prescribing oral medications

[eyeloveu]

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I have always been confused and a bit insulted as to why optometrists are not given the ability to prescribe oral medications to the patients. I was wondering if anyone already practicing or in school can help explain why this is? Thanks!

 

[KHE]

I have always been confused and a bit insulted as to why optometrists are not given the ability to prescribe oral medications to the patients. I was wondering if anyone already practicing or in school can help explain why this is? Thanks!

Optometrists in most states can prescribe oral medications for ocular conditions. The vast majority of these are oral antibiotics and anti-allergy medications. I can't remember the last time I wrote an Rx for an oral medication what was not in one of those two classes.

 

[blysssful]

My roommate & I were talking about this the other day and she was asking me about being able to prescribe painkillers, and I had no idea (though I was assuming not). Is it strictly one way or another, or does that vary by state?

 

[VA Hopeful Dr]

My roommate & I were talking about this the other day and she was asking me about being able to prescribe painkillers, and I had no idea (though I was assuming not). Is it strictly one way or another, or does that vary by state?

Here in SC, ODs can prescribe narcotics but are limited to a 7-day supply.

 

[Oculomotor]

In 99.9% of cases germane to primary ocular care a course of up to 3-4 days of narcotics-narcotic preparations (Schedule III) like Vicodin or Tylenol 3 or 4 with codeine is the standard of optometric care when narcotics are even necessary which most of the time they are not. So a 7 day course would be an extremely rare circumstance usually warranting a referral anyway. Again, the question is what is best for the patient.

source: My pharmacology class! lol


Here is the Oral Drug Breakdown

1)GLAUCOMA Tx = 49 states + DC + Guam
2)ORAL Rx AUTHORITY = 47 states + DC + Guam
(Florida, New York, and Massachusetts have no oral authority)
3)CONTROLLED SUBSTANCE Rx AUTHORITY = 43 states + Guam
4)INJECTABLES AUTHORITY = 32 states + DC
(32 states have injectables regarding anaphylactic shock, only 9 states have true ocular injectables)
source: AOA

 

[Carly Ess]

no flossing before oral! 😛

 

[Meibomian SxN]

Also Vicodin is Rx'd q4-6h so that would mean you can give 42pills max! WOW! You will become a HUGE referral source for "subjective headaches" 😴

 

[afasano]

In 99.9% of cases germane to primary ocular care a course of up to 3-4 days of narcotics-narcotic preparations (Schedule III) like Vicodin or Tylenol 3 or 4 with codeine is the standard of optometric care when narcotics are even necessary which most of the time they are not. So a 7 day course would be an extremely rare circumstance usually warranting a referral anyway. Again, the question is what is best for the patient.

source: My pharmacology class! lol


Here is the Oral Drug Breakdown

1)GLAUCOMA Tx = 49 states + DC + Guam
2)ORAL Rx AUTHORITY = 47 states + DC + Guam
(Florida, New York, and Massachusetts have no oral authority)
3)CONTROLLED SUBSTANCE Rx AUTHORITY = 43 states + Guam
4)INJECTABLES AUTHORITY = 32 states + DC
(32 states have injectables regarding anaphylactic shock, only 9 states have true ocular injectables)
source: AOA

do you think as a student who is choosing btwn optometry schools, that I should take this into consideration, esp cause one school is NECO and the other is ICO... So if I would have Oral RX authority, while @ NECO I wouldn't... I'm trying to decide btwn the two schools, and Im looking at every thing that there could possibly be different about the schools.

thxs

 

[jefguth]

do you think as a student who is choosing btwn optometry schools, that I should take this into consideration, esp cause one school is NECO and the other is ICO... So if I would have Oral RX authority, while @ NECO I wouldn't... I'm trying to decide btwn the two schools, and Im looking at every thing that there could possibly be different about the schools.

thxs

Doesnt' matter which school you choose. The VAST majority of your training will occur at off-campus externship sites - often out of state. Furthermore, you're not going to be Rx'ing orals on a very routine basis either.

 

[meister]

Which state doesn't give Optometrists glaucoma Tx authority? That seems pretty pecuiliar.

 

[fkajoshaj]

do you guys believe New York Optometrists will be able to prescribe oral meds anytime soon??

 

[Shnurek]

Which state doesn't give Optometrists glaucoma Tx authority? That seems pretty pecuiliar.

Massachusetts, possibly because of the high concentration of ophthalmologists in that state.

 

[mclem222]

I been in practice for two years and I recently got into trouble with prescribing pain medicine for eye pain. The patient was also on a high blood pressure medicine that didnt react well and had to get admitted. Long story short..the primary care MD basically bawled me out on the phone for prescribing Dilaudid. Hopefully things will be ok but the patient called the state board on me. Gonna think twice about that one now.

 

[Shnurek]

I been in practice for two years and I recently got into trouble with prescribing pain medicine for eye pain. The patient was also on a high blood pressure medicine that didnt react well and had to get admitted. Long story short..the primary care MD basically bawled me out on the phone for prescribing Dilaudid. Hopefully things will be ok but the patient called the state board on me. Gonna think twice about that one now.

mclem222 your comments about your partner missing a tear and you prescribing a medication that was contraindicated with their hypertension meds certainly don't bode well for commercial optometry. We need more internal medicine training as DILLIGAF pointed out but anyway the pharmacist should have caught that one as they know way more about pharmacology than any MD or OD.

 

[VA Hopeful Dr]

I been in practice for two years and I recently got into trouble with prescribing pain medicine for eye pain. The patient was also on a high blood pressure medicine that didnt react well and had to get admitted. Long story short..the primary care MD basically bawled me out on the phone for prescribing Dilaudid. Hopefully things will be ok but the patient called the state board on me. Gonna think twice about that one now.

With respects, why on earth did you prescribed Dilaudid? I've never written for that as an outpatient, nor seen it done except in rare cases (older sicklers, CP with bad contractures, acute pancreatitis allergic to morphine).

I wouldn't have bawled you out, but I would (and am) ask why you went with that over tylox, oxy, or even morphine.

 

[Idocanesthesia]

I been in practice for two years and I recently got into trouble with prescribing pain medicine for eye pain. The patient was also on a high blood pressure medicine that didnt react well and had to get admitted. Long story short..the primary care MD basically bawled me out on the phone for prescribing Dilaudid. Hopefully things will be ok but the patient called the state board on me. Gonna think twice about that one now.

Holy crap dilaudid? Anytime I am Rx ing orals its hydrocodone or nothing else, very few and absolutely NO refills. As primary care docs will tell you pain meds are a huge problem. Drug seekers are everywhere...

 

[KHE]

I been in practice for two years and I recently got into trouble with prescribing pain medicine for eye pain. The patient was also on a high blood pressure medicine that didnt react well and had to get admitted. Long story short..the primary care MD basically bawled me out on the phone for prescribing Dilaudid. Hopefully things will be ok but the patient called the state board on me. Gonna think twice about that one now.

Dilaudid for eye pain? You have got to be ****ting me.

 

[Idocanesthesia]

I been in practice for two years and I recently got into trouble with prescribing pain medicine for eye pain. The patient was also on a high blood pressure medicine that didnt react well and had to get admitted. Long story short..the primary care MD basically bawled me out on the phone for prescribing Dilaudid. Hopefully things will be ok but the patient called the state board on me. Gonna think twice about that one now.

Btw was the htn med clonidine ? its a central alpha 2 agonist that if you put w a narc like dilaudid would make a person pretty sleepy.... possibly resp depressant sleepy if you know what i mean

 

[DILLIGAF]

Well, there is no "long-story short" if you are prescribing a hydromorphone.What condition did the pt (hopefully) have?

Not to be disparaging, but going straight to an opioid of that power immediately, without NSAID or lesser formulation steroid/opiate, can and probably should lose a license. A main contraindication of that MOA opiate is that they have ISA activity (mess with the sympathetic input to the heart). For that reason, I am amazed the MD isn't leading the charge. My head would have exploded....now, I realize there are mitigating circumstances that would force one's hand to rx that, and I didn't read the chart, but I would be watching out if I were you.

Going after eye pain (even if a posterior to anterior uvieitis + scleritis + hot poker in the eye) with Dilaudid is a little like going squirrel hunting with an Apache Helicopter. You best have good reasons and your chinstrap on if they take you to review....not fun times.

 

[Shnurek]

Notice how mclem222 came onto the forums to say very controversial things right after socal/dude was banned? lol

 

[ABaverage]

I have to agree that she is the reincarnated form of socal/dude. The stories are quite entertaining though. It's so obvious!🙄

 

[mclem222]

Not sure of all the meds the patient was on. Listen, I am sorry if none if you have ever made a clinical mistake out there but I made a small mistake and the patient is fine now. NSAIDs don't cover eye pain that well as I am sure most people who have been in practice for more than two days know. The patient was in a lot of pain and I wanted to help them. I am glad everyone who posted is happy that they can monday morning quarterback stuff like after looking up mechanisms of action on google. I;ve been in practice for some time now and I practice well. I have very happy patients and have never made a clinical mistake before. For those of you who claim to be perfect god bless but for the others get off the high horse.

 

[Meibomian SxN]

Not sure of all the meds the patient was on. Listen, I am sorry if none if you have ever made a clinical mistake out there but I made a small mistake and the patient is fine now. NSAIDs don't cover eye pain that well as I am sure most people who have been in practice for more than two days know. The patient was in a lot of pain and I wanted to help them. I am glad everyone who posted is happy that they can monday morning quarterback stuff like after looking up mechanisms of action on google. I;ve been in practice for some time now and I practice well. I have very happy patients and have never made a clinical mistake before. For those of you who claim to be perfect god bless but for the others get off the high horse.

My 1st year out I had a scary case with a girl with subjective eye pain before. Her PCP was on vacation and referred her to me for a consult. She said she was allergic to Vicodin and was fine with Percocet. I Rx'd her 2.5mg #5 until her doctor came back from vacation and to have him evaluate her for migraine headaches. 2 days later she calls us saying she felt her throat closing up so she took some Benadryl on her own. That didn't work so then she went to the ER! 😱 Luckily she was ok.

Long story short, it was a learning experience. Even primary care docs make mistakes and we learn from these medical errors. Its what makes us better doctors.

Just thank god they lived! 😀

 

[Visionary]

Dilaudid for eye pain? You have got to be ****ting me.

Yeah, I've never seen a narcotic of any kind prescribed for presentation of eye pain. NSAIDs, yes. Maybe Lortab for certain post-ops (e.g, scleral buckle, plastics cases).

 

[DILLIGAF]

In regards to the odd rx....I had the same reaction that most people had when I read it. With this said, I can think of times when I gave something rather odd due to mitigating circumstances. For example, I once had a pt referred to me (by an OD) that I was told simply had a nasty case of uveitis. I was to co-manage with an OMD that was 2 hours away, but the pt would not see her for 3 more days. I prescribed a very odd combo of drugs, and the other OD and OMD both pretty much ripped into me after I sent them my prelim. The OD thought it was posterior to anterior uvietis, and the OMD was wondering WHY I had gotten so aggressive, and such an odd rx list. I put the pt on oral steroids (prednisolone), had recommended long term azathrioprine, along with ciclosporin off-label....needless to say, that is a very off the wall rx....but I was quite certain it was Behcet Syndrome (20% go blind even w treatment, but extremely rare. Saw it all of ONE time in my residency) The OMD eventually came to my defense, but I was facing a pretty strong reaction from the pt and the other OD. (Imagine you think you have a simple eye pain of uvietis, and you come to me and get a handful of treatments along with talk of screening for a disease that can blind you next week. NOT a happy pt)

My point is that I wasn't there, I didn't read the chart, I know nothing of the pt or their health. Yes, that is a SUPER strong drug, and in the event that it cannot be justified you would be in a huge amount of trouble. If the MD really wanted to be a jerk you might be in for a board review, and I was trying to tell you to prepare to defend, NOT that you are wrong necessarily. I wasn't there, and I don't second guess other doctors....I just know that some docs get a little too secure in "knowing they're right" and don't take a review seriously, thus they get in hot water....trust me, I am NOT going to question the tx strategy of a pt I never saw. That would be very unprofessional and unrealistic. I am very sorry if my words came off as such, or questioned your competency. That was a mistake and it should not have happened. I apologize to you mclem222.

 

[Idocanesthesia]

Not sure of all the meds the patient was on. Listen, I am sorry if none if you have ever made a clinical mistake out there but I made a small mistake and the patient is fine now. NSAIDs don't cover eye pain that well as I am sure most people who have been in practice for more than two days know. The patient was in a lot of pain and I wanted to help them. I am glad everyone who posted is happy that they can monday morning quarterback stuff like after looking up mechanisms of action on google. I;ve been in practice for some time now and I practice well. I have very happy patients and have never made a clinical mistake before. For those of you who claim to be perfect god bless but for the others get off the high horse.

Well I certainly dont think you need a license review or anything close to that like another poster wrote. Its a heck of a learning experience ... screwing up is the best way to learn. But I am just pretty conservative w pain meds primarily bc I dont want a bunch of drug seekers around.

 

[Idocanesthesia]

Yeah, I've never seen a narcotic of any kind prescribed for presentation of eye pain. NSAIDs, yes. Maybe Lortab for certain post-ops (e.g, scleral buckle, plastics cases).

You must work at lenscrafters then... never saw a raging corneal ulcer w a screaming 40 yo woman as the owner of said eye? Believe me she needed some 5/500 hydro/cet for her husbands and my sanity. No refills and # of 8 of course.

 

[KHE]

You must work at lenscrafters then... never saw a raging corneal ulcer w a screaming 40 yo woman as the owner of said eye? Believe me she needed some 5/500 hydro/cet for her husbands and my sanity. No refills and # of 8 of course.

Ummmmm..........he said lortab?

😕

 

[thiaeyemd]

are you an OMD or OD? I am confused. Thanks for the apology but didn't think you were so The aziothioprine is a big immunosuppressive to give.

 

[Idocanesthesia]

Ummmmm..........he said lortab?

😕

ummmm... he said he never saw an instance outside of post op 😕

Willis what are you talking about...😱

 

[Meibomian SxN]

You must work at lenscrafters then... never saw a raging corneal ulcer w a screaming 40 yo woman as the owner of said eye? Believe me she needed some 5/500 hydro/cet for her husbands and my sanity. No refills and # of 8 of course.

I agree. But the reality is some doctors are stingy and inconsiderate. I have heard of docs not giving anything except 500mg tylenol for a limbus to limbus corneal abrasion! Ouch! 😱

 

[Visionary]

You must work at lenscrafters then... never saw a raging corneal ulcer w a screaming 40 yo woman as the owner of said eye? Believe me she needed some 5/500 hydro/cet for her husbands and my sanity. No refills and # of 8 of course.

Nope, just a private practice retina doc. Yes, I've seen my share of corneal ulcers. Typically, a cycloplegic and topical pain relievers (NSAID or, in rare cases, a short course of diluted anesthetic) are sufficient. Unless the narcotic is to make them stuporous, it's not likely to relieve much eye-specific pain. But, I admit that sometimes it's needed.

 

[Visionary]

I agree. But the reality is some doctors are stingy and inconsiderate. I have heard of docs not giving anything except 500mg tylenol for a limbus to limbus corneal abrasion! Ouch! 😱

Ever heard of a bandage lens? That would provide much more relief than any narcotics you'd give.

 

[200UL]

"Limbus to limbus corneal abrasion" - incredibly painful for most - yes. Narcotics will eliminate the pain - not in my hands. Cyclopegic + antibitic + contact lens. If concern with infection, replace frequent antibiotic ointment for the contact lens.

I am not sure of the patient population in the average optometric practice that needs narcotic rights, but I have provided 1 narcotic script in the last 12 months. I see at least 1 serious corneal ulcer per week, I perform refractive surgery with a significant number of PRK procedures.

I always get a kick out of the optometric bills that ask for narcotics. Why? Number one, the number of times needed should be very rare (call up the primary care doctor and ask them to write the script that 1 time out of very three years a patient actually needs it). Number two, do you really want experiences as listed above (interactions, drug seekers).

Writing a script is easy. Dealing with side effects is hard-especially if you have a heart.

 

[VA Hopeful Dr]

"Limbus to limbus corneal abrasion" - incredibly painful for most - yes. Narcotics will eliminate the pain - not in my hands. Cyclopegic + antibitic + contact lens. If concern with infection, replace frequent antibiotic ointment for the contact lens.

I am not sure of the patient population in the average optometric practice that needs narcotic rights, but I have provided 1 narcotic script in the last 12 months. I see at least 1 serious corneal ulcer per week, I perform refractive surgery with a significant number of PRK procedures.

I always get a kick out of the optometric bills that ask for narcotics. Why? Number one, the number of times needed should be very rare (call up the primary care doctor and ask them to write the script that 1 time out of very three years a patient actually needs it). Number two, do you really want experiences as listed above (interactions, drug seekers).

Writing a script is easy. Dealing with side effects is hard-especially if you have a heart.

I'd just as soon you didn't call me to hand out opioids to your patients.

 

[VA Hopeful Dr]

My 1st year out I had a scary case with a girl with subjective eye pain before. Her PCP was on vacation and referred her to me for a consult. She said she was allergic to Vicodin and was fine with Percocet. I Rx'd her 2.5mg #5 until her doctor came back from vacation and to have him evaluate her for migraine headaches. 2 days later she calls us saying she felt her throat closing up so she took some Benadryl on her own. That didn't work so then she went to the ER! 😱 Luckily she was ok.

Long story short, it was a learning experience. Even primary care docs make mistakes and we learn from these medical errors. Its what makes us better doctors.

Just thank god they lived! 😀

Now, see that's an entirely different scenario. In that case, you're trusting the patient to know what they are allergic to which is usually fine. Unless you have a good reason, you have to trust the history provided by the patient. Besides, cross-reactivity between opioid classes is not usually a big problem.

 

[VA Hopeful Dr]

Not sure of all the meds the patient was on. Listen, I am sorry if none if you have ever made a clinical mistake out there but I made a small mistake and the patient is fine now. NSAIDs don't cover eye pain that well as I am sure most people who have been in practice for more than two days know. The patient was in a lot of pain and I wanted to help them. I am glad everyone who posted is happy that they can monday morning quarterback stuff like after looking up mechanisms of action on google. I;ve been in practice for some time now and I practice well. I have very happy patients and have never made a clinical mistake before. For those of you who claim to be perfect god bless but for the others get off the high horse.

I'm not faulting you for not knowing every smallest detail about the med in question. I'm faulting you for going to one of the strongest pain medications in our arsenal without trying lortab or percocet first. If there was a particular reason why you did this, I want to hear it.

 

[KHE]

"Limbus to limbus corneal abrasion" - incredibly painful for most - yes. Narcotics will eliminate the pain - not in my hands. Cyclopegic + antibitic + contact lens. If concern with infection, replace frequent antibiotic ointment for the contact lens.

I am not sure of the patient population in the average optometric practice that needs narcotic rights, but I have provided 1 narcotic script in the last 12 months. I see at least 1 serious corneal ulcer per week, I perform refractive surgery with a significant number of PRK procedures.

I prescribe lortab probably 3,4 MAYBE 5 times a year for large abrasions or PRK patients. In every case, I tell them that it likely won't do much for the pain but it will help them sleep so that the injury will heal itself. These patients are extremely grateful for that.

"
I always get a kick out of the optometric bills that ask for narcotics. Why? Number one, the number of times needed should be very rare (call up the primary care doctor and ask them to write the script that 1 time out of very three years a patient actually needs it). Number two, do you really want experiences as listed above (interactions, drug seekers).

My drug seekers usually ask for marijuana because they heard it's good for your eyes. I never get narcotic seekers.

 

[Idocanesthesia]

I'm not faulting you for not knowing every smallest detail about the med in question. I'm faulting you for going to one of the strongest pain medications in our arsenal without trying lortab or percocet first. If there was a particular reason why you did this, I want to hear it.

This^ ... Starting to think that the OP may be a troll trying to make ODs look like idiots. It worked in this instance as I have no idea why you would Rx a med that is very rarely used outside of a hospital and usually in the O.R. at that = on monitors etc.

 

[IndianaOD]

"Limbus to limbus corneal abrasion" - incredibly painful for most - yes. Narcotics will eliminate the pain - not in my hands. Cyclopegic + antibitic + contact lens. If concern with infection, replace frequent antibiotic ointment for the contact lens.

I am not sure of the patient population in the average optometric practice that needs narcotic rights, but I have provided 1 narcotic script in the last 12 months. I see at least 1 serious corneal ulcer per week, I perform refractive surgery with a significant number of PRK procedures.

I always get a kick out of the optometric bills that ask for narcotics. Why? Number one, the number of times needed should be very rare (call up the primary care doctor and ask them to write the script that 1 time out of very three years a patient actually needs it). Number two, do you really want experiences as listed above (interactions, drug seekers).

Writing a script is easy. Dealing with side effects is hard-especially if you have a heart.

There are only a few times that I have wanted the ability to Rx a narcotic. I just tell the patients I blame "medical politics" 😀 Indiana ODs got rejected from narcotic rights a few years ago. I think the request was only for some of the milder drugs for short durations. Honestly, besides helping out a few patients here and there, a second major reason for the request was encourage more ODs to get DEA numbers. DEA numbers would make it much simpler for pharmacists and medical insurances.

I would be totally cool with a limitation of 5 days or whatever. It would be nice for the drug companies to realize how many Rx's I write.

 

[Visionary]

Honestly, besides helping out a few patients here and there, a second major reason for the request was encourage more ODs to get DEA numbers. DEA numbers would make it much simpler for pharmacists and medical insurances.

The new standard is NPI number. I'm rarely asked for my DEA number anymore.

 

[IndianaOD]

The new standard is NPI number. I'm rarely asked for my DEA number anymore.

Huh, Indiana must be behind the times! 🙂

 

[VA Hopeful Dr]

Huh, Indiana must be behind the times! 🙂

I still use my DEA #, mainly because its easier to memorize for when I'm calling in my own prescriptions.

 

[Meibomian SxN]

I'm not faulting you for not knowing every smallest detail about the med in question. I'm faulting you for going to one of the strongest pain medications in our arsenal without trying lortab or percocet first. If there was a particular reason why you did this, I want to hear it.

In another thread he said it was because an oculoplastic down the street prescribes it after surgeries.....

 

[VA Hopeful Dr]

In another thread he said it was because an oculoplastic down the street prescribes it after surgeries.....

Right, and the pain management guy down the road from me routinely has patients on oxy 80mg tid... but I sure as hell am not doing that

 

[Caffeinated]

In my opinion and experience, there is no good reason for oral dilaudid to even exist. If pain is severe enough to require dilaudid, it's usually severe acute pain, and it should be for parenteral use in the inpatient environment.

 

[Idocanesthesia]

In my opinion and experience, there is no good reason for oral dilaudid to even exist. If pain is severe enough to require dilaudid, it's usually severe acute pain, and it should be for parenteral use in the inpatient environment.

Just be glad a chemist hasnt figured out to make fentanyl or sufenta in a pill... ERs would be full if not the morgue