Walmart to limit first fill of opioids

[txpharmguy]

Walmart to restrict opioid prescriptions at its pharmacies

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[txpharmguy]

Sorry about double thread posting. I'd be on board with this, especially EPCS. Thoughts?

 

[BigBoss]

I agree, though I can imagine the hordes of patients yelling and screaming at the counter as a result.


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[zelman]

I think the more interesting announcement is the 2020 deadline for electronic control Rx’s.

 

[BidingMyTime]

I would rather see ramifications for doctors who are inappropriately prescribing, then hard and fast opiod limits. Because there are exceptions to every rule. Say someone who was just discharged after 2 months in the hospital following a traumatic accident with multiple bone breaking and spinal damage. Or a burn victim with 50% 3rd & 4th degree burns. This person will need more than a 7 day supply, and possibly more than a 50 MME/day. Not everyone is on Medicaid or has health insurance. Co-pays along can quickly add up if a person has to pay them every 7 days (especially since they won't be working.)

A far better solution would be to make sure pharmacies are adequately staffed, so pharmacists can call and talk to doctor's about the issue, and then use their professional judgement on filling a prescription .

 

[Sine Cura]

Note that the day-supply and MME limit applies to "first-time opioid prescriptions for 'acute pain'," so basically this does not change anything. You might curtail a 10-day supply to 7-day supply.

First-time fill of Norco 10/325 for #120 for M54.5? You would probably deny that anyway

2020 deadline for electronic controlled Rx - this will never happen with unorganized FQHCs, mental health clinics that serve > 99% Medicaid, dental corporations and private practitioners that are too cheap to set up EPCS so basically we are telling people to go to CVS or Rite Aid.

I'm sure there will be a mechanism for exceptions

 

[Prepharm1214]

Ohio passed this law last November for all pharmacies in the state...most insurances hard stop these cases that go over the 7 day limit in our state so we're 'not the bad guy' in the patients eyes anyway - only problem being they were hard stopping every first fill script for >7 day after November even though most of them were long term pain patients and had been on monthly pain scripts for years. As others have said I'd rather see doctors put on notice rather than these types of policies

 

[ldiot]

These policies are just a pain in the ass for everyone involved; the patient, pharmacy, and physician. What data is available to suggest that it is going to help?

 

[Carbon14]

These policies are just a pain in the ass for everyone involved; the patient, pharmacy, and physician. What data is available to suggest that it is going to help?

Most cite the following study:

BidingMyTime: your proposed solution covers only an occasional exception to the rule. No for-profit company will throw those kind of resources around with barely anything to gain. Pharmacists should document exceptions to the rule when it's appropriate to do so or deny when in doubt. Adequate staffing is a pipe dream.

Overall, looks like we're trying to prevent addiction of newcomers. Those that are already addicted will have increased access to naloxone. Meanwhile gabapentin abuse will rise. In a few years it'll be the gabapentin epidemic and the cycle will go on.

 

[BenJammin]

How is that legal? You can't partial fill a C2 unless you're out of stock

 

[Ra1nMak3r]

How is that legal? You can't partial fill a C2 unless you're out of stock

You can dispense less than the original quantity written and void the rest as long as the patient gives you the consent and you notify the prescriber.

 

[owlegrad]

How is that legal? You can't partial fill a C2 unless you're out of stock

Not sure why you think they plan to partial it?

They can simply refuse to fill it or require the doctor to change the quantity to being a seven day supply.

 

[hye345]

How is that legal? You can't partial fill a C2 unless you're out of stock

Technically it wouldn't be a partial; at CVS, when this comes up and patient only wants the amount that insurance will cover, we change the dispensed amount to that amount, and patient effectively forfeits the rest.

 

[Invokanyetnyet]

Partial-filling a C2 is now legal (at least at the federal level, i.e. unless your state specifically forbids it) because of the CARA law.

One of many links about CARA:
(Sorry, SDN has forbidden me from posting links. Search Google for "cara partial fill," and look for the North Carolina Board of Pharmacy link, among others.)

 

[BenJammin]

You can dispense less than the original quantity written and void the rest as long as the patient gives you the consent and you notify the prescriber.

Not according to the DEA.

 

[Ra1nMak3r]

Not according to the DEA.

Wrong

 

[owlegrad]

Wrong

Can you show where the DEA has updated its regulations? I am not saying that they haven't, but I don't see where they have.

Congress To DEA: Update Schedule II Partial Fill Regulations Swiftly

 

[Ra1nMak3r]

Can you show where the DEA has updated its regulations? I am not saying that they haven't, but I don't see where they have.

Congress To DEA: Update Schedule II Partial Fill Regulations Swiftly

To clarify, I wasn't talking about partial filling. I was talking about dispensing less than the original quantity and voiding the remaining is legal as long as the patient agrees and you consult with the prescriber. It's basically changing the written quantity with the prescriber's approval.

 

[BenJammin]

What you just described is a partial fill. That's not legal if you have the full quantity on hand.

 

[johnpharm01]

Can you show where the DEA has updated its regulations? I am not saying that they haven't, but I don't see where they have.

Congress To DEA: Update Schedule II Partial Fill Regulations Swiftly

Thanks for your posting. I did not know about this. If they want to really solve an opioid epidemic lets start with the fifth vital sign people- joint commission- and the schools of pharmacy that taught that philosophy (mine is one). Then move on to drs who inappropriately prescribe narcotics.

 

[owlegrad]

What you just described is a partial fill. That's not legal if you have the full quantity on hand.

Well...what in the law or DEA regulations prevents a prescriber from changing the written quantity verbally? Nothing that I am aware of. I think you are confusing the pharmacists changing the amount dispensed to being less than what was prescribed (which I agree would be a partial fill) vs calling the doctor and asking them to change the written quantity (which would then not be a partial fill).

Are you aware of anything that prevents a prescriber from changing the written quantity verbally after the fact? Certainly there maybe state laws but I am not aware of any DEA regulation or federal law that prohibits this.

Of course in practice pharmacists do this all the time anyway, but since we are discussing legal minutia lets go ahead and discuss what is legally allowed.

 

[owlegrad]

Thanks for your posting. I did not know about this. If they want to really solve an opioid epidemic lets start with the fifth vital sign people- joint commission- and the schools of pharmacy that taught that philosophy (mine is one). Then move on to drs who inappropriately prescribe narcotics.

Personally I enjoy these legal discussions but only when we post links and show our sources. Simple declarations of "You're wrong" and "No, you're wrong!" aren't very informative.

 

[Ra1nMak3r]

Personally I enjoy these legal discussions but only when we post links and show our sources. Simple declarations of "You're wrong" and "No, you're wrong!" aren't very informative.

My bad. I was trying to impersonate Trump with my post and exert dominance. But all jokes aside, this 7-day supply will be the norm very soon. Third party insurance already has this limit for acutes.

 

[owlegrad]

My bad. I was trying to impersonate Trump with my post and exert dominance. But all jokes aside, this 7-day supply will be the norm very soon. Third party insurance already has this limit for acutes.

Oh how did I miss the trump reference. It’s a good one too. My bad as well.

 

[Twentytwelve2]

What you just described is a partial fill. That's not legal if you have the full quantity on hand.

Section 4052.10 is added to the Business and Professions Code, to read: (a) A pharmacist may dispense a Schedule II controlled substance, as listed in Section 11055 of the Health and Safety Code, as a partial fill if requested by the patient or the prescriber. (b) If a pharmacist dispenses a partial fill on a prescription pursuant to this section, the pharmacy shall retain the original prescription, with a notation of how much of the prescription has been filled, until the prescription has been fully dispensed. The total quantity dispensed shall not exceed the total quantity prescribed. (c) Subsequent fills, until the original prescription is completely dispensed, shall occur at the pharmacy where the original prescription was partially filled. The full prescription shall be dispensed not more than 30 days after the date on which the prescription was written. Thirtyone days after the date on which the prescription was written, the prescription shall expire and no more of the drug shall be dispensed without a subsequent prescription.

 

[hye345]

Section 4052.10 is added to the Business and Professions Code, to read: (a) A pharmacist may dispense a Schedule II controlled substance, as listed in Section 11055 of the Health and Safety Code, as a partial fill if requested by the patient or the prescriber. (b) If a pharmacist dispenses a partial fill on a prescription pursuant to this section, the pharmacy shall retain the original prescription, with a notation of how much of the prescription has been filled, until the prescription has been fully dispensed. The total quantity dispensed shall not exceed the total quantity prescribed. (c) Subsequent fills, until the original prescription is completely dispensed, shall occur at the pharmacy where the original prescription was partially filled. The full prescription shall be dispensed not more than 30 days after the date on which the prescription was written. Thirtyone days after the date on which the prescription was written, the prescription shall expire and no more of the drug shall be dispensed without a subsequent prescription.

How exactly would a 'subsequent' fill work in this situation? I can't speak for other computer systems, but with CVS, if you don't dispense the full amount, it effectively voids the rest.

 

[zelman]

How exactly would a 'subsequent' fill work in this situation? I can't speak for other computer systems, but with CVS, if you don't dispense the full amount, it effectively voids the rest.

Via software update.

 

[BidingMyTime]

I have never heard that it is illegal to dispense less than the amount being ordered on a CII. My understanding was "partial fill", refers to the patient getting a partial fill and then getting the rest of the fill at a later date. Dispensing less than the prescribed amount wouldn't be a "partial fill", it's the complete fill, because that is all the patient can get off of that prescription.

 

[ldiot]

I have never heard that it is illegal to dispense less than the amount being ordered on a CII. My understanding was "partial fill", refers to the patient getting a partial fill and then getting the rest of the fill at a later date. Dispensing less than the prescribed amount wouldn't be a "partial fill", it's the complete fill, because that is all the patient can get off of that prescription.

I know there were times when we only had like 28 Adderall XR in stock and the patient agreed to lose 2 pills vs waiting 3 days for the drug order. Even if it's for a pain med that we have in stock, I don't see any reason why a pharmacist shouldn't be able to fill for less than prescribed so long as the patient is okay with it. Only if the patient has an issue with it would I bother to call the MD and get the quantity changed. And my interpretation is the same; the term "partial fill" carries the implication that the patient will be able to pick up the remaining quantity at a later date, which isn't the case here.

I could be wrong with my interpretation of the current law, but regardless of what the DEA says I don't see any reason why a pharmacist should be required to call the MD in this situation unless the patient objects to it.

 

[CetiAlphaFive]

Walmart to restrict opioid prescriptions at its pharmacies

Texas is also going to force prescribers to check PMP before writing, and force us to check before filling.

TMB is going to limit MDs that aren't pain docs to 7 days as well.

 

[Slippers]

A far better solution would be to make sure pharmacies are adequately staffed, so pharmacists can call and talk to doctor's about the issue, and then use their professional judgement on filling a prescription .

YES! And can we please also change the setups of doctor's offices, so the pharmacy can actually contact the doctor within a reasonable period of time, and not just be sent to a voicemail that is answered "within 48 to 72 hours" or sent to a secretary that promises us the doctor will get back with us ASAP (as slow as possible... AKA never). Conveniently enough, the end of that 48 to 72 hours also often falls on a weekend day, which means no reply until Monday...maybe.

 

[txpharmguy]

Texas is also going to force prescribers to check PMP before writing, and force us to check before filling.

TMB is going to limit MDs that aren't pain docs to 7 days as well.

Yes. The mandatory check is supposed to go into effect Sept 1, 2019 for opiates, benzos, and for some reason barbiturates (I only have dogs on phenobarb at my pharmacy). It'll be a cluster fudge, no doubt.

 

[zelman]

Yes. The mandatory check is supposed to go into effect Sept 1, 2019 for opiates, benzos, and for some reason barbiturates (I only have dogs on phenobarb at my pharmacy). It'll be a cluster fudge, no doubt.

Butalbital might be their concern.