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

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

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  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 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
     
    CetiAlphaFive likes this.
  9. Dr Wario

    Dr Wario Hey you! Want to try this pill? 5+ Year Member

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

    allantois 2+ 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 2+ Year Member

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    Less tiring than counting 500 pills :D
     
    CYP-0 and CetiAlphaFive like this.
  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? 5+ 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.
     
    BidingMyTime and CetiAlphaFive like this.
  16. owlegrad

    owlegrad Uncontrollable Sarcasm Machine Staff Member SDN Administrator 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!
     
  17. allantois

    allantois 2+ 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.
     
    BidingMyTime and owlegrad like this.
  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
     
    CetiAlphaFive likes this.
  19. owlegrad

    owlegrad Uncontrollable Sarcasm Machine Staff Member SDN Administrator 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 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.
     
    CetiAlphaFive likes this.
  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....
     
    Niosh likes this.

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