Retail Pharmacist Question: Dilaudid 2mg, #10, 1 po as needed

[Musculus]

Just wanted to know if any of you guys would have a problem filling a prescription written like this. There's no question it was valid, but the other pharmacist I was with didn't feel comfortable filling it with directions of "1 po as needed." The patient was in pain from an ear infection, was willing to pay cash, and also had prescription for some ear drops (Ciprodex) which she was getting. Dr office was closed.

In the end I did fill it for her, but just wanted to hear your opinion on the matter.

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[StellargalS]

I would have counseled and documented the patient's understanding of the appropriate frequency.

 

[bananaface]

Lack of minimum frequency on any pain med is a liability. The patient could take a tablet every 5 minutes with that sig. It seems very odd for Dilaudid to be prescribed for an ear infection. In combination with the sig being jacked up, you might want to reconsider the whole validity question. Any other red flags? Was the patient know to you? Paying cash? Out of state resident? Is that Rx something you have seen previously from that prescriber?

I would have offered to page the doctor to clarify the sig, piggybacking order verification. But, I recently practiced in a high fraud rate area and am especially wary of the hydromorphone for ear infection issue. If you know the patient and document counseling about safe use frequency, you will fulfill your duty to warn. You could have issues with an insurance audit.

 

[StellargalS]

Lack of minimum frequency on any pain med is a liability. The patient could take a tablet every 5 minutes with that sig. It seems very odd for Dilaudid to be prescribed for an ear infection. In combination with the sig being jacked up, you might want to reconsider the whole validity question. Any other red flags? Was the patient know to you? Paying cash? Out of state resident?

Yes. There is that risk. But I would argue that it is a disservice not to dispense. Are we given, and I do not know the answer to this, so little latitude for all of our knowledge. Cannot we cover our asses with consult and documentation? If this is not a legally defensible action than leaders better get to work. Medication experts or puppets?

 

[Gombrich12]

I would not fill it without a frequency for liability reasons. Page the doctor and get it fixed. As for dilaudid for ear infection, I have to roll my eyes about that. It is only 10 though.

 

[tompharm]

How do you document it? Write it on the prescription face?

 

[npage148]

Dilaudid for an ear infection treated only with ciprodex?! Not legit. Were they willing to pay cash for the ciprodex?

 

[Musculus]

Lack of minimum frequency on any pain med is a liability. The patient could take a tablet every 5 minutes with that sig. It seems very odd for Dilaudid to be prescribed for an ear infection. In combination with the sig being jacked up, you might want to reconsider the whole validity question. Any other red flags? Was the patient know to you? Paying cash? Out of state resident? Is that Rx something you have seen previously from that prescriber?

I would have offered to page the doctor to clarify the sig, piggybacking order verification. But, I recently practiced in a high fraud rate area and am especially wary of the hydromorphone for ear infection issue. If you know the patient and document counseling about safe use frequency, you will fulfill your duty to warn. You could have issues with an insurance audit.

Patient regularly gets prescriptions from us and is local. Same Dr (who is local and known to us) also prescribes the patient #60 Norco 10-325 each month which she takes 1 BID. I'm assuming the dilaudid is because the Norco wasn't helping the pain. I agree, though. Still strange. She said she would pay cash because of the insurance audit issue and us refusing to bill her insurance without a minimum frequency (she would have preferred we billed her insurance).

I counseled the patient regarding typical frequency and documented her understanding. Still though, I wonder how liable I would be if she did decide to pop 1 every 5 minutes like you mentioned. Just trying to get an idea of ways to handle it again if it comes up again

 

[StellargalS]

Patient regularly gets prescriptions from us and is local. Same Dr (who is local and known to us) also prescribes the patient #60 Norco 10-325 each month which she takes 1 BID. I'm assuming the dilaudid is because the Norco wasn't helping the pain. I agree, though. Still strange. She said she would pay cash because of the insurance audit issue and us refusing to bill her insurance without a minimum frequency (she would have preferred we billed her insurance).

I counseled the patient regarding typical frequency and documented her understanding. Still though, I wonder how liable I would be if she did decide to pop 1 every 5 minutes like you mentioned. Just trying to get an idea of ways to handle it again if it comes up again

You are as liable as you are found to be in court. Would you get dragged? Depends on the lawyers, the judge and maybe the DA.

Equipotent dosing of an alternate opiate not combined with apap allows use of tylenol first then dilaudid if needed. Maybe the doc had good exp with the drug in his general practice. I am not aware of the frequency business. I mean it would make my skin crawl for sure but I would evaluate the situation and document thoughtfully as you have.

Why don't u call on Monday and ask the doctor for med justification. I mean I bet alot of docs are getting ready for the stupid roll out of lowered apap C3 combo products and just wanna steer the clear of it for the holiday. Who knows.

 

[opinionfree]

All these questions about C2's and cash. Enough already. I usually post a brutally sarcastic response, but it's enough.

Let's look at the scenario posted.
If the claim cannot be honored by the patient's insurance why on Earth would you consider allowing the patient to make a cash payment? Nothing fishy about that.
Norco, 1 BID each month. Why not generic? Chronic use of a narcotic for an ear infection. That sounds like a reasonable standard of care for an ear infection.
Dilaudid. Why not generic? Patient in pain will only take Brand name pain medication.
Physician not familiar with the strict RX requirements for writing C2 scripts.
Pain that warrants a C2, yet patient waits to get RX filled when MD's office is closed.
The other pharmacist wouldn't fill it but the thread creator did. That should be a good defense when audited.
If a pharmacist and has questions regarding the legality surrounding the dispensation of a controlled substance for a specific state they should at least specify the state and direct the questions to the appropriate Board of Pharmacy.

Spare me the defense that this is a real patient case nonsense. I don't believe it and after the most basic evaluation, no one else should have either.
I'm not sure what is worse: the person obsessed with posting these ridiculous controlled substances questions or the fools desperate to post testaments to their egos by fielding them.

 

[Musculus]

All these questions about C2's and cash. Enough already. I usually post a brutally sarcastic response, but it's enough.

Let's look at the scenario posted.
If the claim cannot be honored by the patient's insurance why on Earth would you consider allowing the patient to make a cash payment? Nothing fishy about that.
Norco, 1 BID each month. Why not generic? Chronic use of a narcotic for an ear infection. That sounds like a reasonable standard of care for an ear infection.
Dilaudid. Why not generic? Patient in pain will only take Brand name pain medication.
Physician not familiar with the strict RX requirements for writing C2 scripts.
Pain that warrants a C2, yet patient waits to get RX filled when MD's office is closed.
The other pharmacist wouldn't fill it but the thread creator did. That should be a good defense when audited.
If a pharmacist and has questions regarding the legality surrounding the dispensation of a controlled substance for a specific state they should at least specify the state and direct the questions to the appropriate Board of Pharmacy.

Spare me the defense that this is a real patient case nonsense. I don't believe it and after the most basic evaluation, no one else should have either.
I'm not sure what is worse: the person obsessed with posting these ridiculous controlled substances questions or the fools desperate to post testaments to their egos by fielding them.

I just used the brand names to spare me from typing out hydrocodone-acetaminophen 10-325 and hydromorphone 2mg. The generic medication is what was dispensed. The patient was on Norco for a different pain issue. The ear infection was acute. Hence Dr writing for just 10 tabs of dilaudid. What requirements for a c2 was the Dr not familiar with? His
DEA# was on it. Quantity in words and numerically. Patient's address was even on it. I don't understand why you think this isn't a real case? If someone brought in a script for viagra with directions 1 po prn would you not fill it?

 

[zelman]

Since it's such a small quantity, I'd page the doc, and dispense if they didn't call back in an hour. If it was for enough to overdose and die, no way.

 

[Wheresmyaricept]

If you don't feel comfortable filling a prescription, don't fill it. It's your license. End of story. Personally, I wouldn't have andI know many pharmacists that wouldn't. And I know some that would.

 

[BenJammin]

I want you guys to shut off the lights in whatever room you're currently in, close your eyes, and say this statement out loud so it echoes throughout the room: hydromorphone for ear pain. Hydromorphone. For ear pain.

There better be some past history involving hydrocodone, otherwise I wouldn't fill that crap.

 

[Old Timer]

Really:

This is silly in so many ways. In the more than 30 years I have been a pharmacist, I have NEVER seen a fake rx for 1o Dilaudid 2mg. So let's get real. So now lets get to the insurance issue. If you are worried about getting audited for a script for 10 Dilaudid 2mg you are nuts. With MAC pricing you are looking at $3.00-$5.00 rx. they NEVER get audited. So now the only real issue is appropriate therapy.

So you have a regular patient, with insurance who has a script for Dilaudid 2 mg. Did you look in his ear with your otoscope? Is there an effusion? Is the drum perforated? You don't know. I once had a prescription for MS-Contin 1800mg BID. When I called the doctor I was informed the patient is a heroin addict and 15mg wouldn't touch his pain (prostate cancer with bone mets).

The appropriate thing to do is ask the patient of the doctor told them how often to take the medication. If not, you are justified to wait until you can clarify the directions with the prescriber. If the doctor told him to take 1 tablet every 4 hours, you are good to go. He won't die, so the family won't sue you. The insurance could care less about the script, so just fill it and counsel the patient appropriately and call it a day.

 

[npage148]

Where do you practice that you never see funny diaudid scripts? That's like the tab of choice to abuse. Small (few excipients), potent and no APAP

The idea that opiates are even considered for ANY ear infection speaks perfectly to the insane situation the US is dealing with when it comes our overt love of narcotics.

 

[genesis09]

I would just call and get the dosing clarified. Dilaudid is a little hardcore for an ear infection, though.

 

[Old Timer]

Where do you practice that you never see funny diaudid scripts? That's like the tab of choice to abuse. Small (few excipients), potent and no APAP

The idea that opiates are even considered for ANY ear infection speaks perfectly to the insane situation the US is dealing with when it comes our overt love of narcotics.

I said I never saw a fake prescription for 10 Dilaudid 2mg

That we are promiscuous with narcotics I thoroughly agree with. When I started out if a patient got 100 Percocet, it was the talk of the pharmacy for days.

 

[kvl1027]

I agree that dilaudid is excessive for an ear infection, but we don't know all of the details of this case. For someone who does not regularly take opiates for chronic pain I would say no way, but in this case for such a small qty, it's not really a big deal. And trust me, I am the most strict pharmacist in my store when it comes to C-IIs.

If someon is going to BS a script it's not going to be for 10 dilaudids, it's going to be for 180 or 240 or something crazy.

 

[npage148]

If someon is going to BS a script it's not going to be for 10 dilaudids, it's going to be for 180 or 240 or something crazy.

Idiot BSers will go for 240 dilaudid. The smart ones pass fake scripts for 10-2o because (as demonstrated here) even seasoned pharmacists will just glance it through.

 

[BidingMyTime]

You guys who can't believe someone is getting dilauded for an ear infection...have any of you actually had an ear infection? Ear infections can be incredibly painful, and the patient was already on hydrocodone (although I question why the doctor didn't try increasing the hydrocodone to q 4 - 6 hours first.)

My state limits CII's to a 30 day supply, so technically directions would be needed to verify it wasn't over a 30 day supply. I would make an effort to contact the doctor. But honestly, if the patient knew how to take, I would probably just document that & bill accordingly (another option would be to figure 1 tablet/day and bill as a 10 day supply.) I just can't see either the pt's insurance or the state question the days supply on #10 dilaudid.

 

[npage148]

My p4 year I had double ear infections with strep throat that gave me a 102 fever. Somehow I managed to get through the pain with only amox, OTC IBU and some ice cream. Maybe i just have a high pain tolerance though because i never had pain (despite bruised ribs, broken legs, and teeth extractions) that I felt needed opiates to manged

 

[kvl1027]

Idiot BSers will go for 240 dilaudid. The smart ones pass fake scripts for 10-2o because (as demonstrated here) even seasoned pharmacists will just glance it through.

It's not a matter of just glancing it through. Based on what was presented here, this script doesn't seem like a BS script. I could see dilaudid for a very painful ear infection in a patient with some opiate tolerance.

 

[Musculus]

It's not a matter of just glancing it through. Based on what was presented here, this script doesn't seem like a BS script. I could see dilaudid for a very painful ear infection in a patient with some opiate tolerance.

For those of you who offered their opinion regarding my question of filling the prescription with directions '1 po as needed,' thank you.

I didn't intend for this to turn into a debate about the legitimacy of the prescription. For the doubters, it was a valid prescription.

 

[owlegrad]

Personally I am a sucker for people in pain. I probably would have filled it. I always think, what if it was me? I don't mean crazy stuff like Oxy 30mg 1-2t q4h #720, but a low number like #10 with a technical problem...I probably would have filled depending on the surrounding situation.

 

[knight on horse]

Need MDD

Ear problems can be dramatically debilitating, though fortunately they are not commonly encountered and thereby may be a source of ignorance. (After all, if they were both debilitating and common, half the sick people would be wiped out from ear problems instead of flu during the flu season)

As you should know as medical professionals, the inner ear contains the sensory organs for our balance. If there are disturbances here, they result in the infamous whispered of feeling of impending doom - as one could predict to be the case after the simple experience of the supreme discomfort of nausea

Moving on to earaches specifically, the locus is very pinpoint and narrowed, and so more disturbing than a conventional headache. Sleep becomes impossible. The probable cause can take weeks to heal. And as both our hearing and balance are located in the ear, any injury is of grave concern

 

[KidPharmD]

A Few thoughts
- While I was a retail pharmacist, I saw a fake small quantity low dose C2 about every other week. People are right about organized crime (espically) using these kind of Rx's to keep from raising suspicion. For my state, they also wouldn't have required the CSMD to be checked so they are generally less suspicious.
- I get 2mg Dilaudid approximately equal to 5mg Hydrocodone. I think we forget how potent hydrocodone really is. Would anyone have questioned 5mg or 7.5mg hydrocodone product?
- I would not have filled this Rx as is. My state requires "frequency" on controlled Rx's. Even if it wasn't required, these aren't appropriate directions. Wouldn't question the drug, but would have had to have it clarified. That is what after hours lines at the MD office are for. If they don't take after hours call, then it becomes their patient care issue and not mine. Patient wouldn't die from their earache.

Knight on horse- What you described is more like ear injury than "earache." I think the rest of us are imagining the kind of pain that comes from an ear infection. If it were really that painful, then how do our very sensitive children go with nothing more than Tylenol (only maybe) for their frequent bacterial infections. Not saying its not appropriate as we don't have enough information. You are just making assumptions in the opposite direction as the rest of us.

 

[npage148]

The fact it's only being treated with ciprodex is proof enough it's not that serious of an infection.

 

[thephoenician88]

Really:

This is silly in so many ways. In the more than 30 years I have been a pharmacist, I have NEVER seen a fake rx for 1o Dilaudid 2mg. So let's get real. So now lets get to the insurance issue. If you are worried about getting audited for a script for 10 Dilaudid 2mg you are nuts. With MAC pricing you are looking at $3.00-$5.00 rx. they NEVER get audited. So now the only real issue is appropriate therapy.

So you have a regular patient, with insurance who has a script for Dilaudid 2 mg. Did you look in his ear with your otoscope? Is there an effusion? Is the drum perforated? You don't know. I once had a prescription for MS-Contin 1800mg BID. When I called the doctor I was informed the patient is a heroin addict and 15mg wouldn't touch his pain (prostate cancer with bone mets).

The appropriate thing to do is ask the patient of the doctor told them how often to take the medication. If not, you are justified to wait until you can clarify the directions with the prescriber. If the doctor told him to take 1 tablet every 4 hours, you are good to go. He won't die, so the family won't sue you. The insurance could care less about the script, so just fill it and counsel the patient appropriately and call it a day.

I think you're assuming too much in your current position "old timer"

 

[Hibiclens]

If it was a stranger yet I deemed the rx legit, I would just be sure to have a conversation with the patient to be sure they weren't going to do anything stupid with the pills and label it to the effect of "take one tablet as needed - standard dose is one tablet every 4 hours". (Or something to that effect, don't have dilaudid dosing info on hand)