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Pt on 500 ts Dilaudid 8mg a month?? Dispense??

Discussion in 'Pharmacy' started by fxok425, Sep 11, 2017.

  1. fxok425

    fxok425 7+ Year Member

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    I got a RX, Dilaudid 8mg, 2 to 3 ts po Q 4 to 6 hr prn, #300 for 17-day supply. I looked at this pt's history, pt has been filling 300 ts every 17 days and has been like this for over a year according to CURES. She is also on MS Contin. My RPH manager filled for her before, but he is on vacation. I refused filling this RX. She called here again and again and argued why my manger could fill for her, but I would not. I faxed the dr and requested detailed clinic notes and treatment plan, though I haven't received anything.
    My question is why a pt is on such a high dose short acting pain meds? Should she be on a long acting one with less abuse possibility? Is Fentanyl patch better for her?
     
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  3. CetiAlphaFive

    CetiAlphaFive

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    You did absolutely the right thing by asking for documentation.

    Is she filling at different pharmacies?
    Why only 17 days at a time?
    Is she going to the MD office every 17 days?

    Very bizarre.
    I probably wouldn't have filled it either.
     
    Abby Atwood likes this.
  4. doublehh03

    doublehh03 Senior Member 10+ Year Member

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    You did the right thing. The point of having a long acting pain medication as an adjunct is to minimize the use and frequency of the short acting meds. No reason why that amount of dilaudid lasts her only 17 days. A good discussion with the doctor and full documentation are completely necessary in this case.
     
    Abby Atwood likes this.
  5. BidingMyTime

    BidingMyTime Lost Shaker Of Salt 10+ Year Member

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    One of the reasons why people fill large amounts of SA's, and don't have LA's, is because public aid often won't cover LA's (except Morphine SR, so if the person is intolerant/allergic to that, they are out of luck.) I also do not like to see people on round-the-clock SA's, but often there is a financial reason for that.

    But what I've seen is RX's like a Norco every 4 hours schedule. The example you gave is a HUGE amount. Whatever pharmacist originally started filling this, should have documented the diagnosis and the reason why the pt couldn't take a LA. Since they didn't, you have every right/responsibility to ask for this documentation before filling the RX.
     
  6. VA Hopeful Dr

    VA Hopeful Dr Senior Member Physician 10+ Year Member

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    A certain prescriber needs to be reported to the medical board if he/she isn't pain management boarded (assuming this isn't a hospice patient). In today's world that amount of Dilaudid is not OK.
     
  7. Bubba98

    Bubba98 2+ Year Member

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    Is the patient on Medicare? Pill mills will take advantage of the fact that Medicare will pay for two office visits a month this way.
     
  8. Sine Cura

    Sine Cura 10 seconds or less 7+ Year Member

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    With those kinds of quantities I would suspect the patient is allocating some/all for sale. Documentation won't save you from scrutiny for permitting this quantity of fill regardless of any long-acting regimen

    > 500 a month was also 10% of my monthly hydromorphone quota at CVS (people on these same forums were aghast that I would reach those kinds of quantities) so another piece of anecdote to show how bad this looks
     
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  9. Dr Wario

    Dr Wario Hey you! Want to try this pill? 7+ Year Member

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    The shortest, complete sentence in the English language, "No."
     
  10. allantois

    allantois 5+ Year Member

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    I work for a pain clinic, and we have a few patients on 500-600 MEs/day.
     
  11. CetiAlphaFive

    CetiAlphaFive

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    Does it get tiring writing "fibromyalgia" that many times a day?
     
  12. allantois

    allantois 5+ Year Member

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    Less tiring than counting 500 pills :D
     
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  13. CYP-0

    CYP-0 Navigator

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    Debts' Ocean
    Chemo/terminally ill?
     
  14. Dr Wario

    Dr Wario Hey you! Want to try this pill? 7+ Year Member

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    What do you do with all that cash you collect, bet the bill for all those money counting machines gets expensive.
     
  15. Old Timer

    Old Timer SDN Advisor SDN Advisor 10+ Year Member

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    I would not fill this without documentation. I once called a local cancer hospital about an RX for 1800 mg MS Contin every 12 hours. Turned out the patient was a heroin addict and had prostate cancer with bone mets. He did not fill it many times before he passed. Just do your due diligence.

    As for counting 500 of these, they come in bottles of a 100, how hard is it to print 5 labels.
     
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  16. owlegrad

    owlegrad Uncontrollable Sarcasm Machine Staff Member Administrator Pharmacist 7+ Year Member

    I hope you are joking about printing five labels. You wouldn't really label a stock bottle of a C2 and send it out that way? I mean you can do whatever you want and I am sure your patients would love it if you do!
     
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  17. allantois

    allantois 5+ Year Member

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    That's really uncalled for - the practice is not a pill mill. Those few patients on extremely high doses have malignant tumors. We have very few patients under 40, and very few cash-paying patients. In fact a lot of the patients are on Medicaid, whose insurance is not accepted by other clinics. Everyone is regularly tested for compliance and illicit drug use, and if they test inconsistently they are dismissed from the practice.

    I understand that there is an opioid epidemic going on, but there are still a lot of people with legitimate pain who are already treated as criminals in the healthcare system.
     
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  18. Old Timer

    Old Timer SDN Advisor SDN Advisor 10+ Year Member

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    If there is any thought it would be used for anything other than a legitimate purpose, I don't fill it. If it's a good rx, I don't worry about diversion
     
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  19. owlegrad

    owlegrad Uncontrollable Sarcasm Machine Staff Member Administrator Pharmacist 7+ Year Member

    Well it's totally up to you of course but consider that a legitimate patient can have a family member or friend steal from them or that you can never be totally sure that it won't be diverted. Of course it doesn't really matter if it is in an amber bottle or stock bottle but personally I wouldn't want to dispense in a container that will only make it more appealing or recognizable to a drug dealer.

    Not to mention dispensing it in five containers makes it even easier to sell/steal!
     
  20. npage148

    npage148 Senior Member PhD Pharmacist 10+ Year Member

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    How big are your labels, mall hydromorphone bottles are like the size of a a stack of 4 bottle caps.
     
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  21. Old Timer

    Old Timer SDN Advisor SDN Advisor 10+ Year Member

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    If they are going to steal, they are going to steal....... No miscounts. I will use manufacturer's sealed bottles whenever possible....
     
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  22. Jimmyjohn6969420

    Jimmyjohn6969420 Banned Banned

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    I’m not trying to reply to you specifically but I don’t know how to reply to the topic in general so I just hit reply at the bottom of your post as it was the most recent post in this topic.

    Anyhow as to the people who expressed concern for the patient not being on a long acting med maybe you missed the op stating that the patient is also on MS Contin?

    Also to the person or people who just automatically assumed patient is selling I think that is a little harsh. Also these medications are indicated for moderate to severe pain. They are not required to have cancer or be in unbearable excruciating pain in order to be on dilaudid. I will agree with you that it is a high dose though and the every 17 day thing seems weird.

    Please don’t take this as any disrespect or anything I am a new member I am just stating my opinion. I am a chronic pain patient and I was recently switched to dilaudid by my doctor. I am not on anywhere near that dose though. I was started on 4 mg 3 times a day and My doctor said I can have 4 a day next time if I need it and that if I need more medication beyond that I can have er morphine or something else er in addition to the Dilaudid. I really like the dilaudid it works way better than 10mg lortab.

    My normal chain pharmacy told me they didn’t have it and they probably would next month. The pharmacist also took ne in the consult room and wanted to know all this stuff about my diagnosis and expected length of treatment. I said I wasn’t sure but I have at least one if not 2 herniated disks and they could feel more than welcome to talk to my doctor about it. At least they were very courteous about it and apologized for “not having it” Lol I’m not gonna hold my breath on that from what I hear. Thankfully the mom and pop across the street filled it no questions asked very quickly.

    So I just have a question: what is the main reason that so many pharmacists hate to fill dilaudid? I mean I know you guys get scrutinized but if you verify it with the doctor is t that enough? I mean what more could you be expected to do? I am under 30 so that may cause some suspicion but I have the mri to back up my diagnosis . I don’t understand how you as the pharmacist could be on th hook if you verify it and fill it. Also the pharmacy that filled it for me didn’t even Verify it. I actually wanted them too because I wanted them to tell my doc why I was using a different pharmacy but they said they were familiar with my doctor and didn’t need to verify.

    So what I’m getting at is if that pharmacist felt comfortable filling it don’t you guys think you’re worrying s little too much? I’m sure that pharmacist values their license and job and freedom. I mean if they felt comfortable filling it with no verification then surely you would be in the clear if you verified it right? I know it’s the stupid dea making it hard for patients to get their meds and for pharmacists to do their jobs. I get it that there’s an epidemic but that’s just something that’s gonna have to be accepted by law enforcement. Patients shouldn’t have a hard time getting meds and pharmacists shouldn’t have to worry about breaking the law for doing their job. Also the epidemic is way worse not that they made it harder to get pills. Now heroin and illicit fentanyl are killing people left and right. There are way more deaths now than when the pill mills were still operating. Way to go deA. They need to give up on the war on drugs. When are they gonna realize it’s over they lost and intelligent people can still get prescribed good drugs it’s just a little harder than it used to be.
     
  23. zelman

    zelman 7+ Year Member

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    When I have to choose between you being in pain or a high chance of this outcome, I won’t pick you.
     
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  24. maria1oh

    maria1oh 7+ Year Member

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    It is usually better to just say out of stock than deal with these shady doctors. If you dispense in manufacturer bottles make sure they are child resistant lids. A rph was sued for dispensing phenobarbital in stock bottle and lid was not child resistant.
     
  25. Jimmyjohn6969420

    Jimmyjohn6969420 Banned Banned

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    Wow that’s crazy and I certainly couldn’t be angry with you for your decision on this. Who I am angry at I guess is the legal system and the juries and law enforcement. I mean I don’t know the specifics of the cases but it sounds like that could happen to anyone who prescribes or dispenses these drugs. I mean we as patients are told the risks of addiction. That to me as well as deliberately disregarding this should have completely precluded any convictions here. God that is absolutely ridiculous. I wonder if there is more than meets the eye here as far as the prescribing and dispensing practices of the providers.

    It seems very clear that the stupid general public and law enforcement just doesn’t want anyone to be on opiates. At least for me for the moment I am not having any trouble getting what I need but I worry about the future. Only time will tell I guess.
     
  26. Jimmyjohn6969420

    Jimmyjohn6969420 Banned Banned

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    That’s nuts. I really wanted to be a pharmacist but I decided against it after getting a job at Walgreens. I was just a clerk but I had to help in the pharmacy sometimes and I welcomed the opportunity to learn more about it. In my state even clerks can ring up and sell already filled and bagged prescriptions. I just couldn’t deal with the customers and they were wayyy worse in the pharmacy lol. But now that I see all this legal bs you guys have to deal with I’m glad I didn’t go that route.
     
  27. CetiAlphaFive

    CetiAlphaFive

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    too long; didn't read.

    Can we start forcing people to answer 100 difficult questions related to their field before allowing them to register?

    Are patients allowed to make accounts under the TOS?
     
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  28. zelman

    zelman 7+ Year Member

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    Just use the ignore function. It’s not worth getting into arguments about censorship.
     
  29. Lnsean

    Lnsean 7+ Year Member

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    Unless terminally ill/cancer...i would not dispense this. If **** goes down, no amount of documentation will save you. They're going to wonder what kind of pharmacist dispenses #500 pills of dilaudid...and the answer is not a "reasonable" one. I barely dispense anything over 120 these days.
     
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