Methadone Rx

[mimi06bg]

Hi everyone,

There's a patient who has been filling methadone (~12 tabs/day= 120 mg) and klonopin at the pharmacy for almost 3 years. Upon review of the state's PDMP report, that's 369 mgEq/day. Per the dr's office the diagnosis code is M54.5 for chronic low back pain. I am relatively new to the pharmacy, and am not feeling comfortable filling the script. Under what circumstances, if any, would you fill the Rx? What if I don't fill it and the patient ends up going through withdrawal...? Any feedback/advice would be greatly appreciated!

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[DiscoverID]

If they on it for years, if you get proper documents from Dr. then it's up to you to fill it. A lot of pharmacists I know don't take M54.5 as a reasonable dx anymore. But once again, are you willing to cut someone off of something that they has been on for years?

 

[CetiAlphaFive]

Hi everyone,
There's a patient who has been filling methadone (~12 tabs/day= 120 mg) and klonopin at the pharmacy for almost 3 years. Upon review of the state's PDMP report, that's 369 mgEq/day. Per the dr's office the diagnosis code is M54.5 for chronic low back pain. I am relatively new to the pharmacy, and am not feeling comfortable filling the script. Under what circumstances, if any, would you fill the Rx? What if I don't fill it and the patient ends up going through withdrawal...? Any feedback/advice would be greatly appreciated!

Why would the patient go through withdrawal?

 

[Charcoales]

I deny if any gaps (1+ month with no maintance narc) in their filling history, or discharged from another pain management in the area (I look as far back as the pdmp will go). I don't fill for people at high risk of overdose (fill gap and restarted at same high dose), or those with high likelihood of abuse (discharged from other pain managements). Also deny if no dx code on maintance Rx.

 

[josh6718]

Hi everyone,

There's a patient who has been filling methadone (~12 tabs/day= 120 mg) and klonopin at the pharmacy for almost 3 years. Upon review of the state's PDMP report, that's 369 mgEq/day. Per the dr's office the diagnosis code is M54.5 for chronic low back pain. I am relatively new to the pharmacy, and am not feeling comfortable filling the script. Under what circumstances, if any, would you fill the Rx? What if I don't fill it and the patient ends up going through withdrawal...? Any feedback/advice would be greatly appreciated!

To some extent on what you decide to do may depend on the state your licensed in. Florida, for example, has board rules in place for "Minimum Standards Before Refusing to Fill a Prescription".

One thing to also consider (if I remember correctly) as a possible reason for the dose of methadone is that a physician cannot prescribe methadone for maintenance or detoxification in opioid addicted individuals. The prescriber could be using the diagnosis of 'chronic lower back pain' to get around this.

Lastly, I would consider the patient's other co-morbid conditions. If for example they are having worsening asthma/COPD exacerbations (or even hospitalizations from it), I would make an effort to talk to the patient directly. Explain that you are concerned with their health and that you would be willing to work together with them and their prescriber to discuss medications that may be worsening this and could be adjusted. They still may say no, but it at least gives a better impression that you care, rather than saying you suddenly aren't going to fill their prescriptions any longer after they have been on it for 3 years.

 

[RxRetailRx]

Check PDMP each time ... Offer Narcan NS

 

[CetiAlphaFive]

for "Minimum Standards Before Refusing to Fill a Prescription".

One thing to also consider (if I remember correctly) as a possible reason for the dose of methadone is that a physician cannot prescribe methadone for maintenance or detoxification in opioid addicted individuals. The prescriber could be using the diagnosis of 'chronic lower back pain' to get around this.

Lastly, I would consider the patient's other co-morbid conditions. If for example they are having worsening asthma/COPD exacerbations (or even hospitalizations from it), I would make an effort to talk to the patient directly. Explain that you are concerned with their health and that you would be willing to work together with them and their prescriber to discuss medications that may be worsening this and could be adjusted. They still may say no, but it at least gives a better impression that you care, rather than saying you suddenly aren't going to fill their prescriptions any longer after they have been on it for 3 years.

Some can
You can check this on the DEA verification website.

The prescriber will have "DW", followed by the number of patients they're allowed to treat

 

[josh6718]

Some can
You can check this on the DEA verification website.

The prescriber will have "DW", followed by the number of patients they're allowed to treat

Outside of an NTP?

 

[zelman]

Some can
You can check this on the DEA verification website.

The prescriber will have "DW", followed by the number of patients they're allowed to treat

Are you thinking of buprenorphine? Retail pharmacies can’t fill methadone for opioid dependence in any state where I’m licensed. They need to go to a methadone clinic.

 

[RxPreceptor]

Check PDMP each time ... Offer Narcan NS

Narcan won't really help with methadone...half life is highly variable & long & drug accumulates/sequesters-resequesters.

 

[CetiAlphaFive]

Are you thinking of buprenorphine? Retail pharmacies can’t fill methadone for opioid dependence in any state where I’m licensed. They need to go to a methadone clinic.

Yup.
Brain fart

 

[zelman]

Narcan won't really help with methadone...half life is highly variable & long & drug accumulates/sequesters-resequesters.

It will help more than no narcan.

 

[imcallingcorp]

Hi everyone,

There's a patient who has been filling methadone (~12 tabs/day= 120 mg) and klonopin at the pharmacy for almost 3 years. Upon review of the state's PDMP report, that's 369 mgEq/day. Per the dr's office the diagnosis code is M54.5 for chronic low back pain. I am relatively new to the pharmacy, and am not feeling comfortable filling the script. Under what circumstances, if any, would you fill the Rx? What if I don't fill it and the patient ends up going through withdrawal...? Any feedback/advice would be greatly appreciated!

You do your job and fill the script based on the information you provided. Im not even hating on how you feel , I also remember fealing such as a newb pharmacist when someone needed 4 -100 fentanyl patches at a time and it was just new to me and scary. if you want to call md and verify sure but after that shove the concern in the back of your mind and keep it moving. If the patient gives you legit red flags in person thats diff story but you can’t not fill meds just because you’re not comfortable. and trust me in time you will be

 

[Apotheker2015]

mimi06bg,

there is nothing wrong with not feeling comfortable. You probably don't come across that many methadone prescriptions often. Based upon what you stated, the only red flag to you is the really high morphine milliequivalents. (Kuddos for even looking at that. I have run into a lot of pharmacists who do not even know what to make of that information on the PDMP. Don't forget that depending upon the state you are in, that calculation provided by your PDMP may not be entirely accurate; e.g., if patient is taking fentanyl or buprenorphine. The CDC has an app that is pretty accurate and useful. Check it out.)

This sounds like a good-stay-out-of-trouble methadone patient. Has been going to the same pharmacy for 3 years. If you are the only one on staff, you can look at the fill history and contact those pharmacists who have verified those prescriptions for this patient. That's if you really really want to.

I personally would call the doctor's office and whenever I am able to check in with the prescriber I would confirm the purpose of the therapy and reassure the prescriber that you're calling because you're not familiar with such a dosing regimen. You do not want to create problems for this patient at his/her doctor's office. I would also not interrupt this patient's therapy or make them feel judged. You're in retail. At the end of the day, we are customer service agents. It's our reality. That's begging for a complaint for no reason.

These are the cards you have on the table. Same prescriber, same drug combination, same directions - scheduled and not PRN, same pharmacy for 3 years and no evidence of doctor shopping or polypharmacy per the PDMP report. You are good to go. You do your due diligence, talk with the patient, get to know them, feel them out. Patient might say that his/her pain management contract should be on fine somewhere. But before putting the patient on the spot, you can reach out to the other pharmacists who have filled for her before.

That's my humble 2 cents.