Question About Non Cancer Pain Management

Teddybear123456 · Apr 28, 2018

Hi all fellow pharmacist,

I am a pharmacist practicing in a retail. I have a question in regards to chronic pain management for non cancer patients. I understand pain a fifth vial sign, and the goal is to have patients pain free. Doctors establish relationships with their regular patients. Doctors know what regimen is best to manage patients' chronic pain. On another hand, I am a floater pharmacist. I work at different stores and I do have my regular customers. When customers bring in opioid prescriptions, PDMP is the best tool that I use to make my professional judgement whether to fill that prescription. In retails, I have seen so so many non cancer patients on immediate release hydrocodone or oxycodone for chronic pain. These patients take these C2 every 4-6 hours every day for like 3-4 years. Some of these pt are also take non opioid meds in conjunction: SSRI, anti seizure, tricyclic , NSAID. None of these patients are on long acting opioids.

From what I was being taught in school, long term use of opoid increase tolerance, pain sensitivity, drug dependency, low quality of life. In addition to chronic use of opioid, pt should be treated with non pharm: physical therapy, erobic exercise, behavioral therapy.....etc

I understand not all insurance plans cover physical therapy

I see so many pt on like oxycodone 5 mg : 1q4h for 3 years. (same dose same strength for 3 years) I feel so uncomfortable filling these Rx. These pt are taking opioid just like blood pressure med daily (sad). I called the pain specialists and they told me that the opiod works for pt. Drs dont have any plan yet for tapering down the dose. Every time I call the doctors to ask about the pt pain regimen, it usually take them 2-3 days to get back to me. Pt was yelling at me because they couldnt wait 2-3 days in pain.

On other hand, I have tons of pressure from the retail corporate and DEA for filling these narcotic rx. Every single Rx I fill, I need to have a reasonable justification for filling it. I dont want to lose my job. How can I make a right decision when it is so hard to get a hold of the doctor and the only tool i have is PBDM? I am sorry for the lengthy post. Pls let me know if u need any clarification. Thank you in advance for all of your suggestions.

owlegrad · Apr 28, 2018

Being pain free is actually not a goal of pain management.

Other than that I have no constructive remarks to make. If you work in retail this is the reality of daily life. I never could decide which patients actually needed it and which were diverting or just plain addicted. I don't think anyone can and that is part of the problem. There are no objective tests after all.

Charcoales · Apr 28, 2018

1. If you see on the pdmp theyve ever been to another pain management, refuse to dispense until you figure out why they were discharged. Happens often that you call the previous one, and they tested positive for illicit drugs or failed bottle counts, etc.

2. Dont be gullible and fill oxy 15 q4h when theyve never tried anything in the past before... until doctor provides proof of detailed medication history

3. Dont fill early. Doesn't matter what start date the doctor wrote in script. We have corresponding duty dea said to ensure appropriate use. Aka prevent stock piling.

4. Give rx back if they dont want to wait for md office to fax back proof, document they wouldn't wait...

hye345 · Apr 28, 2018

Interesting you mention this... in my district, they've started clamping the screws on opioid fills: not only do we need diagnosis code on all hard copies, but if patient is on a high dose (higher than 50 MME, or 5 norco 10's a day), or on various combos (opioid + benzo comes to mind...), we gotta call doc and talk to them about any tapering plans going forward. It's been a hassle to say the least, both for us and for our (legitimate) patients.

Hope1974 · Apr 29, 2018

Teddybear123456 said:
Hi all fellow pharmacist,

I am a pharmacist practicing in a retail. I have a question in regards to chronic pain management for non cancer patients. I understand pain a fifth vial sign, and the goal is to have patients pain free. Doctors establish relationships with their regular patients. Doctors know what regimen is best to manage patients' chronic pain. On another hand, I am a floater pharmacist. I work at different stores and I do have my regular customers. When customers bring in opioid prescriptions, PDMP is the best tool that I use to make my professional judgement whether to fill that prescription. In retails, I have seen so so many non cancer patients on immediate release hydrocodone or oxycodone for chronic pain. These patients take these C2 every 4-6 hours every day for like 3-4 years. Some of these pt are also take non opioid meds in conjunction: SSRI, anti seizure, tricyclic , NSAID. None of these patients are on long acting opioids.

From what I was being taught in school, long term use of opoid increase tolerance, pain sensitivity, drug dependency, low quality of life. In addition to chronic use of opioid, pt should be treated with non pharm: physical therapy, erobic exercise, behavioral therapy.....etc

I understand not all insurance plans cover physical therapy

I see so many pt on like oxycodone 5 mg : 1q4h for 3 years. (same dose same strength for 3 years) I feel so uncomfortable filling these Rx. These pt are taking opioid just like blood pressure med daily (sad). I called the pain specialists and they told me that the opiod works for pt. Drs dont have any plan yet for tapering down the dose. Every time I call the doctors to ask about the pt pain regimen, it usually take them 2-3 days to get back to me. Pt was yelling at me because they couldnt wait 2-3 days in pain.

On other hand, I have tons of pressure from the retail corporate and DEA for filling these narcotic rx. Every single Rx I fill, I need to have a reasonable justification for filling it. I dont want to lose my job. How can I make a right decision when it is so hard to get a hold of the doctor and the only tool i have is PBDM? I am sorry for the lengthy post. Pls let me know if u need any clarification. Thank you in advance for all of your suggestions.

I’m a floater too. I’ve come across all types of scripts being filled on a regular basis that I don’t believe should be filled.

Example 1: Stadol 5ml or 2 bottles being filled every 4 days at a pharmacy because the pharmacist there called the doctor and gave the same song and dance the customer did with me on the phone- that she had all these problems.
Red Flags:
1. Doctor and patient from other suburb.
2. Dosing totally off 2 to 3 sprays ever 3 hours or something like that.
3. Dx: Being used for chronic pain? Lol....right.
4. Other pharmacies wouldn’t fill for her.
5. Now current pharmacy stock piles the drug exclusively for her because rph said md okd it lol

Example 2: morphine IR 30mg #180 being filled for a patient ever month. Patient claims she can’t tolerate ER pills (ER pills are formulated in such away that the pills can’t be smashed and abused like IR). While working that day the patient called up saying her mail order prescription didn’t come in, and wanted me to fill an additional script for 30 pills for 5 days which her son was going to send her because she was in Florida at this time? Lol really?

The chains received hell from the DEA in aroun 2010 or so I recall. In Florida, where I was at the time several big red pharmacies lost their license to sell C2s. Before this it was common that the DMs would put pressure on you to fill these.

I remember when I was working in a big chain pharmacy, after having looked for a job for 3 months, my boss that hired me, was in the pharmacy with her assistant showing me and making me fill out and order C2s for scripts that clearly were coming from pill mills.

Another classmate of mine had refused to fill to scripts for C2s, whereupon the customer complained and the DM (a pharmacist) called her telling her to fill the scripts. Evenso, she only filled one.

Today it’s not like this. The chains will support you, and the board of pharmacy will as well. You have a right to not fill, however you must have a reasonable reason as to why. (Which is why it’s easier to say you don’t have it.) I try to find a reason. I realize the doctors and pain clinics hand the stuff out like candy, but that just how it is.

You can’t always tell by the PDMP. You can check that as well as the profile in the pharmacy. One time O forgot to do this. Had I checked, I would have denied the script because all the patient had was C2s on file.

Dr Wario · Apr 29, 2018

The best defense to excessive opioids I have come across is the fairly recent CDC guideline to not exceed 90 MME/day in non-cancer patients, this works out to only 60mg/day of oxycodone. Anything over that, I have a conversation with the prescriber (assuming the patient is a regular, otherwise they can pound sand) about an immediate dose reduction plan or a massively strong justification for excess dosing.

If the prescriber gives me some speal that I am not a doctor and should not be practicing medicine, I respond simply that the DEA has made it the responsibility and obligation of pharmacists to police the dispensing of controlled substances because prescribers could not do it themselves...thank you for that by the way.

Hope1974 · Apr 29, 2018

Teddybear123456 said:
Hi all fellow pharmacist,

I am a pharmacist practicing in a retail. I have a question in regards to chronic pain management for non cancer patients. I understand pain a fifth vial sign, and the goal is to have patients pain free. Doctors establish relationships with their regular patients. Doctors know what regimen is best to manage patients' chronic pain. On another hand, I am a floater pharmacist. I work at different stores and I do have my regular customers. When customers bring in opioid prescriptions, PDMP is the best tool that I use to make my professional judgement whether to fill that prescription. In retails, I have seen so so many non cancer patients on immediate release hydrocodone or oxycodone for chronic pain. These patients take these C2 every 4-6 hours every day for like 3-4 years. Some of these pt are also take non opioid meds in conjunction: SSRI, anti seizure, tricyclic , NSAID. None of these patients are on long acting opioids.

From what I was being taught in school, long term use of opoid increase tolerance, pain sensitivity, drug dependency, low quality of life. In addition to chronic use of opioid, pt should be treated with non pharm: physical therapy, erobic exercise, behavioral therapy.....etc

I understand not all insurance plans cover physical therapy

I see so many pt on like oxycodone 5 mg : 1q4h for 3 years. (same dose same strength for 3 years) I feel so uncomfortable filling these Rx. These pt are taking opioid just like blood pressure med daily (sad). I called the pain specialists and they told me that the opiod works for pt. Drs dont have any plan yet for tapering down the dose. Every time I call the doctors to ask about the pt pain regimen, it usually take them 2-3 days to get back to me. Pt was yelling at me because they couldnt wait 2-3 days in pain.

On other hand, I have tons of pressure from the retail corporate and DEA for filling these narcotic rx. Every single Rx I fill, I need to have a reasonable justification for filling it. I dont want to lose my job. How can I make a right decision when it is so hard to get a hold of the doctor and the only tool i have is PBDM? I am sorry for the lengthy post. Pls let me know if u need any clarification. Thank you in advance for all of your suggestions.

You can’t always tell. It’s really best to make eye contact with the patient and talk to them. It’s happened before where I thought I shouldn’t fill a script, but the patient truly needed it. I don’t want to deny pain meds to patients in pain.

For responding to patient where it’s obvious it shouldn’t be filled you could:

Say you don’t have it, but I can’t always do it as I feel pressure because technicians know I do have it.

Check with your state, you can’t just decline and give a reason, you might have to call the doctor. For this just go to the complaint form patients fill out that customers send to the board.(again, why it’s easier to say you don’t have it) Either way, even if the doctor says it’s ok and they always do, you don’t have to agree to fill.

One clinic was known for writing all types of C2s for anyone. We simply don’t old patients coming with those scripts that we don’t fill from that clinic.

Sometimes on occasion the PDMP was down, so I said I can’t fill it till it comes back up because I had little to go on in their profile.

Once I was working at a store and I had a questionable script. The staff pharmacist had just walked in and I asked her about it, whereupon she agreed it shouldn’t be filled. The “problem” patient was with two relatives, so I had to figure out how to deny the script in a nice way. I approached the patient and told them that I was sorry that I couldn’t fill it. I gave them the reason and when questioned I repeated why and stated that I was a new graduate and the board of pharmacy was paying special attention to me because I was new, and I’d already been reprimanded for something else. They were sympathetic and left.

Another example per another pharmacist, a friend of mine said to just give them the reason etc, he said you don’t have to tell them your uncomfortable filling, just give the reason, like “It doesn’t clinically make sense in my clinical judgement”. Hand them the script, and that’s it.

Electronic scripts the come in where the patient per pdmp has 30 different controls, amounts, etc, no consistency, doctors that I know are shady....I’m on the phone with that office right away letting them know they need to send it else where.

Another floater, I heard, who sees scripts from patients who constantly go to the ER for 15 or 10 or 5 pain pills, tells the patient, if they’ve been to the ER 2 or 3 times that month already, hands the script back and tells the patient that theyve seen an ER doctor 3 times that month, they need to find a primary care doctor, and then hands them the script.

To the patients that say “I get it filled here all the time.” I say “I haven’t filled it here all the time.”

To the patients that say, “Why must you verify it, the doctor wrote it?” I say “I’ve been getting a lot a fake prescriptions lately”.

To the patients that say “I’m going on vacation”, I say, and this has worked, “I already reached the limit of early refills I can do this month. I can’t exceed this limit. I’ve had problems in the past with the board of pharmacy for this, please, I’m sorry but I’d like to keep my license” ....something along those lines and mention “the opined epidemic”. And doctors can send an electronic script to the state your vacationing at I believe or ..... you can check the pdmp and allow one early fill a year.

For the patients traveling in state and say there’s no pharmacy..... ok then on the way there stop at one or make that 4 hour drive. And there are pharmacies in bumblef**k because I’ve worked in bumblef**k.

Remember, you don’t have to fill the prescription if it doesn’t make sense. No ones pointing a gun to your head and telling you to fill it. It’s your license.

Don’t be scared. Theses patients already called corporate on me as well as other pharmacists. And, taken it to the board. You don’t have to fill it. You don’t have to fill.

hye345 · Apr 29, 2018

Hope1974 said:
You can’t always tell. It’s really best to make eye contact with the patient and talk to them. It’s happened before where I thought I shouldn’t fill a script, but the patient truly needed it. I don’t want to deny pain meds to patients in pain.

For responding to patient where it’s obvious it shouldn’t be filled you could:

Say you don’t have it, but I can’t always do it as I feel pressure because technicians know I do have it.

Check with your state, you can’t just decline and give a reason, you might have to call the doctor. For this just go to the complaint form patients fill out that customers send to the board.(again, why it’s easier to say you don’t have it) Either way, even if the doctor says it’s ok and they always do, you don’t have to agree to fill.

One clinic was known for writing all types of C2s for anyone. We simply don’t old patients coming with those scripts that we don’t fill from that clinic.

Sometimes on occasion the PDMP was down, so I said I can’t fill it till it comes back up because I had little to go on in their profile.

Once I was working at a store and I had a questionable script. The staff pharmacist had just walked in and I asked her about it, whereupon she agreed it shouldn’t be filled. The “problem” patient was with two relatives, so I had to figure out how to deny the script in a nice way. I approached the patient and told them that I was sorry that I couldn’t fill it. I gave them the reason and when questioned I repeated why and stated that I was a new graduate and the board of pharmacy was paying special attention to me because I was new, and I’d already been reprimanded for something else. They were sympathetic and left.

Another example per another pharmacist, a friend of mine said to just give them the reason etc, he said you don’t have to tell them your uncomfortable filling, just give the reason, like “It doesn’t clinically make sense in my clinical judgement”. Hand them the script, and that’s it.

Electronic scripts the come in where the patient per pdmp has 30 different controls, amounts, etc, no consistency, doctors that I know are shady....I’m on the phone with that office right away letting them know they need to send it else where.

Another floater, I heard, who sees scripts from patients who constantly go to the ER for 15 or 10 or 5 pain pills, tells the patient, if they’ve been to the ER 2 or 3 times that month already, hands the script back and tells the patient that theyve seen an ER doctor 3 times that month, they need to find a primary care doctor, and then hands them the script.

To the patients that say “I get it filled here all the time.” I say “I haven’t filled it here all the time.”

To the patients that say, “Why must you verify it, the doctor wrote it?” I say “I’ve been getting a lot a fake prescriptions lately”.

To the patients that say “I’m going on vacation”, I say, and this has worked, “I already reached the limit of early refills I can do this month. I can’t exceed this limit. I’ve had problems in the past with the board of pharmacy for this, please, I’m sorry but I’d like to keep my license” ....something along those lines and mention “the opined epidemic”. And doctors can send an electronic script to the state your vacationing at I believe or ..... you can check the pdmp and allow one early fill a year.

For the patients traveling in state and say there’s no pharmacy..... ok then on the way there stop at one or make that 4 hour drive. And there are pharmacies in bumblef**k because I’ve worked in bumblef**k.

Remember, you don’t have to fill the prescription if it doesn’t make sense. No ones pointing a gun to your head and telling you to fill it. It’s your license.

Don’t be scared. Theses patients already called corporate on me as well as other pharmacists. And, taken it to the board. You don’t have to fill it. You don’t have to fill.

Wow, these are gold...

zelman · Apr 29, 2018

Hope1974 said:
doctors can send an electronic script to the state your vacationing at

Not Hawaii. If they're going to Hawaii, they're SOL for any controls (C2-5).

And not Massachusetts for C2 narcotics unless your state is Maine or touches Massachusetts and the Rx is written by a physician.

And probably not some other states where I'm not licensed, so call a pharmacy there and make sure before you make assertions about laws in states where you don't practice.

Charcoales · Apr 29, 2018

I t

zelman said:
Not Hawaii. If they're going to Hawaii, they're SOL for any controls (C2-5).

And not Massachusetts for C2 narcotics unless your state is Maine or touches Massachusetts and the Rx is written by a physician.

And probably not some other states where I'm not licensed, so call a pharmacy there and make sure before you make assertions about laws in states where you don't practice.

Yeah I tell them we dont do vacation supplies on narcotics, if they ask what they should do, I say see if you can plan around your monthly fill, or talk with md, if they can help you find clinic in area if extended stay (many pharmacy wont fill out of state rxs, and some ins wont work outside state like medicaid). If they still complain just apologize but the medicine you take is highly controlled and you're sorry about the barriers in place but the medicine is highly regulated.

Teddybear123456 · Apr 29, 2018

Let me add some clarification to my post. When I fill the C2 narcotics, I let them fill 1 day early (that's it ). Based on PDMP, I also calculate the dates they filled in the past to see if they have early fill pattern. If they are getting benzo and opioid: red flag. Tramadol and IR opioid: duplicate therapy. if Primary care dr has been wring C2 rx for pt for like 3 years: red flag. It seems it is out of their scope of practice and pt should be referred to pain specialist. I told them it will take me at least an hour to get the med ready (cause I have to do documentation on my end). I read the CDC guide line. Is there any other sources for me to brush up on chronic pain management?

ldiot · Apr 29, 2018

Here's the most important things to consider in my opinion:

1) Decide where the line is for you when it comes to early fills. It could be 2 days, it could be the exact due date, but once you make a decision stick to it for every pharmacy and every patient.
2) Check PDMP for multiple pharmacies/doctors
3) Watch for high doses/unnecessary combinations

It's literally impossible to tell if the medical need for every script is legitimate. The best you can do is refuse early fills, doctor shoppers, and ridiculous doses/drug combinations.

Modest_anteater · May 1, 2018

Charcoales said:
1. If you see on the pdmp theyve ever been to another pain management, refuse to dispense until you figure out why they were discharged. Happens often that you call the previous one, and they tested positive for illicit drugs or failed bottle counts, etc.

2. Dont be gullible and fill oxy 15 q4h when theyve never tried anything in the past before... until doctor provides proof of detailed medication history

3. Dont fill early. Doesn't matter what start date the doctor wrote in script. We have corresponding duty dea said to ensure appropriate use. Aka prevent stock piling.

4. Give rx back if they dont want to wait for md office to fax back proof, document they wouldn't wait...

"prevent stockpiling"

do you really think that is why they are filling early? bc that's not what I think.

Question About Non Cancer Pain Management

Teddybear123456

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owlegrad

Uncontrollable Sarcasm Machine

Charcoales

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hye345

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Hope1974

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Dr Wario

Hey you! Want to try this pill?

Hope1974

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hye345

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zelman

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Charcoales

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Teddybear123456

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ldiot

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Modest_anteater

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