New grad - to fill or not to fill?

[pepperann]

I’ve been browsing these forums since I was in undergrad, and they’ve helped me tremendously. I recently graduated pharmacy school and started a new job at a major chain retail pharmacy. I am trying to become more comfortable with filling C2s. I always check our state’s PMP database before dispensing and document diagnoses as appropriate. I have a million questions that I wish I could pick some of your brains with… I’ll do my best to limit them here.


What would you do or consider in these situations?


Scenario 1

Patient gets promethazine/codeine 473ml every month. Nurse at the doctor’s office said it was for chronic pain. I asked if I could discuss alternative therapies with the doctor. Nurse called back later that day to report that the doctor had said the patient had tried everything else and it was the only thing that worked. Would you have asked them to fax a copy of patient prescription hx if patient had never filled anything at your store besides prometh/cod?


Scenario 2

Patient (30-50 y/o) we've never filled for before kept checking on the status of their prescription which we had not yet received from the doctor’s office. One of the techs had even called the doctor’s office during this time. The patient got very angry when I refused to call the doctor’s office a second time until more time had surpassed. Finally the prescription comes through and it’s for Soma 350 TID #30. PMP reveals that they’re on chronic opiates (including Exalgo) and benzos. PMP shows they were prescribed 10-day supply of Soma 2 months ago. When you go to speak to the patient, you start to explain that you’re concerned about filling the medication, but the patient becomes angry and cuts you off and answers your questions before can even ask them- they say they have to have that medication because none of the other muscle relaxers work, and they want to know which med they need to stop in order to take it.


Scenario 3

Patient you’ve never filled for before drops off a prescription for Oxycontin 60mg q4h #180. PMP reveals hx of chronic opioid therapy and that they had oxycontin 40mg #180 as a 30-day supply filled last month at a cancer specialty pharmacy. I feel horrible because I was not comfortable filling this medication. No red flags, but it seemed like such a high dose and I was worried that they would OD. Ideally, I’d ask the patient to come back in 48 hours so I could speak with the doctor office and study pain management guidelines to determine the safety of the dose and titration…


If there is no ceiling dose with hydrocodone/oxycodone, how do you know if it’s appropriate? I can document diagnoses all day long and I can verify that they’ve been on X dose for a long time and that it’s not going to cause them to OD, but sometimes I still do not feel confident in filling these. Especially if they're >90 MME. I understand cancer/palliative can have some crazy high doses… How do I assess the appropriateness of therapy for everyone else who says they need something stronger to control their pain? Most of the questionable prescriptions have diagnoses for non-palliative pain such as back pain, chronic pain syndrome, or just “chronic pain.”? Any tips for how to approach and collaborate with a prescriber when it comes to pain management that seems excessive ?

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[PharmNewbie]

Note I've only worked retail as a staff pharmacist for a year and just started switched to prior auth pharmacist so I don't have the expertise of the retail pharmacists that worked for years.

Scenario 1: Would not fill sounds suspicious, Phenergan with codeine not approved for chronic pain. I would be wary of this one. I personally would ask for 2 peer reviewed articles or research showing that this is legit indication or t/f every other med under the sun.

Scenario 2: Sounds like a holy trinity case. You see it alot in retail. Are all 3 prescribed by same md? If they've been on it regularly year after year then I might let it go, but if not you can speak with the md office your concerns.

Scenario 3: It is your license and I've seen pharmacists at my rotations tell patients they aren't comfortable filling that rx. You can collaborate with doctors and call them but in this day and age its hard to make time to completely assess a patient. You can't really assess pain levels with patients. Only thing you can check is usually opioid tolerant and have they titrated up before.. .etc.

Hope I was a little clearer or someone else with more experience can help.

 

[Sine Cura]

Scenario 1 - total B.S. One time I did request a "history" from a prescriber 100 miles away writing for prometh/codeine left and right and to my surprise their office did forward "official" looking documents, hx etc. Still didn't fill because it was total B.S. Sometimes you just have to say no.

Scenario 2 - holy trinities you should always try to ferret out or deny. 99 out of 100 times they tend to be problem pts.

Scenario 3 - special snowflake with special P.K./P.D. warranting Q4H dosing. The patient can go back to this so-called "specialty pharmacy."

Half these prescribers DGAF and cave in to their patients demands and so do we as pharmacists.

 

[hye345]

At the very least, document conversations you have with the patients/doctors. If the scripts are all from different doctors, make sure they are all on the same page. More than once, doctors have asked me to void a prescription because they had no idea that another doc had already prescribed them similar medications.

 

[radio frequency]

All three need follow up. Number two sounds like a problem patient especially. I find when patients act this way, often there's something else going on. Careful; if they're a regular they could make your life miserable.

Number one sounds sketchy; nobody uses that for pain.

Number three might be warranted but I'd need to confirm everything including titration plans with the doctor.

If you have any questions on any prescription always follow up. It really is your license on the line and prescribers do make errors regularly or not check the PMP (or sometimes they just don't care/are easily pressured by patients into writing bad prescriptions).

 

[Charcoales]

Get the reason from MD office and then either refuse if it is a bs reason and tell them to go elsewhere, or document and dispense.

 

[BenJammin]

No, no, and yes.

 

[lord999]

I’ve been browsing these forums since I was in undergrad, and they’ve helped me tremendously. I recently graduated pharmacy school and started a new job at a major chain retail pharmacy. I am trying to become more comfortable with filling C2s. I always check our state’s PMP database before dispensing and document diagnoses as appropriate. I have a million questions that I wish I could pick some of your brains with… I’ll do my best to limit them here.


What would you do or consider in these situations?


Scenario 1

Patient gets promethazine/codeine 473ml every month. Nurse at the doctor’s office said it was for chronic pain. I asked if I could discuss alternative therapies with the doctor. Nurse called back later that day to report that the doctor had said the patient had tried everything else and it was the only thing that worked. Would you have asked them to fax a copy of patient prescription hx if patient had never filled anything at your store besides prometh/cod?


Scenario 2

Patient (30-50 y/o) we've never filled for before kept checking on the status of their prescription which we had not yet received from the doctor’s office. One of the techs had even called the doctor’s office during this time. The patient got very angry when I refused to call the doctor’s office a second time until more time had surpassed. Finally the prescription comes through and it’s for Soma 350 TID #30. PMP reveals that they’re on chronic opiates (including Exalgo) and benzos. PMP shows they were prescribed 10-day supply of Soma 2 months ago. When you go to speak to the patient, you start to explain that you’re concerned about filling the medication, but the patient becomes angry and cuts you off and answers your questions before can even ask them- they say they have to have that medication because none of the other muscle relaxers work, and they want to know which med they need to stop in order to take it.


Scenario 3

Patient you’ve never filled for before drops off a prescription for Oxycontin 60mg q4h #180. PMP reveals hx of chronic opioid therapy and that they had oxycontin 40mg #180 as a 30-day supply filled last month at a cancer specialty pharmacy. I feel horrible because I was not comfortable filling this medication. No red flags, but it seemed like such a high dose and I was worried that they would OD. Ideally, I’d ask the patient to come back in 48 hours so I could speak with the doctor office and study pain management guidelines to determine the safety of the dose and titration…


If there is no ceiling dose with hydrocodone/oxycodone, how do you know if it’s appropriate? I can document diagnoses all day long and I can verify that they’ve been on X dose for a long time and that it’s not going to cause them to OD, but sometimes I still do not feel confident in filling these. Especially if they're >90 MME. I understand cancer/palliative can have some crazy high doses… How do I assess the appropriateness of therapy for everyone else who says they need something stronger to control their pain? Most of the questionable prescriptions have diagnoses for non-palliative pain such as back pain, chronic pain syndrome, or just “chronic pain.”? Any tips for how to approach and collaborate with a prescriber when it comes to pain management that seems excessive ?

Scenario #1 - Really? The codeine isn't in there as a pain relief dose (intentionally subthereapeutic for that). Write marginalia on the script that you actually confirmed this as odd as it sounds. I wouldn't dispense in your position. I'd ask for the real stuff.

Scenario #2 - Accidentally play the flamingo game the next time. People who are on your case for a script don't deserve prioritization.

Scenario #3 - If it's oncology, you can sleep easy (and if it's a suicide dose, you can sleep easy). Oncology pain treatment is something where the OD rule for opioids apply over the usual high dose (which is to say, no real ceiling besides RR depression).

Nonsarcastic: In general, you should not decline to fill on feelings. You need a reason, and depends on the person, but it usually needs to be a concrete one that can be stated objectively to someone. I probably would not fill #2 again as being a jerk to the staff is good enough as a reason. I definitely would not fill #1 on grounds that the codeine dose at dosing levels is subtherapeutic for pain, and that the physician should write for C-II codeine if that's the only thing that works (I have not only a concrete reason, but a clear clinical one not to do this). On #3, given the context you've given, I'd let it slide as I wouldn't have a concrete reason to say no. Also, as you get to figure out who writes in your area, you'll figure out who knows what they are doing usually and manslaughter capable soon enough.

 

[Apotheker2015]

I’ve been browsing these forums since I was in undergrad, and they’ve helped me tremendously. I recently graduated pharmacy school and started a new job at a major chain retail pharmacy. I am trying to become more comfortable with filling C2s. I always check our state’s PMP database before dispensing and document diagnoses as appropriate. I have a million questions that I wish I could pick some of your brains with… I’ll do my best to limit them here.


What would you do or consider in these situations?


Scenario 1

Patient gets promethazine/codeine 473ml every month. Nurse at the doctor’s office said it was for chronic pain. I asked if I could discuss alternative therapies with the doctor. Nurse called back later that day to report that the doctor had said the patient had tried everything else and it was the only thing that worked. Would you have asked them to fax a copy of patient prescription hx if patient had never filled anything at your store besides prometh/cod?


Scenario 2

Patient (30-50 y/o) we've never filled for before kept checking on the status of their prescription which we had not yet received from the doctor’s office. One of the techs had even called the doctor’s office during this time. The patient got very angry when I refused to call the doctor’s office a second time until more time had surpassed. Finally the prescription comes through and it’s for Soma 350 TID #30. PMP reveals that they’re on chronic opiates (including Exalgo) and benzos. PMP shows they were prescribed 10-day supply of Soma 2 months ago. When you go to speak to the patient, you start to explain that you’re concerned about filling the medication, but the patient becomes angry and cuts you off and answers your questions before can even ask them- they say they have to have that medication because none of the other muscle relaxers work, and they want to know which med they need to stop in order to take it.


Scenario 3

Patient you’ve never filled for before drops off a prescription for Oxycontin 60mg q4h #180. PMP reveals hx of chronic opioid therapy and that they had oxycontin 40mg #180 as a 30-day supply filled last month at a cancer specialty pharmacy. I feel horrible because I was not comfortable filling this medication. No red flags, but it seemed like such a high dose and I was worried that they would OD. Ideally, I’d ask the patient to come back in 48 hours so I could speak with the doctor office and study pain management guidelines to determine the safety of the dose and titration…


If there is no ceiling dose with hydrocodone/oxycodone, how do you know if it’s appropriate? I can document diagnoses all day long and I can verify that they’ve been on X dose for a long time and that it’s not going to cause them to OD, but sometimes I still do not feel confident in filling these. Especially if they're >90 MME. I understand cancer/palliative can have some crazy high doses… How do I assess the appropriateness of therapy for everyone else who says they need something stronger to control their pain? Most of the questionable prescriptions have diagnoses for non-palliative pain such as back pain, chronic pain syndrome, or just “chronic pain.”? Any tips for how to approach and collaborate with a prescriber when it comes to pain management that seems excessive ?

Everyone's given you pretty solid insight here. Bottom line is, even though you don't have that much experience, you knew something wasn't right. Trust that. When you get that, follow up on it and trust that. It's your license at the end of the day. And really, if you do not feel a prescription satisfies all the requirements to be a valid prescription; including confirmation of patient-prescriber relationship, then you have no obligation to back it up with your license. They can go somewhere else. You can tell them where else they may go. You can have the courtesy of calling a couple of places and asking if what the patient needs is in stock.

With those prescriptions calling for outrageous daily doses, you can always tell the prescriber: "You wrote this prescription to be taken as needed and that would be a total of 12 tablets per day. I am able to fill it only if you agree to a maximum of 6 tablets per day." They either agree or the highway. It's that simple.

Prescribers have no jurisdiction over your license. You should know that if something happens to that patient, you are also responsible. It's your license and whatever you bless with it, you are responsible for. In this day and age, and saturated market, you want to make sure you can pay back those loans. That's my humble two cents.

 

[RxPreceptor]

Agreed with what others have said for scenarios 1 & 2 (questionable indication & red flags with qty & Hx & potential polypharma for the "holy trinity", respectively).
Scenario 3: Seems odd since oxycontin is Q8-12H (keyword=usually), definitely clarify with MD & see if they are on PRN Oxycodone IR. Likely Cancer/hospice for that high of MDD

 

[Carboxide]

I don't think there's anything wrong with not filling #3, even if they are cancer and titrated up. They can get the drug from a pharmacy that works closely with their cancer center - they probably have one in the hospital cancer center itself. That's a 50% bump in dose and even though the dose itself might be reasonable, I don't know if I'd want to do it. But if you did fill it, I think that's ok too - you looked into it. That one's a dealer's choice, so to say.

That patient really should be on a fent patch.