Narcotics: Patients or Criminals?

[pharmboyrx]

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How do you handle the situation when you receive a prescription for narcotics (roxicodone, ocycontin)? As a young pharmacist I have received little advice/instruction on good practices when these prescriptions are given to me. I have a huge desire to protect my license. At the same time I don't want to treat every customer who takes those meds like a criminal.

I worked at a store today where I spent all day turning away prescriptions for 200+ roxicodones from some office that was 3 hours away from me. I just went back to floating and feel really exposed when it comes to this because I don't have my usual customers with valid medical conditions that I've becomed accustomed too.

Any advice on how to handle these people?

 

[Hels2007]

How do you handle the situation when you receive a prescription for narcotics (roxicodone, ocycontin)? As a young pharmacist I have received little advice/instruction on good practices when these prescriptions are given to me. I have a huge desire to protect my license. At the same time I don't want to treat every customer who takes those meds like a criminal.

I worked at a store today where I spent all day turning away prescriptions for 200+ roxicodones from some office that was 3 hours away from me. I just went back to floating and feel really exposed when it comes to this because I don't have my usual customers with valid medical conditions that I've becomed accustomed too.

Any advice on how to handle these people?

Whenever in doubt, call the prescriber and double-check. Check the patient profile. Listen to your gut instinct. Then make your decision based on all three. You are only liable if you knowingly fill a fake script, or a script that is medically strange - like someone never had an opioid in their profile, and they bring a script for 200mg Oxycodone a day, or something like that... If something is fishy, or scripts look suspicious - then your options are calling state patrol (or whomever it is in your state you should call for drug-related issues) or give the script back to the person, saying your don't think this is a valid prescription. Then if this is a bunch of people with the same stolen pad, for example, they will know you know, and won't bother you anymore... at least, that has been my experience. I don't call the authorities unless they really start making a fuss or threatening me, etc. Most people just give up when they see you know it is a fake, and go in search of a more trusting pharmacist (which is why it's good to let other pharmacies in the area know when you detect a pattern of fakes).

 

[Quiksilver]

How do you handle the situation when you receive a prescription for narcotics (roxicodone, ocycontin)? As a young pharmacist I have received little advice/instruction on good practices when these prescriptions are given to me. I have a huge desire to protect my license. At the same time I don't want to treat every customer who takes those meds like a criminal.

I worked at a store today where I spent all day turning away prescriptions for 200+ roxicodones from some office that was 3 hours away from me. I just went back to floating and feel really exposed when it comes to this because I don't have my usual customers with valid medical conditions that I've becomed accustomed too.

Any advice on how to handle these people?

profile goes a long way to help me and the words "i'm paying cash" also is a big red flag. other then that, clinical judgement, if they are on oxy 80 mg and they have no profile, then maybe something's up. if they are on something for everything, then its type of insurance, is it on comp? It might also pay to have friends in other chains that can look this **** up. but my opinion is just a student opinion. Always err on the side of caution, however, don't be wrong, if they are legit, and they are really in pain, you will hear about it from your 6 different bosses.

 

[Sparda29]

profile goes a long way to help me and the words "i'm paying cash" also is a big red flag. other then that, clinical judgement, if they are on oxy 80 mg and they have no profile, then maybe something's up. if they are on something for everything, then its type of insurance, is it on comp? It might also pay to have friends in other chains that can look this **** up. but my opinion is just a student opinion. Always err on the side of caution, however, don't be wrong, if they are legit, and they are really in pain, you will hear about it from your 6 different bosses.

Really, even if the prescription appears to be suspect?

We got a prescription for Morphine IR #360 w/ 6 refills the other day, patient didn't really look like they were out to score drugs, we turned it down, but if it was real, it was because of an incompetent prescriber.

 

[Vitamin K]

You can always refuse to fill prescriptions that are dosed too high. Understanding that some people (e.g. cancer patients) really DO take ridiculous doses of oxycontin, you still have the right to phone the physician, check profile, and refuse the fill if it's something that you deem excessive. For example, we had a patient with psych issues bring in a prescription for 3 times the max dose of methylphenidate. She stated that it was for ADHD and we confirmed the dose with the prescriber. BUT...just because the doc wants a ridiculous dose doesn't mean you can/should fill it. We refused the Rx on the basis that the patient was at high risk for further psychosis and arrhythmia issues due to her PMH. You always have the right to refuse a prescription if it's for the right reason.

On the drug seeking issue, my thought is that it's best to treat every patient like their pain is 100% legitimate until I'm given reason to believe otherwise. If they ask to pay cash, I call the prescriber. If they recently picked up another narcotic or have multiple docs prescribing narcotics (per profile), I call the prescriber. If they want to pick up their hydrocodone but not the amoxicillin that came on the same Rx blank, I tell them that it's "all or none". I agree about listening to your gut and watching for red flags.

 

[Pharmavixen]

Students aren't given enough direction on this, but at the same time, pharmacists are expected to be the opioid police, and it was one of my pet peeves about working retail.

I recommend being completely hard-nosed: call and verify every narcotic rx. If you can't, don't fill it. I've filled too many forged rxs over the years to worry about possibly hassling a legitimate pain pt.

And as I've mentioned on other threads, many of these pain pts, even if the script is legit, are scammers. Most doctors are vigilant, but it only takes a couple who give the addicts everything they ask for to keep the underground economy of your entire state supplied with Oxycontin.

I've phoned drs to tell them their pt is selling their Oxycontin (because they're doing it right outside the store), and they get nasty, saying I can't prove it. So we have to get the police involved, and that's a huge hassle. And I'd just as soon not have addicts thrown in jail. It's not the most effective tx strategy for them.

 

[Quiksilver]

Really, even if the prescription appears to be suspect?

We got a prescription for Morphine IR #360 w/ 6 refills the other day, patient didn't really look like they were out to score drugs, we turned it down, but if it was real, it was because of an incompetent prescriber.

you have a legal issue with that script in new york state, I am sure you are aware. I would have never let that script leave the store. You are NOT far away from state lines, someone in NJ could easily fill that script not knowing any better.

as vitamin K suggests there is no sure fire way to pick out a fake or habitual user, outside the complete obvious stuff. its a lot of detective work and common sense really. multiple narcs, tht sort of stuff is tricky. I once caught a patient that would call different dentists to get a script for really really bad dental pain. it would be done every couple weeks. My cousin who was a dentist was scammed also in bad way, the lady was so convincing to him, she had it down to the tooth number and complained with such detail that she must have really something wrong. It wasn't until the pharmacy caught it later. I guess keeping a good degree of skepticism is okay, but they are innocent until proven guilty.

 

[meister]

I recommend being completely hard-nosed: call and verify every narcotic rx. If you can't, don't fill it. I've filled too many forged rxs over the years to worry about possibly hassling a legitimate pain pt.

This might work for CIIs, but calling on every vicodin script? You'd be on the phone all day. Unless by narcotic you just meant CII, in which case I agree with you completely unless the patient is a known factor who has been using your pharmacy for a while with a documented diagnosis. "I'm paying cash," "I want the TEVA brand," and "I don't want the amoxicillin" are all you need to hear to know it's an abuser.

I consider it a real tragedy in this country that our situation is such that pharmacists are almost forced to view patients presenting CII scripts as de facto criminals. **** the DEA and **** drug prohibition, all this system does is prevent legitimate patients from getting the best medicine. What a shame.

 

[confettiflyer]

Yeah, I agree. Pharmacists are trained to be pharmacists, we aren't trained to be opioid police, lie detectors, and drug detectives. Luckily, so long as you exercise due diligence and aren't knowingly filling a bum script, you aren't liable. Still, it gets annoying...what's worse is when you actually confront or challenge a patient, we aren't trained in handling combative patients the way police/SWAT are.

Unfortunately, it's a de facto job role for retail pharmacy.

 

[Quiksilver]

This might work for CIIs, but calling on every vicodin script? You'd be on the phone all day. Unless by narcotic you just meant CII, in which case I agree with you completely unless the patient is a known factor who has been using your pharmacy for a while with a documented diagnosis. "I'm paying cash," "I want the TEVA brand," and "I don't want the amoxicillin" are all you need to hear to know it's an abuser.

I consider it a real tragedy in this country that our situation is such that pharmacists are almost forced to view patients presenting CII scripts as de facto criminals. **** the DEA and **** drug prohibition, all this system does is prevent legitimate patients from getting the best medicine. What a shame.

thats even hard to do with CII's depending on your store. We have to view them in a regulatory way. Really as long as you don't throw obvious red flags, and your script is on time, well then Have a nice day. I am not going to be the narc police and search for things out of the ordinary. the only thing the law does is to make sure you look at their profile on every fill, if I see something that catches my eye then so be it. We are only negligent when we knowingly fill it wrongfully or things are so quite obvious. and thats all that should be a concern

 

[Aznfarmerboi]

Always call a prescriber to double check when in doubt. If it is after hours, refuse script or tell them to come back tomorrow.

If they cannot wait for tomorrow for what ever reason, I would fill the script even if it was for cash and/or high dose as long as it was written properly with all the legal requirements there (MD signature, date, legitimate serial coder number, DEA, etc). Denying somebody their pain medications just because you suspect it is a fake script due to the person paying cash or high dose is not a good enough reason.

 

[meister]

Always call a prescriber to double check when in doubt. If it is after hours, refuse script or tell them to come back tomorrow.

If they cannot wait for tomorrow for what ever reason, I would fill the script even if it was for cash and/or high dose as long as it was written properly with all the legal requirements there (MD signature, date, legitimate serial coder number, DEA, etc). Denying somebody their pain medications just because you suspect it is a fake script due to the person paying cash or high dose is not a good enough reason.

Yes but thanks to ridiculous DEA nanny-state bureaucratic rules, it's either all or nothing with CIIs! Great idea feds, thanks! I'm sure you all know how to practice pharmacy!

 

[confettiflyer]

Anyone know the law regarding discrimination and providing health care? I wonder if this has been tested or done...what're the rates of rejection of C-II scripts for African Americans vs. Caucasians vs. Others.

I know under Fair Housing, agents actively seek out (sting op of sorts) landlords/apartment companies that may deny having a room to someone who "sounds" foreign on the phone, for example.

I can't recall if filling of scripts is covered under existing discrimination laws, but I'd think an enterprising attorney would look into this and you'd end up with headlines like, "RITE-AID CHARGED WITH RACISM IN DENYING MEDICATIONS."

Just a random thought...if the above were actively going on, it's possible that a company/pharmacist would be liable if there were a disproportionate # of scripts being denied from one racial group over the other.

 

[meister]

That's an interesting point you raise, because one of the staff RPhs at my old store was accused of our Rx supervisor of discriminating against a certain ethnic group. It turned out that she had twice denied a CII script from one of our supervisor's family members, and they got pissed and told him about it.

She was pretty offended and there was no merit to his claim, but I can see it being a potential problem. (although in Orange County the typical scumbags were always white 909ers who happened to hop on the 91 and found their way into the OC)

 

[Pharmavixen]

I've worried about discriminating against a legitimate patient on the basis of appearance, though not on race. I live in a city where white people are about 50% of the population, yet 99% of the Oxycontin scammers are white. But I've been taken in by respectable-looking people who can talk about a painful condition with convincing detail.

And yeah; the trouble with all of this scamming is it criminalizes honest people with real medical problems. What muddies the waters further is the fact that addicts are more likely to become pain patients. They've taken so many opioids that they've down-regulated their pain receptors such that they feel more pain with less.

 

[Doctor M]

Im honestly tired of pain medicine. Out of 500 rx, 35-50 rx's are CII narcotics. I dont even look at them anymore in the eyes...I know most of the narc patients that come in...i think the word is out that my partner and I are SOBS if we dont know you...It just gets so asinine when they ask if their blue pills, or they only want brand...or we shorted them 32 pills...i mean come on...just plain pain in the ass..

 

[Sparda29]

I dunno, like for my post-op arthroscopic knee surgery (lateral meniscus repair), Vicodin ES didn't work unless I took 3 tablets at once. (First time ever with opioid.)

I'm almost sure when I go to complete the knee surgery (ACL Reconstruction) that I'm going to require morphine.

 

[Doctor M]

I dunno, like for my post-op arthroscopic knee surgery (lateral meniscus repair), Vicodin ES didn't work unless I took 3 tablets at once. (First time ever with opioid.)

I'm almost sure when I go to complete the knee surgery (ACL Reconstruction) that I'm going to require morphine.

good luck!

 

[meister]

Im honestly tired of pain medicine. Out of 500 rx, 35-50 rx's are CII narcotics. I dont even look at them anymore in the eyes...I know most of the narc patients that come in...i think the word is out that my partner and I are SOBS if we dont know you...It just gets so asinine when they ask if their blue pills, or they only want brand...or we shorted them 32 pills...i mean come on...just plain pain in the ass..

What a sad state of affairs. 🙁

 

[Doctor M]

What a sad state of affairs. 🙁

Yeah, no crap...tell me about it...its the same story everyday