Ways to be 100% sure that a controlled substance prescription is legitimate?

[swatchgirl]

I have 3 different scenarios:

Patient A has been getting hydrocodone/apap 10-325mg #150, phentermine 37.5 mg #30, promethazine /codeine syrup 473 ml, and Soma 350mg #90 every single month, with a diagnosis of "chronic pain and emphysema" for the past 3+ years, verified by her pain-clinic doctor, who writes all four scripts for her every month. She doesn't seem to have any symptoms of emphysema as her lung capacity is quite good when she shouted, screamed and threatened us for an entire 8 minutes at the drive-thru when we questioned her prescription.

Is it okay to fill? I read many times on this forum that as long as a real doctor says a script is legit, then it must be legit, and therefore it's the pharmacist's duty to fill the script. Is this still correct?

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Patient B fills for percocet #30 once a month, is never early, uses insurance and does not pay cash, and has been consistently filling for the percocet for the last 2 years at just one pharmacy. The patient is an MD himself. Is it okay to fill?

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Patient C fills for multiple controlled substances every month, including hydrocodone/apap 10-325mg #120, tramadol 50mg #120, phentermine 37.5mg #30, Fentora 400mcg, #112, Xanax 2mg, #30, Soma 350mg #30, diazepam 5mg, #30, morphine 15mg, #60, fentanyl 25mcg patch, #10, Xanax 0.5mg, #60, promethazine/codeine syrup 120ml. She had been getting all these filled at 12 different pharmacies.

She has filled for butrans #4 four times in 2014 and 2015, but has stopped filling for it this year.

The phentermine, diazepam, clonazepam, Soma and tramadol have also been discontinued. So all she has been filling this year are the hydrocodone/apap, morphine, fentora, fentanyl patches, promethazine/codeine syrup and Xanax.

All except for the cough syrup and the Xanax, which are written by two different doctors, a well-known local pain clinic doctor writes the rest of her scripts. He has verified over the phone that the patient is legit, and the prescriptions are legit. Still okay to fill?

I suppose it's late to ask, because I have already filled her hydrocodone/apap #120. She did not present with any other prescriptions at the time, my tech accepted the script without asking me, he typed it up and filled her script, I did not have time to run a PDMP check on her and just verified the script in a hurry. I had a bad feeling about it but ignored it for the time being because I was too busy attending to other prescriptions. Half an hour after she had left the store with the medication, I finally got a minute to do a PDMP check on her, and discovered her long history... Should I report myself and this patient to the DEA? I am a new pharmacist by the way. I recognize my error and have learned my lesson. I will tell all my technicians to consult me first before they type up and fill for any controlled scripts from now on, especially those that are more than #60, no matter the time-constraint.
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Is a long history of filling at a single pharmacy enough evidence to justify that the patient should continue to receive the controlled substance for an apparently infinite amount of time, just because the prescribing doctor okays it (even if it is a pain clinic doctor)?

Lastly, what are some 100% fail-proof ways to tell that a controlled substance prescription is legit to fill? Other than that a patient does not use more than two pharmacies, does have insurance, the quantity is less than #60, and the script has been verified to be legitimate by her doctor?

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[zelman]

Lastly, what are some 100% fail-proof ways to tell that a controlled substance prescription is legit to fill?

There's only one. Become a prescriber an write it yourself. Everything else is educated guesswork.


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[swatchgirl]

There's only one. Become a prescriber an write it yourself. Everything else is educated guesswork.


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Thanks for the reply. I did fill for the #120 hydrocodone/apap in that third scenario in my original post. Even though I was able to catch it retrospectively because my gut was telling me that something was not right, but still what is done is done. Do you think I should report myself to the DEA? I did put a comment on her profile to alert other pharmacists.

 

[zelman]

No. A lot of patients are just victims of bad medicine. You need to figure out if she wants drugs or pain relief. If it's the former, talk to the doctor about how therapy has gone off the rails. If the latter, tell them their doctor is making things worse.


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[PikminOC]

In case b, the doc is not writing the meds for himself is he?

 

[PikminOC]

She doesn't seem to have any symptoms of emphysema as her lung capacity is quite good when she shouted, screamed and threatened us for an entire 8 minutes
...
Alrighty then.

 

[swatchgirl]

In case b, the doc is not writing the meds for himself is he?

No, the percocet scripts are written by a different doctor who has been writing for him for 2+ years... so I imagine they are on friendly terms?

 

[PikminOC]

Wow

 

[swatchgirl]

She doesn't seem to have any symptoms of emphysema as her lung capacity is quite good when she shouted, screamed and threatened us for an entire 8 minutes
...
Alrighty then.

Some woman working at the doctor's office (I can never get a hold of the doctor himself) told me the promethazine/codeine syrup is used to treat her emphysema... so apparently, it is working.

 

[Sine Cura]

Since you care about whether this **** makes sense instead of being a pharmacist who just cares about data entry and needs a DUR engine to alert them about egregious dosing errors or nonsense prescribing like promethazine w/ codeine prescribed month after month after month, you are unlikely to be sanctioned by a board of pharmacy or face the DEA's wrath.

 

[swatchgirl]

She doesn't seem to have any symptoms of emphysema as her lung capacity is quite good when she shouted, screamed and threatened us for an entire 8 minutes
...
Alrighty then.

The patient had these nasal cannula plugged into her nostrils when she pulled up in the drive-thru. I was confused because judging from the way she was hollering non-stop at my staff and me for 8 whole minutes, and all without a single cough or wheeze... she definitely did not need the nasal cannula. She was so very loud that we could all hear her across the glass window.

 

[swatchgirl]

Since you care about whether this **** makes sense instead of being a pharmacist who just cares about data entry and needs a DUR engine to alert them about egregious dosing errors or nonsense prescribing like promethazine w/ codeine prescribed month after month after month, you are unlikely to be sanctioned by a board of pharmacy or face the DEA's wrath.

After I turned her scripts down on Saturday, she came back in the drive-thru today. My pharmacist manager says the doctor wishes for us to fill the scripts, so he told me to fill the cough syrup for her (he didn't verify the script himself, of course). When I called around for advice, many of the pharmacists in my area also told me to fill for her, because the doctor said so.

I am a new hire, so I felt compelled to do as I was told. When I went to "counsel" the patient after she finally obtained her cough syrup, she just grinned at me in the drive-thru without a word to me, it almost made me sick. I had put an alert on her profile on Saturday so she would not be able to fill at the other pharmacies, but by doing so AND after being forced to fill the script by my pharmacist manager, now I am afraid she will just keep coming back to my pharmacy every month. If she comes in next time for more hydrocodone/apap and cough syrup, can I just tell her that I don't have the medication(s) in stock?

 

[ldiot]

My manager would have banned patient A from the store whether it was legit or not for abusing the staff but otherwise would probably fill it if it's a local doctor that they are familiar with.

Patient B is okay.

Patient C would be instantly denied based on that insane med list and the fact that they are using multiple pharmacies.

You should fill them based on your own judgement, not based on what your manager tells you to do. It's fine to ask for your manager's advice but I truly I hope that your manager will back up your decision whether or not he/she agrees. It's good when you are on the same page so that patients don't get conflicting info.

Also you don't need to have your technicians check with you before the script is typed if it's a regular patient/local doctor. Just check the database at verification and if you don't want to fill it page them back to drop off or call them. If it's out of state or a new patient/insane quantity then it's fine to have the techs check with you. They likely know the patients and doctors so let them use their best judgement in terms of which script to run by you (not what to fill but what to check with you first before typing it). Also, you don't need to report yourself to the DEA for filling a legitimate script, despite you regretting it, because you made no error and did nothing illegal.

 

[BidingMyTime]

Unfortunately, the DEA has no clear-cut rules, other than their expectation that pharmacists act as undercover police concerning controlled RX's.

Scenario A: No, the doctor being a legal doctor and verifying the prescription as legal, will not absolve you of guilt if the DEA decides the scripts are not legal. It would seem that combination of medications would be hard to justify medically. Seriously, phentermine for 2 years???? If she isn't actively losing weight, she shouldn't be on phentermine. Promethazine/codeine, oh no, nobody would abuse that drug---is she on any other drugs for emphysema, if not then there it's hard to justify promethzine/codeine. I would refuse to fill the promethazine/codeine & phentermine based on the info you gave, as there doesn't seem to be medical justification for those drugs (some office clerk saying she has emphysema is not medical justification.) And given that 2 of the prescriptions seem shady, I'd probably refuse the other 2 as well.

Scenario B: Sound legitimate, a well-controlled pain patient who is on a stable dose, and who is only seeing one doctor. (whether or not the patient themselves is a doctor has nothing to do with determining if the prescription they have received is for a legitimate medical condition.) It certainly wouldn't hurt to document their diagnosis code.

Scenario C: Sounds like a mess. I might fill an individual prescription for her, but I would contact the doctor to make sure he is aware of everything else she is on, and I would probably contact her other doctors as well. The multiple pharmacy thing is a red flag, but since something like 49 out of 50 states have controlled drug registries, it's not the problem it once was.

 

[VA Hopeful Dr]

A) Hydrocodone is a much better cough suppressant than codeine (assuming the patient can actually metabolize codeine worth a darn), a pain doctor should not be managing emphysema, and yelling at the pharmacy is a no-no. I would absolutely not want to fill those scripts.

B) Seems OK to me

C) Absolutely not, call the prescriber about the multiple pharmacies/other scripts, consider reporting to medical board as I can't think of a single reason why someone would need fentanyl patch, fentanyl sublingual, norco, and morphine. 10:1 someone is running a pill mill.

 

[297point1]

I always start by flagging the CII scripts that are written in crayon as "suspicious".

 

[Lnsean]

I'd hold a meeting with all the staff members that are currently present and I would present each script on my computer screen to the audience. We would then have a vote on it. Polls close at 8PM and the results are announced the next morning. These scripts would then get filled.

 

[wagrxm2000]

I do not fill drug cocktails, its that simple. Some of these docs think the solution is just make their patients zombies. Some sort of psychotherapy would have to be documented and called on every month for me to fill an adhd, muscle relaxer, benzo, and pain combination.

I do not fill if patients go to different mds for their meds unless both places are contacted and they are seeing the correct specialist. Their benzo and pain med shouldn't be with their family doctor while their psych meds are at another.

Absolutely no pharmacy hoppers.

All meds must be picked up not just the GOOD ones.

When it comes to a single pain med for years that is never changed, I have no problem.

Their are a ton of situations and you just have to stay consistent and no one will come after you.

 

[nextyearrx]

Just dispense all rxs!!

 

[genesis09]

If you read the information about promethazine with codeine, one of the contraindications is COPD. Yet, it is regularly written for people with COPD.

With patient A, there is no need to have both Norco and Promethazine with codeine. Promethazine with codeine should be changed to plain promethazine. Hydrocodone is a cough suppressant and some cough syrups use it. I have had physicians write for Norco as a cough suppressant for Medicare patients.

Patient B looks okay to fill.

Patient C is a mess. So many red flags are present. Patient should only be on one immediate release narcotic and one extended release. Again, no codeine cough syrup for people on narcotics.

 

[HelpfulPharmer1]

Should I report myself and this patient to the DEA?
No. You don't need unwanted inspection to your store. Every inspection means they will dig out more errors and mistakes and fine you.

I am a new pharmacist by the way.
Congratulations! Please update your status (Still listed as student).

I will tell all my technicians to consult me first before they type up and fill for any controlled scripts from now on, especially those that are more than #60, no matter the time-constraint.
Agree. Seen this rule at many of over 120 stores I have been through in the past 10 years.
________________________________________________________________________

Is a long history of filling at a single pharmacy enough evidence to justify that the patient should continue to receive the controlled substance for an apparently infinite amount of time, just because the prescribing doctor okays it (even if it is a pain clinic doctor)?
Depends on the level of pain med. My guess is we still get under investigation for serving street drug dealers if doctors were shady like the one in Southern Florida as in this documentary video titled "Oxycontin Express",

Lastly, what are some 100% fail-proof ways to tell that a controlled substance prescription is legit to fill? Other than that a patient does not use more than two pharmacies, does have insurance, the quantity is less than #60, and the script has been verified to be legitimate by her doctor?[/QUOTE]

Walgreens came up with a good checklist for pharmacist to use called Good Faith Dispensing. Walgreens tried minimize the chance of getting fined again after Walgreens got fined by FDA in Florida. You can try to incorporate some of the check list into your practice and perhaps doing so will minimize the chance of you being dragged to court. Also to please remember to do as much as you possibly can because we may get blamed for certain percent of the case. The more we do, we less percent of blame we get in the court of law.


Link is here and also uploaded here:
http://ftpcontent.worldnow.com/wthr/PDF/WalgreensGFDdocuments.pdf
http://nationalpainreport.com/walgreens-secret-checklist-pain-meds-8821775.html


Good luck and let's share how we practice...As you see from around the country and from reading many court cases, the pharmacist judgment is very individualized. A rule that worked for a manager may not work for another team. I have worked with many different Pharmacy Managers and District Pharmacy Managers who have their own ways of doing C2.
At the end of the court case, you are the one that gets blamed.

Pharmacy Managers come and gone, have seen over 10 gone.
District Pharmacy Managers come and gone, have seen over 6 gone.

When you go to court, often, you go alone, not with your Pharmacy Managers. You may even see a different District Pharmacy Manager at court case simply because the old ex-District Pharmacy Manager is now gone. The current District Pharmacy Manager must attend court case.

So, pick your word wisely and spread the news of bad court case to your bosses. I am planning to mass fax pharmacist conviction to scare dummy Pharmacy Managers from being too lax and bully their co-workers to be lax as well.

When I was Pharmacy Manager, I respected the decision of other pharmacists and never even suggest anything to them. I learned that from my District Pharmacy Manager. Hope you will meet some like that, too.

 

[swatchgirl]

Updated status. Thanks for the GFD list and documentary vid!

 

[lord999]

Under most states (OR and WA are exceptions), management may not compel a staff pharmacist to fill a prescription over professional objection, that's your license. OR and WY can force the matter, but you note those objections in writing (the compel to fill relates to the old law before Plan B went OTC). If the pharmacy manager thinks its a bright idea, then let them fill it. I had no problem turning down suspicious cases or cases that I didn't feel comfortable with. Chewed out by a pharmacy manager and an RxS in one case, but I outlasted both of them (the RxS was actually fired and the Board went after him for getting into Walgreens into regulatory trouble with DEA). It's one of the headaches of working retail. I do think though that with the state PDMP's in place, DEA is taking a bigger ban hammer approach to both pharmacists and prescribers over excessive or bad prescribing.

Scenario B with very, very few exceptions, try not to bring someone's professional status into your dispensing. I'd suggest you treat them like you would anyone else except for the aforementioned 'self-prescribing.' Aside from that, looks legit if it's straightforward like that.

Scenario A, welcome to Social Security Disability and SWC. That sort of thing turns pharmacists Republican (I had the satisfaction of seeing my uberliberal colleagues get thoroughly disabused of their ideals). I would react to Scenario A in the sense of refusing to fill until said MD calls you. If the MD gives an attitude about it, refuse to dispense and strike two problems off your list. If the MD does explain properly even if you don't agree necessarily, you can note the issues on the script and fill. If you see multiple patients from this MD where this is a problem, drop a note to the PDMP to follow up on it.

 

[Rukn]

Who cares

Every case is different

Use your judgement and do your best to ensure that you are dispensing a legit script and forget about it

 

[Rukn]

just saw a pharmacist fill a script for #240 oxy 30 mg

I would've never fill something that ridiculous ...

but **** gets filled

 

[Lnsean]

Should I report myself and this patient to the DEA?
No. You don't need unwanted inspection to your store. Every inspection means they will dig out more errors and mistakes and fine you.

I am a new pharmacist by the way.
Congratulations! Please update your status (Still listed as student).

I will tell all my technicians to consult me first before they type up and fill for any controlled scripts from now on, especially those that are more than #60, no matter the time-constraint.
Agree. Seen this rule at many of over 120 stores I have been through in the past 10 years.
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.

That walgreens checklist is bull****...aint nobody got timmme for that. Sorry..too lazy to lick meme

 

[Rukn]

That walgreens checklist is bull****...aint nobody got timmme for that. Sorry..too lazy to lick meme

I heard you don't even get in trouble if you don't do the GFD

 

[rx201605]

Does Oxycontin is on the Walgreens' GFD checklist? I thought only Oxycodone IR form is considered , but could not get a straight answer, please help !

 

[imcallingcorp]

1st. stop thinkibg that the DEA gives a sh$t. about you or the scripts you fill. unless your store is a pill mill. meaning a true shady pharmacy. stop thinking the DEA this or the DEA that

2nd. accept the fact that you will not "catch" all the shady patients. and you know what. who cares.

3rd. if you really dont feal confortable. take a stand and say im bot comfortable filling your rxs. period. its not easy but its sometimes necessary

ur obviously a rookie to this. my advice is implement in your own way some of the advice given and sleep better and make your life easier

 

[wagrxm2000]

1st. stop thinkibg that the DEA gives a sh$t. about you or the scripts you fill. unless your store is a pill mill. meaning a true shady pharmacy. stop thinking the DEA this or the DEA that

2nd. accept the fact that you will not "catch" all the shady patients. and you know what. who cares.

3rd. if you really dont feal confortable. take a stand and say im bot comfortable filling your rxs. period. its not easy but its sometimes necessary

ur obviously a rookie to this. my advice is implement in your own way some of the advice given and sleep better and make your life easier

And they say I'm the inconsiderate one