Prescription monitoring and methadone

[PikminOC]

Today a new patient came in. I ran his date of birth and name through the prescription monitoring for my state. I ran it for adjoining states as well. It came up empty.

He tells me he is on methadone, liquid from a clinic. He showed me the bottles. He gets the medication from the clinic.

Do these clinics bypass having to report to the prescription monitoring sites? This kind of defeats the purpose for a doctor like me.

Luckily, he told me he is on it and showed me the bottles. I have sent consent to the methadone doctor for records.

Please let me know if this is normal when the place dispenses it themselves...

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[ChalupaBatman86]

It's not really dispensed it is "administered" therefore not in the database of any states that I know of.

 

[PikminOC]

He has bottles of this stuff. So he takes it home.

 

[Carboxide]

My understanding is that if they are dispensing for outpatient home usage, it should be billed through prescription insurance. I think in-clinic usage is the only stuff that goes through medical - e.g. you get the single dose, take it, and go home.

 

[PikminOC]

He gets 3 days worth. Regardless of who pays for it, it doesn't show up in the prescription monitoring. This is really bad for physicians like me as these patients can lie about taking it.

 

[samuricool]

I can't speak to these clinics but I do know that the VA doesn't submit to online databases either. So I suppose it's not out of the question that other facilities are exempt as well. I agree, it defeats the purpose (for both prescribers and pharmacists) if this is suppose to be our tool to track prescribing/dispensing of controlled substances.

 

[zelman]

This is state-specific. Some do a better job than others. Why don't you ask the clinic about it and let us know? I'm guessing that only entities licensed as pharmacies report to the PMP, and they are licensed as some other entity.

 

[Sine Cura]

In some states controlled substance dispensing reporting is mandatory by the BOP, so if you're in a state with mandatory reporting, if there is a label with assigned Rx number, that's dispensing and that is a BOP violation.

Edit: For example California specifically refers to dispensing clinics in its PDMP regulations so dispensing clinics must ("shall") report.

(d) For each prescription for a Schedule II, Schedule III, or Schedule IV controlled substance, as defined in the controlled substances schedules in federal law and regulations, specifically Sections 1308.12, 1308.13, and 1308.14, respectively, of Title 21 of the Code of Federal Regulations, the dispensing pharmacy, clinic, or other dispenser shall report the following information to the Department of Justice as soon as reasonably possible, but not more than seven days after the date a controlled substance is dispensed, in a format specified by the Department of Justice: ...

http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=HSC&sectionNum=11165

One question would be "is this dispensing pursuant to a prescription"

 

[Wheresmyaricept]

Technically a pharmacist is not dispensing it and it is not coming from a pharmacy, but rather a clinic. The doctor is dispensing under his controlled substance license. How does a doctor report dispensing to PMP? I don't know of a way honestly. Maybe this is an oversight to PMP since all pharmacies are required to automatically upload their controlled substance dispensing every X days.

 

[RPh Who]

I can't speak to these clinics but I do know that the VA doesn't submit to online databases either. So I suppose it's not out of the question that other facilities are exempt as well. I agree, it defeats the purpose (for both prescribers and pharmacists) if this is suppose to be our tool to track prescribing/dispensing of controlled substances.

Do you work for the VA? I'm just curious because I had one patient two months ago that I ran a PDMP search for in WI and I actually had multiple hits on controls filled at a major VAMC in the months preceeding. Now that you mention it, I thought it was odd seeing them as the listed dispenser when I ran the search

 

[PikminOC]

This is state-specific. Some do a better job than others. Why don't you ask the clinic about it and let us know? I'm guessing that only entities licensed as pharmacies report to the PMP, and they are licensed as some other entity.

I tried to ask another clinic that was giving out another controlled sub and all I got was the runaround. I couldn't even find out who the collaborating physician was !!

 

[Carboxide]

Technically a pharmacist is not dispensing it and it is not coming from a pharmacy, but rather a clinic. The doctor is dispensing under his controlled substance license. How does a doctor report dispensing to PMP? I don't know of a way honestly. Maybe this is an oversight to PMP since all pharmacies are required to automatically upload their controlled substance dispensing every X days.

Physicians are held to the same dispensing laws as pharmacists IF they are dispensing. It is not pharmacists that have to report. It is pharmacies. If you are dispensing to outpatients, you are a pharmacy.

I would suggest you contact the Board of Pharmacy or Board of Medicine in your state and ask them about it. If a patient is taking home 3 days at a time, I don't understand how it is a). not being billed under prescription insurance, and b). not reportable to the state system.

 

[croquemonsieur]

The prescription of any (not just methadone) narcotic for the treatment of opiate addiction is illegal; therefore, methadone administered by these clinics won't show up in any prescription monitoring program. People in these programs are subject to regular urine drug screening, must attend NA meetings, and take their methadone under observation, initially (they can earn the privilege to take their methadone home over time). These programs are comprehensive.

OP: You couldn't figure out who the collaborating physician was, which means their name wasn't on the methadone bottle your patient showed you. All prescriptions must have the prescriber's name on the label. The methadone in that bottle isn't legally considered a prescription.

 

[samuricool]

Do you work for the VA? I'm just curious because I had one patient two months ago that I ran a PDMP search for in WI and I actually had multiple hits on controls filled at a major VAMC in the months preceeding. Now that you mention it, I thought it was odd seeing them as the listed dispenser when I ran the search

I don't. But it appears that I spoke too soon and that it is state specific. Long story short I had a patient getting scripts filled at both my pharmacy and the VA. Despite my searches in the database they were clean every time. Finally the VA did a search and busted him. I only found out because they came to our pharmacy to collect the hard copies. The board agent mentioned to me that the VA does not have to submit to the database.

 

[PikminOC]

The prescription of any (not just methadone) narcotic for the treatment of opiate addiction is illegal; therefore, methadone administered by these clinics won't show up in any prescription monitoring program. People in these programs are subject to regular urine drug screening, must attend NA meetings, and take their methadone under observation, initially (they can earn the privilege to take their methadone home over time). These programs are comprehensive.

OP: You couldn't figure out who the collaborating physician was, which means their name wasn't on the methadone bottle your patient showed you. All prescriptions must have the prescriber's name on the label. The methadone in that bottle isn't legally considered a prescription.

This patient refuses NA meetings.

And I apologize for the confusion. The other place I was talking about is a weight loss center where midlevels give out stimulants. I called over and could not get the name of the physician.

 

[RPh Who]

I don't. But it appears that I spoke too soon and that it is state specific. Long story short I had a patient getting scripts filled at both my pharmacy and the VA. Despite my searches in the database they were clean every time. Finally the VA did a search and busted him. I only found out because they came to our pharmacy to collect the hard copies. The board agent mentioned to me that the VA does not have to submit to the database.

Definitely interesting, thanks for sharing!

 

[Carboxide]

This patient refuses NA meetings.

And I apologize for the confusion. The other place I was talking about is a weight loss center where midlevels give out stimulants. I called over and could not get the name of the physician.

Isn't that straight up against federal law, to use stimulants for weight loss? Or maybe it's just a state law. Here you have to write the dx on the script.

 

[ChalupaBatman86]

Isn't that straight up against federal law, to use stimulants for weight loss? Or maybe it's just a state law. Here you have to write the dx on the script.

Apparently you haven't heard of the new disease Pharma invented called "Binge Eating Disorder". Guess how it is treated?

 

[BidingMyTime]

Wow, I'd never thought about this before and would not have know that VA and methadone clinics are apparently exempt from reporting requirements. I agree that this is a major oversight--the intent of monitoring databases is so physicians and pharmacists can know what exactly a patient is taking and from where. And while I get that legally a 3-day-take-home from a methadone clinic isn't a "prescription", it not being reported defeats the intent of the law. Especially if pharmacists and physicians aren't aware that places are exempted and may not be showing up in the database. Bad enough when one lives next to a border and can't know about patients crossing the border to get stuff, but the databases should be comprehensive for the state. Maybe methadone clinics reporting requirements could be every 2 - 4 weeks (since generally they have a stable patient base.....yeah maybe the clinic does a good job of monitoring the database to see if there patients are getting drugs elsewhere, but maybe they don't. So pharmacists and physicians should be able to look up a patients usage of a methadone clinic.)

 

[pillpharmer14]

Isn't that straight up against federal law, to use stimulants for weight loss? Or maybe it's just a state law. Here you have to write the dx on the script.

State specific. My state does not require dx on the script unless the pharmacy/company is under probation for some sort of infraction.

 

[PikminOC]

Apparently you haven't heard of the new disease Pharma invented called "Binge Eating Disorder". Guess how it is treated?

These nurses were using the stims long before this indication came into being..

 

[BidingMyTime]

off label use......don't ask, don't tell

 

[PinkICUpharmD]

I don't. But it appears that I spoke too soon and that it is state specific. Long story short I had a patient getting scripts filled at both my pharmacy and the VA. Despite my searches in the database they were clean every time. Finally the VA did a search and busted him. I only found out because they came to our pharmacy to collect the hard copies. The board agent mentioned to me that the VA does not have to submit to the database.

I work for the VA and all VAs are now being required to report to the state in which they located. I run a report and every patient who is admitted to my ICU if they have a positive drug screen. I've even caught patients obtaining controls from two different VAs that way. I also run a report on every control I dispense at my PRN retail position.

I don't think methadone clinics are required to report though. And it makes me sad/mad.

 

[Snoops1974]

I work for the VA and all VAs are now being required to report to the state in which they located. I run a report and every patient who is admitted to my ICU if they have a positive drug screen. I've even caught patients obtaining controls from two different VAs that way. I also run a report on every control I dispense at my PRN retail position.

I don't think methadone clinics are required to report though. And it makes me sad/mad.

I know this post is old but I wanted to respond in hopes to change a few of people minds, if you're open minded. Think of it another way. Not everyone who goes to methadone clinics are trying to get over or get high. Some actually need the treatment and have tried everything else and have failed. Methadone is the only thing that has worked for them. I have a friend in the health care profession and he has had trouble staying off opioids for more than 15 years. He has even been to prison and his disease is still so strong he has stolen from the place he was working. That was until he put himself in the methadone therapy program. He doesn't want or crave any opioids. He hasn't used anything or stolen anything since entering the program. But if it was reported he would not be able to be apart of the methadone program and still work his job in healthcare. This would be very sad after years of education and years of helping patients and being excellent at what he does. So you have to look at both sides of it. He doesn't abuse the system in any way. He just doesn't want anyone including any doctor he may see to know he's on a methadone program because he could be fired from his job. Even though he's working on methadone and is now safe from the opioids he administers because the methadone blocks his cravings. We need to start thinking out of the box a little when it comes to this. There are doctors, pharmacists, nurses and other medical professionals on methadone so they can safely work without craving these opioids they deal with everyday. It have saved his life and his career. A career he worked very hard for. Years of college and student loans so he could be a medical professional and help people and for the first time since he had surgery and got addicted to opioids, he feels free from them. Free from thinking about them and he's able to concentrate on his family, and his career. So I for one do not think methadone clinics should have to report. This would be terrible for a lot of people. Not everyone at the methadone clinic is trying to do something wrong and get over on doctors. Most are there to get there life back. Also just FYI most insurances don't cover it and most people don't want their insurnace to know because of privacy issues. It costs my friend $115 a week. So you have to really want to get better to pay that kind of money. Just my opinion, but I'm hoping it will open up some minds. Thank you.

 

[CetiAlphaFive]

I tried to ask another clinic that was giving out another controlled sub and all I got was the runaround. I couldn't even find out who the collaborating physician was !!

Yikes.
That's a bit of a red flag, no?


As to the original clinic dispensing 3 days supply at a time, I'm willing to bet they're doing it to save time.

 

[bacillus1]

Would methadone fall under the "drug abuse" part of HIPAA, where it can't be shown without patient's consent?

 

[PikminOC]

I sent over the consent. The issue is that i wouldn't otherwise know as it does not show up on pmp

 

[lord999]

Wow, I'd never thought about this before and would not have know that VA and methadone clinics are apparently exempt from reporting requirements. I agree that this is a major oversight--the intent of monitoring databases is so physicians and pharmacists can know what exactly a patient is taking and from where. And while I get that legally a 3-day-take-home from a methadone clinic isn't a "prescription", it not being reported defeats the intent of the law. Especially if pharmacists and physicians aren't aware that places are exempted and may not be showing up in the database. Bad enough when one lives next to a border and can't know about patients crossing the border to get stuff, but the databases should be comprehensive for the state. Maybe methadone clinics reporting requirements could be every 2 - 4 weeks (since generally they have a stable patient base.....yeah maybe the clinic does a good job of monitoring the database to see if there patients are getting drugs elsewhere, but maybe they don't. So pharmacists and physicians should be able to look up a patients usage of a methadone clinic.)

VA is legally exempt from basically any reporting requirement due to a specific clause in Title 38. We don't even have to follow CMS or other HHS rules in Title 42. We voluntarily comply when it suits us.

In the case of state PDMPs, the way the law used to work (the legendary 7332 clause), we couldn't report it even when we wanted to. We had to ram an exception through Congress to do that, and while the interface is now available through VistaWeb, we don't have inked agreements with certain states for providing the data.

 

[Jimmy crackcorn]

Today a new patient came in. I ran his date of birth and name through the prescription monitoring for my state. I ran it for adjoining states as well. It came up empty.

He tells me he is on methadone, liquid from a clinic. He showed me the bottles. He gets the medication from the clinic.

Do these clinics bypass having to report to the prescription monitoring sites? This kind of defeats the purpose for a doctor like me.

Luckily, he told me he is on it and showed me the bottles. I have sent consent to the methadone doctor for records.

Please let me know if this is normal when the place dispenses it themselves...

I go to a methadone clinic in California. Last month I went to pick up my pain meds at the pharmacy and the pharmacist says the methadone clinic called and said not to release your meds to you, oxycodone and contin. I flipped because first off I never signed anythin giving the clinic authority to call the pharmacy or even my doctor. I call the clinic n they deny they called. The pharmacist calls me 10 minutes later and says you can come p9ck up your rxs. I don't know what happen. I asked the manager at the clinic n he said they have no authority to call and say that. He said they do report to Cures though and the doctors can send messages amongst themselves on the site. I saw my cures report on his desk and didn't see the methadone on it. So how did the pharmacy know about it, did the Dr at the clinic calli them and say that he is worried about my dosages? No clue. I'l find in 2 weeks when I see my pain Dr again. I didn' tell my pain Dr about the clinic but will this month.

 

[Apotheker2015]

Isn't that straight up against federal law, to use stimulants for weight loss? Or maybe it's just a state law. Here you have to write the dx on the script.

Vyvanse has an indication for Binge Eating Disorder. You can stretch that diagnosis and prescribe a stimulant. Easily done. Physicians can prescribe anything for whatever off-label use they want. Not lying.

 

[zelman]

...Physicians can prescribe anything for whatever off-label use they want. Not lying.

Not legally. It’s generally fine, but certain indications are straight-up illegal (e.g. most opiates to prevent withdrawal).

 

[Sine Cura]

Arizona PDMP and California PDMP do show prescriber dispensings if the prescriber actually decides to report. I also have seen Northern Arizona VA results on Arizona PDMP

 

[Apotheker2015]

Not legally. It’s generally fine, but certain indications are straight-up illegal (e.g. most opiates to prevent withdrawal).

Off-label use is generally legal unless it violates ethical guidelines or safety regulations.

 

[lord999]

Not legally. It’s generally fine, but certain indications are straight-up illegal (e.g. most opiates to prevent withdrawal).

Correct, DATA 2000 actually gets enforced on this. There are a couple of exceptions such as buprenorphine where there is explicit indication for withdrawal symptom management (inclusive of prevention)...

On the VA reporting, YMMV depending on the relationship with the state and the availability of the HL7 connector...

 

[radio frequency]

I go to a methadone clinic in California. Last month I went to pick up my pain meds at the pharmacy and the pharmacist says the methadone clinic called and said not to release your meds to you, oxycodone and contin. I flipped because first off I never signed anythin giving the clinic authority to call the pharmacy or even my doctor. I call the clinic n they deny they called. The pharmacist calls me 10 minutes later and says you can come p9ck up your rxs. I don't know what happen. I asked the manager at the clinic n he said they have no authority to call and say that. He said they do report to Cures though and the doctors can send messages amongst themselves on the site. I saw my cures report on his desk and didn't see the methadone on it. So how did the pharmacy know about it, did the Dr at the clinic calli them and say that he is worried about my dosages? No clue. I'l find in 2 weeks when I see my pain Dr again. I didn' tell my pain Dr about the clinic but will this month.

Goodness. That pharmacist has every right to deny those prescriptions.

 

[CetiAlphaFive]

I go to a methadone clinic in California. Last month I went to pick up my pain meds at the pharmacy and the pharmacist says the methadone clinic called and said not to release your meds to you, oxycodone and contin. I flipped because first off I never signed anythin giving the clinic authority to call the pharmacy or even my doctor. I call the clinic n they deny they called. The pharmacist calls me 10 minutes later and says you can come p9ck up your rxs. I don't know what happen. I asked the manager at the clinic n he said they have no authority to call and say that. He said they do report to Cures though and the doctors can send messages amongst themselves on the site. I saw my cures report on his desk and didn't see the methadone on it. So how did the pharmacy know about it, did the Dr at the clinic calli them and say that he is worried about my dosages? No clue. I'l find in 2 weeks when I see my pain Dr again. I didn' tell my pain Dr about the clinic but will this month.

You need to get rid of the idea of practitioners having "no right to ________"

They're human beings with free will.
They don't have to do anything they don't want to.

You're also totally incorrect in every legal sense as well.

 

[Sine Cura]

"Jimmy crackcorn" sounds like a troll

 

[BidingMyTime]

.I flipped because first off I never signed anythin giving the clinic authority to call the pharmacy or even my doctor.

Next time, actually read the "privacy" notice they give you. The "privacy" notice will list the MANY exemptions to it, #1 being, they can share your information with any other healthcare professional who is treating you (and that includes pharmacists.) If you don't like that, they you can choose not to see the doctor, but you can NOT legally keep him/her from sharing your information with a pharmacy that is filling your prescriptions. The privacy notice means your doctor can't call up your local news station and give them your records, or share your records with their next door neighbor just because. The "privacy" notice does spell out how your information can and WILL be shared with other legally permitted entities.

 

[disgonbgud]

Just to clarify the original question about methadone dispensing:

Federal law for NTPs - Typically, patients must go to the clinic for direct methadone administration. Opioid agonist take-home supplies are authorized to be dispensed BY THE CLINIC ONLY after the patient has been determined responsible without supervision. The take-home supply limit is determined by length of treatment. Not pharmacist dispensing.

Take home doses:
First 90 days - one dose per week
second 90 days - two doses/week
third 90 days - three doses per week
rest of first year - six doses/week
1 year + - max 2 week supply
2 years + - max 1 month supply, monthly visits

This is only per federal law, Reiss & Hall as a reference. State laws will vary.