bulimia so was using Lasix to purge. I think you are right to be concerned.
Click to expand...

One of my high school classmates almost died because he used water pills to cut weight before a meet, although IDK what he used. This was ca. 1980, so it's nothing new.

I wonder if this i also what she's up to.
 
Sparda29 said:
I agree with the supplying of families in other countries. I have a friend who does this for his family in Egypt since they can't afford the meds there and he has insurance (but he does 90 days at a time). Doctor writes out the scripts he needs, the owner of the pharmacy knows about it and helps out with it. Illegal but morally right.
Click to expand...

Morally very wrong. Doing the same thing and paying cash price is morally right.
 
Anorexics are known to abuse diuretics and laxatives. I stepped in and denied the sale of a large pot of senna tabs to a teenage girl who was like a stick insect. She shouted abuse at me and left.
 
Mad Jack said:
It's used as what they call a thermogenic agent to aid in cutting, which they've used in place of clenbuterol for years. They believe it boosts metabolism and improves performance when taken at high enough doses (we're talking ridiculous doses, 16 mg BID). There were actually some studies that backed this up and showed that athletes were able to gain strength faster while simultaneously losing weight when using albuterol. But due to the high doses required, they need -large- amounts of the stuff, as they run it for three weeks at a time, meaning they'd need a minimum of 269 single dose 2.5 mg units for one cycle, assuming they carefully measured and saved the remainder of each one. Realistically they wouldn't and would just want 300 or more respules. If anyone comes looking for a crazy large supply of albuterol at once, this could very well be the reason.
Click to expand...
Clenbuterol is used in factory farming to make lean, jacked pigs and veal calves. I think legislation made this illegal recently but that's OK, more and more of our food is coming from China and it's all good over there. Just ask the fish and shrimp farmers who use malachite green as fungicide.
 
Sparda29 said:
Dude is not even middle class. His family in Egypt is even poorer.
Click to expand...
You don't think there are subscribers to his insurance company who are barely scraping by? His fraud raises their premiums.
 
Sparda29 said:
How do you propose he get the medications to his family?
Click to expand...
Since the MD and pharmacist are so on board for this plan, maybe the three of them can foot the bill.
 
rph3664 said:
How, if he's paying cash?
Click to expand...

The post says he is using his insurance. Anyways, this is wrong in so many ways. 1) A doctor prescribing for a patient he has never examined. 2) Writing rxs for a patient that does not need them. 3) Filling an rx for a patient under someone else's name. 4) Using one person's insurance policy to pay for drugs for someone else.

Everyone in this chain - patient, doc, pharmacist - is breaking the law here.
 
Lasix is also used in mega doses for horse racing although it is usually given IM or IV.
 
Who cares? Think about the $$$$ all those tablets generate. They are well within their right to get all refills at once. Didn't they teach you this in your law classes?

The MD must know about it, how else is she getting a prescription with 12 refills every 3 months?

Sometimes pharmacists need to stop playing cop and just fill scripts....
 
owlegrad said:
Funny, I missed that "right". Does it extend to controls also? That would make for one popular pharmacy!
Click to expand...

No it doesn't apply for controls. It obviously doesn't. Don't troll me. They can get every noncontrol script at once if they want to
 
pharmd201389 said:
No it doesn't apply for controls. It obviously doesn't. Don't troll me. They can get every noncontrol script at once if they want to
Click to expand...
So, I can get #1000 clomid at your pharmacy every day, and you:
A) don't care
B) don't see anything wrong with it and
C) would be willing to say so to the authorities when the athletes abusing it get caught?
 
zelman said:
So, I can get #1000 clomid at your pharmacy every day, and you:
A) don't care
B) don't see anything wrong with it and
C) would be willing to say so to the authorities when the athletes abusing it get caught?
Click to expand...

Once again, you're trolling. 1,000 clomids? Are you seriously comparing 1,000 clomids with a years worth of furosemide?

Way to take it to an extreme. No doctor in their right mind would prescribe "1,000 clomids". Never, ever. I have, however, dozens of times seen them write for furosemide with 11 refills. If a patient wants all 11 refills at once, why would I stop him? I'M NOT A COP AND NEITHER ARE YOU. You are NOT breaking the law by giving him all his tablets at once.
 
pharmd201389 said:
Once again, you're trolling. 1,000 clomids? Are you seriously comparing 1,000 clomids with a years worth of furosemide?

Way to take it to an extreme. No doctor in their right mind would prescribe "1,000 clomids". Never, ever. I have, however, dozens of times seen them write for furosemide with 11 refills. If a patient wants all 11 refills at once, why would I stop him? I'M NOT A COP AND NEITHER ARE YOU. You are NOT breaking the law by giving him all his tablets at once.
Click to expand...

Dude, the problem isn't giving a 12 month supply of Lasix at once. It's this person coming back to get another year's supply every couple of months. Did you even read the thread?
 
eagles22 said:
Dude, the problem isn't giving a 12 month supply of Lasix at once. It's this person coming back to get another year's supply every couple of months. Did you even read the thread?
Click to expand...
This
 
FYI, the patient came last week and filled another #360 brand Lasix for cash. Rx notes say she gave the same excuse (I was off those days).

The saga continues... :-/
 
MindOverMatter said:
FYI, the patient came last week and filled another #360 brand Lasix for cash. Rx notes say she gave the same excuse (I was off those days).

The saga continues... :-/
Click to expand...

Here's what I would do to cover myself. Send a fax to the Dr's office tomorrow saying you are refusing to refill this rx again without a medical justification. Staple a copy to the original hard copy and keep a copy for your own records. When you don't hear anything from the doctor and this person shows up again on your shift, you can pull out your documentation explaining its the doctors fault. And when your supervisor jumps on you demanding a reason why you are turning business away, explain to him that its in the companies best interest to avoid a lawsuit when dead anorexics are in the local news.

I agree its someone bringing the drugs to people at home. I helped out at an Egyptian owned independent, and they were lovely people. However, I have babies, and their future is more important to me.
 
If I have agreed to uphold the laws pertaining to my pharmacy practice (part of our practice act), can something be illegal and not immoral at the same time?

One of the presented examples would be me participating in insurance fraud (among other transgressions). I don't think I could ever make myself think this was a moral choice.

As for the Lasix, I would have some serious concern about this patient. She could be supplying to bodybuilders or anorexics who might come to harm from this drug. They or their family might include me in a lawsuit.

I am also pretty sure that a proper drug-utilization review for this patient would not allow #360 lasix to be dispensed every few weeks. Controlled substance or not, this is a patient care disaster. I would not dispense this another time without speaking with the prescriber. She might not be giving him the same story.
 
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