Pain Clinics and Pharmacies

[qaayen]

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Hi all,

First off, it is great to be a member in this forum and I have been an admirer for this forum for a long time.

Today, I have a dilemma and I truly appreciate the input from my senior pharmacists.

I just finished school this year and trying to finish another graduate degree (hopefully in another year). Looking for work that would not drift me apart from the school, I had this job with a friend's small pharmacy that is close to pain clinics. For the first week, I have seen patients pouring in seeking the usual pain cocktail (lorcet, xanax and soma) from the pharmacy and I got intimidated (my first experience with such huge quantities). The prescriptions are legitimate and they meet legal requirements and every thing looks authentic, but deep inside, I am still concerned about the legitmacy of the whole things and whether pharmacists are legally liable just in case some thing happened even in the presence of legitimate prescriptions( which seems to be easy to get).

I had a discussion with owner of the pharmacy and he told me that there is nothing to worry about and it has been like this for the last three years. In fact, an inspector from board just came recently and had minor observations and nothing major. Aside from the concern about my safety, do you have any thoughts about such pharmacies? Have any one of you guys worked in a pain clinic pharmacy or know some who did? and out of curiosity, what is the average number of controlled drugs you are dispensing on daily basis?

looking forward to reading every one's thought!

Thank you,

 

[Pharmavixen]

I worked in a methadone-dispensing pharmacy for 4 years, and yes; I do have a problem with these pharmacies and pain clinics.

Do you have access to medical databases, like Embase or Medline? If you do, have a look, using search terms such as "pain treatment" and "opioid abuse," and see the evidence. Basically, whether to treat chronic non-cancer pain with long-term opioids is not written in stone.

Available free is Opioid Guidelines to the Treatment of Chronic Non-Cancer Pain Pain Physician 2006; 9: 1-40. It's a good overview of the use and pitfalls of opioids. It states that the US makes up about 5% of the world's population, but uses in excess of 90% of the world opioid supply.

Sure pain is a subjective experience, but are Americans (and probably Canadians, too) really suffering all that much?

And then there's the epidemiological evidence showing the rise in the number of deaths from oxycodone and methadone overdose.

If these pain clinics really wanted to help people, they'd provide intensive support for lifestyle measures that would ease pain, such as weight loss and physiotherapy, instead of drugging people to the gills.

An example: one of the inmates in the jail came in on a morphine equivalent of ~ 1000mg/day of opioids, a mix of MS Contin and Oxycontin. This was a legitimate prescription from a doctor who specialized in addiction medicine and pain tx. The doctor and I discussed it and decided to give him MS Contin 30mg bid. So we gave him that, and we did raise it to 60 mg bid, and then he was fine; no WD symptoms. Then he developed a strep A necrotizing fasciitis requiring extensive debridement of his lower leg. One of our jail nurses also works at the hospital, and looked after him for 3 days. She says after the initial post-surgical period, the guy was in no pain at all, receiving MS Contin 30mg bid.

Basically, there's enormous traffic in pharmaceuticals that were initially legitimately prescribed by these pain clinics. The patients take some of the pills and sell the rest to street dealers. I've talked to these guys, and it's pretty easy money. A dealer will give a pain patient a couple of hundred bucks for his Oxycontin, and he'll turn around and sell them for a dollar a mg. We've got remote areas of rural Canada that are having huge Oxycontin problems, that previously had no addiction issues besides EtOH (no heroin or cocaine, like in the cities; but pharmaceuticals get distributed everywhere).

A couple of years ago, a study published in the Canadian Medical Association Journal found that Oxycontin has replaced heroin as the #1 opioid of abuse in all parts of Canada except Vancouver and Montreal (those are port cities = easy access to heroin arriving from overseas).

Anyway, long post...this is my pet subject. And my pet peeve. Addictions to pharmaceuticals increases crime in cities, such as the one where I live. And people who really are in pain are not getting treated properly - just turned into addicts. It's wrong on so many levels, but it goes on because lots of folks are making money: doctors, pharmacists, biker gangs, and the police. Proper pain treatment isn't as lucrative.

 

[metrarx]

....

 

[CopToEM]

A dealer will give a pain patient a couple of hundred bucks for his Oxycontin, and he'll turn around and sell them for a dollar a mg.

You sir, are correct. I worked the streets in the Oxycontin capital of the United States. Lortabs do follow the $1/mg pattern but Oxycontin, in this area, can be as high as $1.50/mg or $120 per 80mg dose.

Last year alone, police agents in our 60 square mile radius bought right around 600 units of Oxycontin. That doesn't include the seizures incident to arrests made but simply the undercover purchases.

Needless to say, we're all anxiously awaiting the arrival or Remoxy, if it ends up making it through the FDA.

Since RX fraud is so highly monitored now, especially here, dealers are starting to get their own distributors as you've described. These distributors are generally the disabled who have legitimate Oxy prescriptions but don't really need them.

Often, they'll sell the entire fill, and the dealer will allow them to call if they legitimately have pain and need their medication. He'll drop off a pill for them as needed. Ironic, huh?

It was just in the paper last week about a local pain clinic physician who's had her license suspended. Her patient charts were over a year behind, she was dispensing narcotic samples without documentation, and treating family and staff without record. They also found out she had been writing pain prescriptions without ever seeing the patient.

 

[CopToEM]

And I wouldn't listen to the owner say things like "don't worry about it, it's been like this for 3 years" So? It's your license right?

You know, I second this. My understanding through law enforcement was you can refuse a prescription anytime you want... if that's the case, sure, your boss is going to lose business, but in the end it's your license that's tied to it. Don't get strong armed into doing something that you're not comfortable with.

Also, a niche I've always thought needed filling locally, is a pharmacy with a vocal pro law enforcement stance. Maybe something to consider in your own career since you seem to have an interest.

 

[Pharmavixen]

You know, I second this. My understanding through law enforcement was you can refuse a prescription anytime you want...

Trouble is, that isn't quite true. There may be some minor differences between jurisdictions but generally, pharmacists are obligated to fill prescriptions unless there are compelling clinical reasons not to, and we can't be passing ad hoc judgements on who we think is diverting their meds.

So we can't refuse to fill a legit script on the basis of suspicion alone (though sometimes we get around this by saying we don't have the medication in stock).

Also, a niche I've always thought needed filling locally, is a pharmacy with a vocal pro law enforcement stance. Maybe something to consider in your own career since you seem to have an interest.

Cool! Another role for people like us (I work in Corrections, running methadone maintenance in a city jail) is education, lecturing medical students about the reality of the huge problem of opioid diversion and the central role that doctors play in causing and perpetuating this problem.

I worked the streets in the Oxycontin capital of the United States. Lortabs do follow the $1/mg pattern but Oxycontin, in this area, can be as high as $1.50/mg or $120 per 80mg dose.

Where's that? I could tell our dealers here, and maybe they'll leave my city for the higher profits to be had in your city 😀

I'm a ma'am, btw.

 

[kdt110]

For the first week, I have seen patients pouring in seeking the usual pain cocktail (lorcet, xanax and soma) from the pharmacy and I got intimidated (my first experience with such huge quantities).

It is common to be intimidated especially with large quantity. Don't be afraid to ask and to look up information.

 

[CopToEM]

Trouble is, that isn't quite true. There may be some minor differences between jurisdictions but generally, pharmacists are obligated to fill prescriptions unless there are compelling clinical reasons not to, and we can't be passing ad hoc judgements on who we think is diverting their meds.

I guess, in a sense, that does make sense. I wonder how that couples with the right of a businessman/woman to refuse the right to serve someone? I think that right is protected from a BUSINESS stand-point, so I'd be interested in seeing how it weighs against the Pharmacy stand-point. Obviously, with health care, it's a gray area and not a clear line.

Cool! Another role for people like us (I work in Corrections, running methadone maintenance in a city jail) is education, lecturing medical students about the reality of the huge problem of opioid diversion and the central role that doctors play in causing and perpetuating this problem.

Agreed. If I end up starting my own Pharmacy in my geographic area after graduation, one of my goals is to 'campaign' locally for reform. It's time that health-care professionals of all kinds start to be accountable around here. I read in the newspaper that they've busted three meth labs in the past month. The last one had wholesale amounts of Psuedophedrine... I don't understand how these things get under the radar.

Just tell them to pick any town in the Southern Appalachian mountains, basically.

 

[qaayen]

I worked in a methadone-dispensing pharmacy for 4 years, and yes; I do have a problem with these pharmacies and pain clinics.

Do you have access to medical databases, like Embase or Medline? If you do, have a look, using search terms such as "pain treatment" and "opioid abuse," and see the evidence. Basically, whether to treat chronic non-cancer pain with long-term opioids is not written in stone.

Available free is Opioid Guidelines to the Treatment of Chronic Non-Cancer Pain Pain Physician 2006; 9: 1-40. It's a good overview of the use and pitfalls of opioids. It states that the US makes up about 5% of the world's population, but uses in excess of 90% of the world opioid supply.

Sure pain is a subjective experience, but are Americans (and probably Canadians, too) really suffering all that much?

And then there's the epidemiological evidence showing the rise in the number of deaths from oxycodone and methadone overdose.

If these pain clinics really wanted to help people, they'd provide intensive support for lifestyle measures that would ease pain, such as weight loss and physiotherapy, instead of drugging people to the gills.

An example: one of the inmates in the jail came in on a morphine equivalent of ~ 1000mg/day of opioids, a mix of MS Contin and Oxycontin. This was a legitimate prescription from a doctor who specialized in addiction medicine and pain tx. The doctor and I discussed it and decided to give him MS Contin 30mg bid. So we gave him that, and we did raise it to 60 mg bid, and then he was fine; no WD symptoms. Then he developed a strep A necrotizing fasciitis requiring extensive debridement of his lower leg. One of our jail nurses also works at the hospital, and looked after him for 3 days. She says after the initial post-surgical period, the guy was in no pain at all, receiving MS Contin 30mg bid.

Basically, there's enormous traffic in pharmaceuticals that were initially legitimately prescribed by these pain clinics. The patients take some of the pills and sell the rest to street dealers. I've talked to these guys, and it's pretty easy money. A dealer will give a pain patient a couple of hundred bucks for his Oxycontin, and he'll turn around and sell them for a dollar a mg. We've got remote areas of rural Canada that are having huge Oxycontin problems, that previously had no addiction issues besides EtOH (no heroin or cocaine, like in the cities; but pharmaceuticals get distributed everywhere).

A couple of years ago, a study published in the Canadian Medical Association Journal found that Oxycontin has replaced heroin as the #1 opioid of abuse in all parts of Canada except Vancouver and Montreal (those are port cities = easy access to heroin arriving from overseas).

Anyway, long post...this is my pet subject. And my pet peeve. Addictions to pharmaceuticals increases crime in cities, such as the one where I live. And people who really are in pain are not getting treated properly - just turned into addicts. It's wrong on so many levels, but it goes on because lots of folks are making money: doctors, pharmacists, biker gangs, and the police. Proper pain treatment isn't as lucrative.

Sometimes when I open up the pharmacy, I see couple of patients (pain scripts) waiting in their latest fancy cars and then arguing about the price. Make you wonder how they get the money huh..

 

[qaayen]

That is my biggest concern. With pain management liability definitely becomes a tricky and gray area. What scares me the most is an inexperienced md/np/pa etc. converting someone over to another opioid and not doing the math correctly or starting someone on a high dose who's opioid naive. And then you have the idiot lawyer or the semi-******ed pharmacy board member ask questions like "well, why didn't you call the prescriber, it was a pretty high dose". What the hell do you say to that? You wouldn't be able to justify not calling based on the type of patients your pharmacy serves. After all, we are supposed to know whether the pt is opioid naive, what the prescriber is treating, for how long, etc., right?

I'm sure you already have done this but if not, I highly suggest you get personal liability insurance. It's dirt cheap (100-500/year) compared to practioner's insurance.

And I wouldn't listen to the owner say things like "don't worry about it, it's been like this for 3 years" So? It's your license right? I would still call on anything that's remotely suspicious. If it annoys the presribers, oh well.

Not trying to scare you, but I wouldn't be lax working in a place like that, even after 20 years.

That is why I like this forum.. The opinions I am getting here is priceless especially for a junior pharmacist like me😳

I always counsel patients coming from these clinics and emphasize on the potential dependency and safety of these drugs. In fact, some of the regular customers started to call before they come just to see if the original owner is there or not. I think they started to hate me for that which I am very cool with😉

Thanks for your advice

 

[qaayen]

The latest news in Houston Texas

Houston area couple charged with health care fraud

A Houston area doctor and his wife, also a physician, were charged Wednesday in federal court, accused of illegally prescribing more than 600,000 pain pills and billing the government more than $8 million for medical care that was never performed.
Dr. Arun Sharma and his wife, Dr. Kiran Sharma, both 54, are charged with conspiracy to commit health care fraud and conspiracy to unlawfully distribute controlled substances not for legitimate medical reasons, officials said.
Investigators said the couple operated their clinics in Webster and Baytown as virtual "pill mills." One patient received more than 8,000 hydrocodone tablets between September 2008 and April — including two prescriptions that were issued the same day.
Customers were charged up to $100 for each hydrocodone prescription, officials said.
Investigators found $700,000 during a search of the couple's home along with $816,000 inside a pair of safe deposit boxes, officials said.
Kiran Sharma, suspected of handling the couple's financial arrangements, was taken into federal custody Wednesday. She is expected to go before a federal magistrate on Thursday, officials said.
A warrant has been issued for Arun Sharma's arrest but officials said he is expected to surrender Thursday to federal authorities.

600,000 pain bills ... WOW .. Who needs fat Tony now

 

[Pharmavixen]

Something I just wanted to share: the inmate who got necrotizing faciitis has recovered and is back in the jail. Recall how I said he was getting a morphine equivalent of about 1000mg per day from his PCP.

So his leg has healed well, though it looks ghastly; it was an aggressive debridement, and he's missing lots of flesh. We've got him on MS Contin 50mg bid. And he's recovering uneventfully, no excess pain.

And the hospital has verified it: when he was getting all that morphine and oxycontin from his PCP, there was nothing wrong with him (besides addiction).

Maybe if pharmacists got more autonomy to refuse to fill scripts.

 

[platon20]

Am I missing something here?

In my neck of the woods, people in jail/prison are not allowed to have any scripts for narcotics. All they can have is NSAIDs.

Does your area actually allow inmates to get narcotic scripts? Thats insane!

 

[Pharmavixen]

Am I missing something here?

In my neck of the woods, people in jail/prison are not allowed to have any scripts for narcotics. All they can have is NSAIDs.

Does your area actually allow inmates to get narcotic scripts? Thats insane!

They can get opioids if it's justified. If a guy comes in with a fractured jaw all wired together, we'll give him Tylenol #3 or plain codeine (all crushed up and mixed with water). Or the guy who tried to take a gun off a cop, and got his arms broken was prescribed Oxycocet (not sure you have that brand stateside; it's generic Percocet).

Some jails in our province don't have any narcotics at all, but we haven't been able to do that because we get them right from the street when they're freshly injured from the crime or the arrest. We also get people with HIV-related neuropathies, and politically it's a very bad idea to take opioids away from people with AIDS.

And they don't, under any circumstances, get Oxycontin. No way, no how.

 

[CopToEM]

You mean to tell me that one guy seriously got 8,000 pain pills in a 6 month period of time and nobody caught on? I find it hard to believe there's not a pharmacist(s) somewhere that should be implicated in that drug ring as well... a urban area like Houston or not. That's insane.

 

[StaviZFingerZ]

Pain clinic pharmacy would be an ideal practice site for Anesthesia Pharmacist.

 

[StaviZFingerZ]

And their #1 method of putting patients to sleep is by reading Pharmacy Times Editorial in Steven Urkel's voice.

 

[metrarx]

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