Refusing to Fill (Dilemma)

[josh6718]

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So really could use some advice-

Have a patient that has been coming to the pharmacy for years. The previous PIC was terminated (for LP related reasons) and left me as acting POA. Patient's prescriptions for 90 days included:

1800 mL Tussionex
495 Morphine ER Tablets
450 Alprazolam
90 Zolpidem tablets

I don't feel as if they should have been filled with to begin with (she isn't a hospice/terminal patient). Though by now, she is clearly dependent and/or addicted.

I've never been in this kind of situation before and am having trouble deciding what to do- especially when the previous RPh had been filling them for so long.

1. Completely cut her off by not ordering it?
2. Contact MD and discuss/request some plan to wean her down if we are to continue filling?
3. Tell patient will no longer dispense that much at a time and only fill 30 days?
4. Continue filling as is?

 

[Old Timer]

So really could use some advice-

Have a patient that has been coming to the pharmacy for years. The previous PIC was terminated (for LP related reasons) and left me as acting POA. Patient's prescriptions for 90 days included:

1800 mL Tussionex
495 Morphine ER Tablets
450 Alprazolam
90 Zolpidem tablets

I don't feel as if they should have been filled with to begin with (she isn't a hospice/terminal patient). Though by now, she is clearly dependent and/or addicted.

I've never been in this kind of situation before and am having trouble deciding what to do- especially when the previous RPh had been filling them for so long.

1. Completely cut her off by not ordering it?
2. Contact MD and discuss/request some plan to wean her down if we are to continue filling?
3. Tell patient will no longer dispense that much at a time and only fill 30 days?
4. Continue filling as is?

You need to call the doctor and have a frank discussion. With the doctor and not through the nurse or tech. Do they have a signed contract with the patient? Are they blood or urine testing to see if they are taking and not selling? You need to know exactly why they are on each of these medications. I see no need to be on both Tussionex and MS-Contin. Duplicate therapy. If you are not satisfied with the information from the MD, call your supervisor and give them a head's up that this may be an issue and ask how they want you to handle it. Then tell the patient you are not comfortable with this and you can no longer fill it. I have no issue with filling it one more time and say this is the last time and they have a month to find someplace else to get it filled as opposed to sending the to the hospital if they go into withdrawal.

 

[Lnsean]

So really could use some advice-

Have a patient that has been coming to the pharmacy for years. The previous PIC was terminated (for LP related reasons) and left me as acting POA. Patient's prescriptions for 90 days included:

1800 mL Tussionex
495 Morphine ER Tablets
450 Alprazolam
90 Zolpidem tablets

I don't feel as if they should have been filled with to begin with (she isn't a hospice/terminal patient). Though by now, she is clearly dependent and/or addicted.

I've never been in this kind of situation before and am having trouble deciding what to do- especially when the previous RPh had been filling them for so long.

1. Completely cut her off by not ordering it?
2. Contact MD and discuss/request some plan to wean her down if we are to continue filling?
3. Tell patient will no longer dispense that much at a time and only fill 30 days?
4. Continue filling as is?

Ok...the zolpidem and xanax are whatevs..doctor ain't gonna change that. Refuse the Tussionex...wtf is she on this consistently? I'm in NJ/PA and I've never seen Tussionex prescribed for chronic pain like this. Also 495 tablets of ms contin? What total daily dose is she at? Is this a combo of two strengths? Move her to higher strength and cut the count down. They're probably not likely to be able to wean her off. This is just the nature of the situation. If she gest all her other meds filled there then I'd be okay with continuing her as a pt as long as the morphine dosage is clarified and the tussionex discontinued.

If all she gets filled are these meds at your pharmacy then just refuse it and be ready for a customer complaint.

 

[Humble Sloth]

So really could use some advice-

Have a patient that has been coming to the pharmacy for years. The previous PIC was terminated (for LP related reasons) and left me as acting POA. Patient's prescriptions for 90 days included:

1800 mL Tussionex
495 Morphine ER Tablets
450 Alprazolam
90 Zolpidem tablets

I don't feel as if they should have been filled with to begin with (she isn't a hospice/terminal patient). Though by now, she is clearly dependent and/or addicted.

I've never been in this kind of situation before and am having trouble deciding what to do- especially when the previous RPh had been filling them for so long.

1. Completely cut her off by not ordering it?
2. Contact MD and discuss/request some plan to wean her down if we are to continue filling?
3. Tell patient will no longer dispense that much at a time and only fill 30 days?
4. Continue filling as is?

I hope you realize Benzo and alcohol are two of the psychoactive drugs that withdrawal can literally kill someone. Heroin withdrawal will not even kill some. By cutting her off of her benzo script you could be responsible for her death (i don't be responsible in the legal sense).

 

[Lnsean]

I hope you realize Benzo and alcohol are two of the psychoactive drugs that withdrawal can literally kill someone. Heroin withdrawal will not even kill some. By cutting her off of her benzo script you could be responsible for her death (i don't be responsible in the legal sense).

Leave these situations for those who are actually practicing pharmacy and not just sitting in a classroom reading off random facts. Your tone is overly condescending for someone who has never even faced any real life practice scenarios where you have to make a clinical judgement call. Move on back to the classroom young lad.

 

[Sine Cura]

Usually when I tell people I won't fill any bad primary care scripts, I give out contact info for reputable pain management practices. 99% of the time these quack docs do not give a **** (don't check PDMP, don't do any drug screens, write Norco 10/325 #180 right off the bat with no history whatsoever) so you shouldn't either about refusing to fill their scripts. Then they either go somewhere else or obtain reasonable pain scripts from pain management.

There really is no legitimate medical reason to fill large quantities of opioid formulations labeled as antitussives long term (BOP can use it against you as it's clearly off-label), much less combined with other opioids for labeled pain so at least the antitussive has to be cut off.

Other tactics to get people to go away include limiting to 30 day supply ("if my wholesaler orders get cut off based on monthly quotas, so should you"), one or zero days early, and practice comprehensive due diligence by demanding patient charts, ICD-10, obtain rationale for duplicate therapy, plans to wean people off opioids, etc, and without meeting the standards of your company policy (which is always to CYA), you have to refuse to fill if these conditions aren't met. I usually have success getting rid of 90-day patients because they don't want to lose the full quantity and people who want **** early all the time.

If pain management practices don't care about cutting people off outright for violating contracts (not even giving people a second chance with 7-day Rx), why should you?

 

[BidingMyTime]

So really could use some advice-
Have a patient that has been coming to the pharmacy for years. The previous PIC was terminated (for LP related reasons) and left me as acting POA. Patient's prescriptions for 90 days included:
1800 mL Tussionex
495 Morphine ER Tablets
450 Alprazolam
90 Zolpidem tablets
?

OK, I know I have a habit of confusing state law vs federal law, but isn't it against federal law to fill more than a 30 day supply of a CII? And what strength of morphine is she on to be taking 5.5 ER tablets/day??? There are a lot of potential issues here. 1st make sure you are filling prescriptions in accordance to the law, 2nd talk to the doctor personally (and as oldtimer said not through a middlenurse.) Any script you fill, you need to be able to medically justify to the DEA why you are filling it, and as the other comments have pointed out, that seems like it would be pretty hard to do with this RX combo.

 

[owlegrad]

There is no federal limit on days supply for C2s.

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[PharmDBro2017]

Honestly I don't recall ever seeing a liter+ of tussionex being written for. Wow.

 

[RPh Who]

She can go elsewhere, tell the doctor that the regimen is excessive and your pharmacy will not be filling it. I will probably get a call out here, but no patient is worth your license.

 

[zelman]

Honestly I don't recall ever seeing a liter+ of tussionex being written for. Wow.

I have. But it was for late stage lung cancer.

 

[npage148]

Tell her you need to discuss her mgmmt directly with her doctor. That alone will take 24-48 hours. Either she will take it elsewhere or her docotornwill tell her to go elsewhere (as to avoid having his practice questioned) problems solved.

 

[PharmDBro2017]

I have. But it was for late stage lung cancer.

That's understandable.

Interested to know the OP patient diagnosis.

 

[lane one]

I see no need to be on both Tussionex and MS-Contin. Duplicate therapy.

But Tussionex is for coughing lolz. silly pharmacist