Floater uses EpiPen on self without prescription

[owlegrad]

Not in AZ, MN, TX, NY, or FL at least (I think CA as well). Emergent situations are excusable under extenuating circumstances for legend drugs (insulin to a diabetic, epi-pen in these situations). Just get the documentation done afterward and it's fine. There's no Board issue whatsoever. TX doesn't even require reconciliation with the prescriber under their emergency refill regulation.

I do expect that the pharmacist makes good on it from a cost standpoint afterwards (insurance or cash), but this is trivial to deal with.

FL is somewhat tricky. We are allowed to dispense based on 'emergency' need in two scenarios. One, the patient has been on the medication previously and is out of refills and it is the pharmacist's judgement that the patient would be harmed by missing doses while waiting for a refill to be authorized from prescriber blah blah blah. I seem to recall that it has to be a maintenance medication, but I could be wrong and I am not nearly interested enough to go look it up right now. Another interesting point I recall about that law is it specifically does allow for controls to be dispensed under that provision although I suspect that no pharmacy in FL would ever allow that, period. And of course just because FL allows for it does not mean that the DEA would allow it under federal law.

Two, if the governor declares a state of emergency there are all kinds of special provisions for emergency dispensing. I don't recall them all but in my mind I always picture it wild-west style where anything goes. LOL

I am not aware of any regulation that allows us to dispense a prescription to a patient where the pharmacy has no record of that patient ever having a prescription for said medication. So if the patient was out of refills for their epipen or proair but had a record of said prescription with the pharmacy, we could probably get away with it under that provision, "maintenance" med notwithstanding.

Also, I am not aware of any regulation that would allow a pharmacist to self-medicate under any circumstance and that is what the OP is referring to.

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[owlegrad]

lol that was fast but this is a little different, seems like the mom just ran to the pharmacy and demanded a pen without giving any details

also it wasn't in US, US news are way more sensationalized lol

Sorry, just dial it to 11 and you have the US version.

 

[MARX22]

Idk what state you’re in but I agree. I see what everyone’s saying about anaphylaxis and proair but wouldn’t that be considered practicing medicine like we are physicians? If this is a patient of ours and we see they have rxs in the system for proair/epinephrine and it’s either not due yet... at this point we know they have been on these meds before and have a refill left even tho insurance wont pay right now. Do we give and expect the cost to be taken care of later or do we not give and risk them dying? This probably has to do with our employers more than law but a legal aspect is if they last got it months ago and didn’t fill that med with us anymore and have no refills, or even if they got it last month but 0 refills left, is it considered wrong to give because they dont have an rx? any thoughts?

If someone’s out of bp meds i give them a few til i get a new rx so I guess if they have been on it and got it last month even if there’s no refill left, legally it should be okay to give til we get a new rx and it would depend more on the employer’s decison on whether to give without payment that moment?

There are three problems with using an epipen without prescription.
1. Theft
2. Possessing a prescription drug without a prescription
3. Administering a prescription as a pharmacist this is not allowed in my state unless anaphylaxis is due to an immunization that the pharmacist gave and an rx must be provided for this epipen.

Pencil and pen your suggestions I find illegal and unethical. I have seen staff get in trouble for simply taking a tablet of tylenol. Walgreens fired a diabetic for taking food off the shelf without paying for it before consuming it to stave off hypoglycemia. AHA BLS does not include training on the use of Epipen and how would you know its anaphylaxis- have you been trained in this area? Even Narcan in my state has to dispensed and PAID for in my state at my employer.

 

[wagrxm2000]

I just don't think people should use the life/death reason. What if a person is out of town on vacation, normally goes to an independent, his scripts have no refills anyways and forgot his meds? This seems to happen daily.

His doctor is also on vacation but that's ok since his last fills should have last him until his next appointment and no one at the office can give a script. If you tell him you can't help him, you know the response will be, oh I guess I can go awhile without them....... And he dies.

While I know my situation is a little out there, older customers do forget their meds at home and will go without it it's too much of a hassle to get them filled.

Oh I'd still give the EpiPen but not the Proair.

 

[Deja]

its sad to see everyone is arguing about not giving EpiPen due to cost when it could potentially save a persons life... I would understand if you made an argument that giving someone EpiPen could potentially harm them more than helping them... but cost? common

 

[Deja]

I just don't think people should use the life/death reason. What if a person is out of town on vacation, normally goes to an independent, his scripts have no refills anyways and forgot his meds? This seems to happen daily.

His doctor is also on vacation but that's ok since his last fills should have last him until his next appointment and no one at the office can give a script. If you tell him you can't help him, you know the response will be, oh I guess I can go awhile without them....... And he dies.

While I know my situation is a little out there, older customers do forget their meds at home and will go without it it's too much of a hassle to get them filled.

Oh I'd still give the EpiPen but not the Proair.

I think the argument here is if some one came to your pharmacy already in danger and not someone who is not in distress and just want a refill just in case

 

[wagrxm2000]

I think the argument here is if some one came to your pharmacy already in danger and not someone who is not in distress and just want a refill just in case

So you wouldn't feel bad if you look at the obituary and saw that man.

Like I said, you know he won't go see anyone for his scripts. He'll risk it.

 

[Digsbe]

If I thought I would die of anaphylaxis I'd do the same. As an asthmatic I'd also grab an inhaler if I didnt have one on me. I'd rather have issues with pretentious boards angry that in professional judgement as a doctorate degree holder that I saved myself over kindly going to the grave because I'm not a physician authorized by the state to prescribe and thus making them unhappy I didnt relinquish myself to death as a lowly pharmacist. The alternative is that you are sentenced with the death penalty because you aren't an almighty nurse practitioner. I'd also not stop a patient from taking an EpiPen or inhaler if they needed one. At the worst it would be that they "robbed" the pharmacy. You cant put a price on human life. If my employer got pissed over the cost of an EpiPen or proair I'd pay it myself over letting someone die in the consultation area. I'd absolutely bend the rules if I thought it would save a life.

 

[Deja]

So you wouldn't feel bad if you look at the obituary and saw that man.

Like I said, you know he won't go see anyone for his scripts. He'll risk it.

now you are arguing another completely different topic

 

[MARX22]

I guess to be safe call 911 as mentioned here and see what they recommend... if this was a patient and we see they got this from us before but has no refills left, would ya’ll still give it then get an rx or still just call 911?

Or if they have refills but arent due yet... we could probably give it then get an insurance override or something but idk if we should still call 911 first?

Would you get a script and charge them? If not how do you quantify that with your DM?



I think this is going too far.

I don't know, to my knowledge I've never had one. If I were a pharmacist, I still would be very hesitant to dispense anything in an emergency. Even in the case of anaphylaxis, I still think it would be best to call 911 and just do basic first aid/monitoring instead of jumping to administer something. If I were personally having a migraine, however I still would probably just take some Ibuprofen and trudge through the rest of the day.

 

[Prepharm1214]

Work for a big chain and we received an email a few months ago that they have a 'good samaritan policy' where if something goes wrong in a life threatening situation and we act in what we believe is the best interests of the patient they will legally back us up. It specifically mentions epipens, CPR, and rescue inhalers.

 

[Lexington2012]

Work for a big chain and we received an email a few months ago that they have a 'good samaritan policy' where if something goes wrong in a life threatening situation and we act in what we believe is the best interests of the patient they will legally back us up. It specifically mentions epipens, CPR, and rescue inhalers.

Name of the big chain?

 

[pencilandpen]

Name of the big chain?

well judging from the post by OP, unless he missed an email, we can rule out WG, so theres really only 1 big chain left.

 

[pencilandpen]

If I thought I would die of anaphylaxis I'd do the same. As an asthmatic I'd also grab an inhaler if I didnt have one on me. I'd rather have issues with pretentious boards angry that in professional judgement as a doctorate degree holder that I saved myself over kindly going to the grave because I'm not a physician authorized by the state to prescribe and thus making them unhappy I didnt relinquish myself to death as a lowly pharmacist. The alternative is that you are sentenced with the death penalty because you aren't an almighty nurse practitioner. I'd also not stop a patient from taking an EpiPen or inhaler if they needed one. At the worst it would be that they "robbed" the pharmacy. You cant put a price on human life. If my employer got pissed over the cost of an EpiPen or proair I'd pay it myself over letting someone die in the consultation area. I'd absolutely bend the rules if I thought it would save a life.

thats exactly what I am trying to say, when its life and death situation, technicality be damned.
I am glad that my employer doesnt care about a box of epipen or proair in these emergency situations.

 

[SWPharm88]

I would give an epipen. I had to give CPR a few years back and it was terrifying but I would have felt terrible if i did nothing. THey found a guy in the bathroom, I was pretty sure he was already dead (he was) but the only one trying to perform CPR was his wife who came to the store looking for him, so i took over until EMT got there. She called to thank me a few days later and let me know he had an aneurysm

However last week we had someone faint and cut themselves pretty badly on a corner shelf and EMT were on the way and this lady came over to us screaming YOU NEED TO GIVE HIM ASPIRIN NOW HE IS HAVING A HEART ATTACK YOU ARE GOING TO LET HIM DIE

yeah let me go shove aspirin down this mans throat brb. That pissed me off because she was acting like we were just letting someone die in the aisle

 

[zelman]

Just give a Tdap and epipens the same day and everyone is covered by protocol. Easy peasy.

 

[Burned]

Just read this entire thread and it's made me feel worse about the profession as a whole, even after the news there would be yet another year of salary freeze today.

Although it sounds like the floater in OP was not truly in need of an Epipen, obviously if they were the correct thing to do is to take it off the shelf and use it immediately. Same goes for someone who is not able to breath due to an asthma attack- give them albuterol. Same for someone who is passed out and opioid overdose is suspected- just give them the Narcan.

What am I missing here? Only an absolutely 100% incompetent DM would be upset over this, and if they were, you should immediately escalate it within HR and find someone with a mf brain to kick them in the face. Some of you guys need to locate your daddy pants and wear em once in a while.

 

[josh6718]

I don't understand why they aren't available OTC or via protocol in some fashion. I can't see them being any more inherently dangerous than any "Tide-Pod" challenge/handgun or rifle/Plan-B pill.

 

[wagrxm2000]

Just read this entire thread and it's made me feel worse about the profession as a whole, even after the news there would be yet another year of salary freeze today.

Although it sounds like the floater in OP was not truly in need of an Epipen, obviously if they were the correct thing to do is to take it off the shelf and use it immediately. Same goes for someone who is not able to breath due to an asthma attack- give them albuterol. Same for someone who is passed out and opioid overdose is suspected- just give them the Narcan.

What am I missing here? Only an absolutely 100% incompetent DM would be upset over this, and if they were, you should immediately escalate it within HR and find someone with a mf brain to kick them in the face. Some of you guys need to locate your daddy pants and wear em once in a while.

While things like what will your DM say were brought up, the point of my thread is how far is too far? I personally don't think a person having a hard time breathing should be given an inhaler but that's just me.

There shouldn't be a single person here that wouldn't give an EpiPen to a parent for a child. Even if you are concerned about not having a script, you can protect yourself so easily by just getting one after the fact and claiming you already had it.

 

[Burned]

While things like what will your DM say were brought up, the point of my thread is how far is too far? I personally don't think a person having a hard time breathing should be given an inhaler but that's just me.

There shouldn't be a single person here that wouldn't give an EpiPen to a parent for a child. Even if you are concerned about not having a script, you can protect yourself so easily by just getting one after the fact and claiming you already had it.

I agree, emergency meds dispensed by a pharmacist directly to the patient should be in times of direct need only. What I've seen in this thread is a continual resurgence of the notion that you should just stand about and (I would assume) call 911 when you have, within walking distance, something that could help the person in need.

I think that a more focused discussion of what the potential adverse effects of the emergency medication is warranted.

1) Narcan- give it. If you have any supposition the person may be experiencing an opioid overdose, give it. This is taught in every CPR course these days. It will not harm the person even if they are not suffering from an actual opioid crisis.

2) Albuterol- I can't really imagine a situation where this would be relevant to give under emergency circumstances in the pharmacy, honestly. I suppose if someone was having a hard time breathing then rapidly progressed to an asthmatic crisis in the waiting area of your pharmacy, then you'd just hand them their inhaler. But i'd assume they were waiting for it already. Just hard to imagine this actually playing out to the point where you felt like you needed to step in instead of just ringing them out for a completed script. If you did, though, I'd make sure they went straight to the hospital after administering it (as with scenarios 1 and 3, of course)

3) Epipen- First, I'd love to know if the floater pharmacist in OP went to the ER. Because every script of Epipen I've ever dispensed came with the caveat that they needed to go to the ER if it was administered. If they took it and went about the shift, it seems likely they didn't need it in the first place. That being said, it's usually pretty evident if someone is in desperate need of an Epipen. However, if you're unsure, just don't give it! Call 911. There's a huge difference between a woman with a limp child in her arms screaming about a peanut allergy and a 75 year old man who nobody knows dragged off the street. I'd say Epipen is the tough one. If you give it to someone in cardiac arrest and NOT suffering from anaphylaxis, it can do more harm than good. So if you freeze up and can't reasonably come to a conclusion (i.e. a frantic mom is not screaming about a bee sting or peanut allergy, etc etc), then call 911 and begin CPR instead.

Here's a brief interview with God-

"Should pharmacists give acute life-saving medications directly and without a prescription and without insurance adjudication and without their DM present and signing off on it and without the approval of a minister?"

"Yes." -God

 

[BidingMyTime]

I would not give an epi-pen. I am not trained to diagnosis, and just because someone says they are having an allergic reaction, doesn't mean they really are (it could be something else wrong with them, that might be worsened by epinephrine.) *If* I were working in an actual rural pharmacy, and it really was a life or death situation, I would probably feel differently. As it is, I work in a city with a good 911 service, and I believe legally and ethically that would be the way to go (not to mention the pt would be getting trained emergency care from them, which they wouldn't be getting from me.)

In the states I have worked in its not illegal, or at least as far as I know. As for "theft" I didnt steal it for my own profit....
My store also has a shrink budget, as long as I dont exceed that I am fine, I lose way more money from bad inventory practice than from a one off emergency dispensing of meds

Um yeah, legally the "motive" for theft has absolutely nothing to do with it being a crime (although you will probably get a reduced sentence or just probation if you have a reasonable motive, ie to save a life.)

If there are loopholes for allergic reactions after vaccination, maybe it could be covered by that, but still think you would be on shaky ground.

At least in IL, epinephrine is administered for an allergic reaction after vaccination via protocol. It's not a "loophole", it's codified in the regulations

We had a person that came in asking for Narcan and Disulfiram one day. We can't dispense Narcan without a prescription, but I hate to think what might have been happening at home for them to ask for those two. I don't even know if they make Disulfiram anymore.

Disulfiram is still available, we had an admit come in with it listed as a home med. I think it is rarely used these days. Disulfiram is RX only (unlike Narcan which might be available without an RX depending on your state.) In your story, it's easy to imagine what is happening, it's not at all uncommon for someone abusing, say heroin, to also be abusing alcohol. Either the person had a bad experience and decided they needed to clean up, or a family member/friend realized they were in bad shape and decided they needed to help them clean up. They then probably googled, or got advice from an addict friend, and decided that disulfiram and narcan was what they needed.

 

[ExpressMaiL]

Would there be any legal ramifications if you did do this?

Maybe but the intention is to clearly help someone... there is no malice here.

 

[Dred Pirate]

Where do you say no? If you have a terrible migraine would you grab a sumatriptan off the shelf?

an asthma attack can kill someone - I migraine won't - that is where I would draw the line

 

[josh6718]

FL is somewhat tricky.

No kidding. HB21 has been a disaster. So tired of seeing "non-acute pain" on e-rx's for metformin and having to call a prescriber for a RX for 252 oxycodone tablets not having non acute pain. Yes somewhat off-topic, just needed to vent

 

[wagrxm2000]

an asthma attack can kill someone - I migraine won't - that is where I would draw the line

Does this include glucagon?

 

[owlegrad]

No kidding. HB21 has been a disaster. So tired of seeing "non-acute pain" on e-rx's for metformin and having to call a prescriber for a RX for 252 oxycodone tablets not having non acute pain. Yes somewhat off-topic, just needed to vent

God I hate HB 21 so much. The checking PDMP has made workflow a disaster at my pharmacy.

 

[Dred Pirate]

Does this include glucagon?

this is a grey area - although I doubt an unconscious person would come into the pharmacy - if they are conscious - grab some glucose gel or juice and have them chug it - works just as good (or better)

 

[wagrxm2000]

this is a grey area - although I doubt an unconscious person would come into the pharmacy - if they are conscious - grab some glucose gel or juice and have them chug it - works just as good (or better)

I do mean unconscious.

 

[Dred Pirate]

I do mean unconscious.

did you check the BG? only way to know if it would work - I work in the ED - so my view is obviously different than a retail rph

 

[CetiAlphaFive]

this is a grey area - although I doubt an unconscious person would come into the pharmacy - if they are conscious - grab some glucose gel or juice and have them chug it - works just as good (or better)

I had a lady lose consciousness in the middle of a flu shot once.

It happens

 

[Rouelle]

For most of these emergencies, ER or 911 are infinitely more appropriate than going to a pharmacy. If not, well then I guess Darwinism is working.

And before I get flamed for this, yes I am joking. (mostly)

 

[wagrxm2000]

did you check the BG? only way to know if it would work - I work in the ED - so my view is obviously different than a retail rph

We don't have a glucometer since we don't do health tests anymore. Obviously I could open a box.

 

[Dred Pirate]

I had a lady lose consciousness in the middle of a flu shot once.

It happens

but you have protocols for that - right? (well if it was due to allergic rxn, etc) - most likely a vaso vagal reaction - just let them sleep it off

 

[CetiAlphaFive]

but you have protocols for that - right? (well if it was due to allergic rxn, etc) - most likely a vaso vagal reaction - just let them sleep it off

It was the 'beetus.

I called 911 while her idiot family dumped soda into her airway

 

[sakigt]

If you give it to someone in cardiac arrest and NOT suffering from anaphylaxis, it can do more harm than good. So if you freeze up and can't reasonably come to a conclusion (i.e. a frantic mom is not screaming about a bee sting or peanut allergy, etc etc), then call 911 and begin CPR instead.

First round of Epi given in field. ACLS would be proud.

Call 911. If patient deteriorates give them what they need.

Narcan, Epi, Albuterol all require monitoring for a few hours after use.