Refill Restrictions - 30th Day Wait?

[ResCon]

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The script is for 15 count of a schedule IV for 30 days. On top of this there is a prescribers note to the pharmacist that the script is intended to be for 30 days. Is this just redundant to stating the 30 day supply along with the quantity or is this specifically instructing the pharmacist to not fill script until the entire supply is exhausted on the 30th day?

I will call the doc to get clarification, but have any of you come across this practice of restricting refills to the 30th day rather than when insurance will cover the 30 day refill? (usually 21 days).

Thanks in advance.

 

[Carboxide]

The script is for 15 count of a schedule IV for 30 days. On top of this there is a prescribers note to the pharmacist that the script is intended to be for 30 days. Is this just redundant to stating the 30 day supply along with the quantity or is this specifically instructing the pharmacist to not fill script until the entire supply is exhausted on the 30th day?

I will call the doc to get clarification, but have any of you come across this practice of restricting refills to the 30th day rather than when insurance will cover the 30 day refill? (usually 21 days).

Thanks in advance.

If it says thirty day SUPPLY, then I wouldn't make them wait 30 days. I would do whatever insurance allows, but no more than 4 days in advance. I have told patients before that we do not fill til the day of for them. This happens when they chronically try to fill early.

 

[cycloketocaine]

The way you describe it, the prescriber is requesting 30 days between dispense dates. I would maybe fill at 29, but no earlier.

 

[PharmDstudent]

The script is for 15 count of a schedule IV for 30 days. On top of this there is a prescribers note to the pharmacist that the script is intended to be for 30 days. Is this just redundant to stating the 30 day supply along with the quantity or is this specifically instructing the pharmacist to not fill script until the entire supply is exhausted on the 30th day?

I will call the doc to get clarification, but have any of you come across this practice of restricting refills to the 30th day rather than when insurance will cover the 30 day refill? (usually 21 days).

Thanks in advance.

It is "specifically instructing the pharmacist to not fill script until the entire supply is exhausted on the 30th day".

 

[Ackj]

Just wondering, why #15 = 30 days? Are they 1/2 tabs, or they can only take it every few days? I'm sure the patient will end up using all 15 in about 18-20 days, so just make sure you remember whatever verdict you reach in about a month's time.

 

[ResCon]

It is "specifically instructing the pharmacist to not fill script until the entire supply is exhausted on the 30th day"

Yep. Doc (an NP) confirmed to not dispense until the 30th day. Haven't really encountered this.

Just wondering, why #15 = 30 days? Are they 1/2 tabs, or they can only take it every few days? I'm sure the patient will end up using all 15 in about 18-20 days, so just make sure you remember whatever verdict you reach in about a month's time.

Since the script was for eszopiclone I'm guessing the NP didn't want the pt taking it any more than every other night. For a CIV it seems like an over-abundance of caution, but that seems rather typical with NPs (but who am I to say really).

Usually when this is a big concern they just write zero refills, maybe an attempt to reduce the number of office visits without increasing med abuse by giving refills?

 

[Farmercyst]

Yep. Doc (an NP) confirmed to not dispense until the 30th day. Haven't really encountered this.



Since the script was for eszopiclone I'm guessing the NP didn't want the pt taking it any more than every other night. For a CIV it seems like an over-abundance of caution, but that seems rather typical with NPs (but who am I to say really).

Usually when this is a big concern they just write zero refills, maybe an attempt to reduce the number of office visits without increasing med abuse by giving refills?

It seems half of our controls are "must last 30 days" Norcos, Vicodins, Percocet. I'd swear if they're that afraid that the meds are being misused, they ought to just cut them off.

 

[PharmDstudent]

It seems half of our controls are "must last 30 days" Norcos, Vicodins, Percocet. I'd swear if they're that afraid that the meds are being misused, they ought to just cut them off.

We get a little bit of that, too. They'll write "must last 30 days" on the script or say it over voicemail.

Will you transfer it out if it's early? They rarely do that here.

 

[PharmDstudent]

Since the script was for eszopiclone I'm guessing the NP didn't want the pt taking it any more than every other night. For a CIV it seems like an over-abundance of caution, but that seems rather typical with NPs (but who am I to say really).

Usually when this is a big concern they just write zero refills, maybe an attempt to reduce the number of office visits without increasing med abuse by giving refills?

Maybe they were supposed to only take half a tablet hs?

 

[CUninja]

Just wondering, why #15 = 30 days? Are they 1/2 tabs, or they can only take it every few days? I'm sure the patient will end up using all 15 in about 18-20 days, so just make sure you remember whatever verdict you reach in about a month's time.

We get a decent amount of these for Xanax (which is a C-IV), among others, where I currently work in retail. We enforce the "must last 30 days" and it becomes part of the sig - so it prints out on the label.

 

[Ackj]

We get a decent amount of these for Xanax (which is a C-IV), among others, where I currently work in retail. We enforce the "must last 30 days" and it becomes part of the sig - so it prints out on the label.

Ah, lovely NY doesn't let you put refills on benzos, so we don't run into this. We have all sorts of laws about when we can fill controls too. Only time I've seen something of this sort is zolpidem where the doc doesn't want them to use it every single night, but the patient seems to do it anyway and runs out.

 

[VA Hopeful Dr]

It seems half of our controls are "must last 30 days" Norcos, Vicodins, Percocet. I'd swear if they're that afraid that the meds are being misused, they ought to just cut them off.

Open invite - come to my clinic and tell some of my choicer narcotic addicted patients that we won't be giving them anymore candy. You'll quickly see why we don't do that as often as we probably should.

Plus, its hard to know if they want more pills/higher dose because they have more pain or because they want to sell the extras.

 

[Carboxide]

Open invite - come to my clinic and tell some of my choicer narcotic addicted patients that we won't be giving them anymore candy. You'll quickly see why we don't do that as often as we probably should.

Plus, its hard to know if they want more pills/higher dose because they have more pain or because they want to sell the extras.

Can you elaborate?

 

[genesis09]

Can you elaborate?

They can become abusive and angry. You try and tell these people they can't get their candy and it is not pretty.

 

[VA Hopeful Dr]

They can become abusive and angry. You try and tell these people they can't get their candy and it is not pretty.

Yeah, basically they would act the same way they act at the pharmacy when you tell them no. Plus, I can't kick them out without offering 30 days of emergency care.

 

[Farmercyst]

Open invite - come to my clinic and tell some of my choicer narcotic addicted patients that we won't be giving them anymore candy. You'll quickly see why we don't do that as often as we probably should.

Plus, its hard to know if they want more pills/higher dose because they have more pain or because they want to sell the extras.

I've been told (no way to know if it's reality) that the "must last 30 days" crowd are the ones who have been irresponsible, argumentative, or otherwise abused the system in terms of early refills, lost refills, doctor shopping, etc and that this is the reason they've been designated as needing must last 30 on their rx's. I'm not saying it would be easy, but this type of abuse seems to be worthy of referral to rehab clinic or something. As you say though, I have no experience on the other side of this argument, so it is probably naive at best.

 

[Carboxide]

Yeah, basically they would act the same way they act at the pharmacy when you tell them no. Plus, I can't kick them out without offering 30 days of emergency care.

Yeah. We deal with angry patients a LOT more than you do. And guess what? It's not a big deal. You don't HAVE to prescribe for patients, and that's a lazy attitude that "I don't want to deal with their anger, so I'm just going to contribute and enable their addiction."

 

[VA Hopeful Dr]

I've been told (no way to know if it's reality) that the "must last 30 days" crowd are the ones who have been irresponsible, argumentative, or otherwise abused the system in terms of early refills, lost refills, doctor shopping, etc and that this is the reason they've been designated as needing must last 30 on their rx's. I'm not saying it would be easy, but this type of abuse seems to be worthy of referral to rehab clinic or something. As you say though, I have no experience on the other side of this argument, so it is probably naive at best.

Usually just early refills. If my chronic pain patients doctor shop, are rude to my staff, or lose more than 1 script then I usually will cut them off.

Yeah. We deal with angry patients a LOT more than you do. And guess what? It's not a big deal. You don't HAVE to prescribe for patients, and that's a lazy attitude that "I don't want to deal with their anger, so I'm just going to contribute and enable their addiction."

It never crossed my mind that y'all get more anger directed at you than I do at me. In an ideal world, I'd do exactly what you suggest but its more complicated than that.

Many (I'd love to say all, but that'd be a lie) chronic pain patients actually have real pathology that needs some kind of chronic pain management. I wouldn't feel comfortable just cutting them off. In addition, I can understand their anger. If I was in constant pain, I'd be irritable too. If it was just me, I wouldn't care at all about angry patients. I'm a reasonably large man, I can deal. My staff, on the other hand, gets flustered if not downright scared when patients lose their tempers.

You also seem to forget that even if I fire a patient, I'm required to see them for 30 more days from the day I fire them. Its not unheard of for fired patients to come in every 1-2 days just to be a pain in the ass during that time.

 

[Carboxide]

Usually just early refills. If my chronic pain patients doctor shop, are rude to my staff, or lose more than 1 script then I usually will cut them off.



It never crossed my mind that y'all get more anger directed at you than I do at me. In an ideal world, I'd do exactly what you suggest but its more complicated than that.

Many (I'd love to say all, but that'd be a lie) chronic pain patients actually have real pathology that needs some kind of chronic pain management. I wouldn't feel comfortable just cutting them off. In addition, I can understand their anger. If I was in constant pain, I'd be irritable too. If it was just me, I wouldn't care at all about angry patients. I'm a reasonably large man, I can deal. My staff, on the other hand, gets flustered if not downright scared when patients lose their tempers.

You also seem to forget that even if I fire a patient, I'm required to see them for 30 more days from the day I fire them. Its not unheard of for fired patients to come in every 1-2 days just to be a pain in the ass during that time.

If you're talking about chronic pain patients that you cut off if they doctor shop, that's one thing. I was thinking more about ER docs. I had a non-fatal but rare virus attack recently, and went to the ER. With a pain scale level of 5, I had three docs ask me if I wanted oxycodone. That's where I see at least a solid 40% of scripts coming from. The other thing is that a lot of patients doctor shop and their docs don't believe us. I had one come down the other day because his patient's morphine was too early for several days to fill. He says, "No no, I am SURE it is not. I gave this for this many days, so she ran out today." Well guess what buddy? The state registrar says she's filled it since then. They honestly don't believe us.

It is my experience that most docs are not interested in keeping drugs out of the hands of users. The number of scripts for CIIs I see (we recently filled a script for almost 800 morphine 5's) is ridiculous. That combined with the number of people I personally know who started getting bad grades and BAM - ADHD diagnosis + Ritalin 10 mg TID has made me lose complete faith in the prescribers.

I do understand that a lot of techs and staff are very uncomfortable dealing with angry patients...however, if they want to work in health care, they have to deal with it. At least people WANT to see the doctor, because they want to feel better - they think that the pharmacy is an inconvenience that will be speeded up by them a). yelling at us, or b). refusing to leave the counter and staring at us. High copay? Our fault. Too early? Our fault. Doctor didn't bother to include a strength/amount/sig? Well, the PATIENT knows what it's supposed to be. HOW DARE WE insist on calling to find out?

So...I guess the point of this post is that I do get that you guys have issues too. But I don't fill for a patient that's scamming docs for meds, and it's frustrating to see that docs CONTINUE to prescribe for them - even when we tell them flat out that they've filled CIIs at 4 different pharmacies from 4 different docs in the last month.

 

[VA Hopeful Dr]

If you're talking about chronic pain patients that you cut off if they doctor shop, that's one thing. I was thinking more about ER docs. I had a non-fatal but rare virus attack recently, and went to the ER. With a pain scale level of 5, I had three docs ask me if I wanted oxycodone. That's where I see at least a solid 40% of scripts coming from. The other thing is that a lot of patients doctor shop and their docs don't believe us. I had one come down the other day because his patient's morphine was too early for several days to fill. He says, "No no, I am SURE it is not. I gave this for this many days, so she ran out today." Well guess what buddy? The state registrar says she's filled it since then. They honestly don't believe us.

It is my experience that most docs are not interested in keeping drugs out of the hands of users. The number of scripts for CIIs I see (we recently filled a script for almost 800 morphine 5's) is ridiculous. That combined with the number of people I personally know who started getting bad grades and BAM - ADHD diagnosis + Ritalin 10 mg TID has made me lose complete faith in the prescribers.

I do understand that a lot of techs and staff are very uncomfortable dealing with angry patients...however, if they want to work in health care, they have to deal with it. At least people WANT to see the doctor, because they want to feel better - they think that the pharmacy is an inconvenience that will be speeded up by them a). yelling at us, or b). refusing to leave the counter and staring at us. High copay? Our fault. Too early? Our fault. Doctor didn't bother to include a strength/amount/sig? Well, the PATIENT knows what it's supposed to be. HOW DARE WE insist on calling to find out?

So...I guess the point of this post is that I do get that you guys have issues too. But I don't fill for a patient that's scamming docs for meds, and it's frustrating to see that docs CONTINUE to prescribe for them - even when we tell them flat out that they've filled CIIs at 4 different pharmacies from 4 different docs in the last month.

The ER issue is very easy to explain. Their jobs/contracts/pay is heavily dependent on patient satisfaction scores. The surverys that measure that are randomly sent to a certain number of patients each day. It doesn't matter if the patient is a drug abusing gang member who was there to get his hand stitched up after punching someone, if he leaves angry (ie. without pain meds) and gets a survey then the doc in charge is in trouble. Get rid of, or change the way patient satisfaction surveys are done in the ER and I guarantee you'll see less narcotics coming out of there.

I somewhat agree with you about the ADHD issue. Many of these kids that I see aren't truly ADHD but are suffering from inconsistent discipline and usually something f-ed up in the early lives (drug babies are at higher risk, kids adopted after 3 years of age, and so on). I'd love to see all of these kids seeing someone in mental health to teach them coping strategies. Sadly, no one in child psych takes state insurance these days so my options are either a) medicate the child or b) watch them fail at school.

I don't have any answer for doctors not believing you that patients are doctor shopping. In my state, MDs can also get access to the controlled substances detabase and I check it regularly. If a pharmacist expressed a concern to me about that, I'd sak for their records and do some checking on my own. Maybe send the MD your computer records showing what they patient has been doing?

 

[Pharmacopia]

Handwritten "no early refills within 30 day's" on controls. I love them. It allows me to say "sorry, can't refill it early, says so right here on your prescription."

I don't hold doctors responsible for over supplying people with narcotics, although its easy to blame them. A doctor friend of mine said that he always treats the pain. I asked him about addiction, he said, it didn't matter, if the patient is truly in pain then he is obligated to treat the patient, Unfortunately, pain is so subjective, anyone can fake it.

The only issue is that I didn't become a pharmacist to become the "narco", I'm sure doctors feel the same way.

If i feel a patient is shopping for doctors, I let the MD know. Usually they are so afraid of getting in trouble with the DEA they just cancel the prescription. Only problem is I don't have the time or man power to verify all controls.