When is it NOT okay to fill for the monthly ADHD prescriptions?

[PikminOC]

Possibly mandating that before any controlled substance is rx'd the doctor has to check PDMP (I believe state of new york does this, someone correct me if I'm wrong). Just caught a guy yesterday who's filled 14 months of xanax 2mg this year alone. Was using different pharmacies but all from the same doctor. I called the doctor and the nurse says "this is why i like xyz pharmacy because you guys are so good at catching this". I wanted to be like, uh you can check this database too you know. Few months ago had an rx faxed to me for valium. in the special comments it says "please make sure patient is not getting from multiple doctors". Check PDMP, what do you know, pt is getting from multiple doctors.

As far as improper prescribing goes, I think harsher punishments and more frequent monitoring of physicians prescribing would maybe curb overprescribing. I've read a lot of the disciplinary records for physicians here in Florida and a lot of the time they just get a fine and a mandate to take some CE hours regarding ethics and proper prescribing. It also takes on average I believe around a year and a half for the board to actually do something from when they receive a complaint. You can put a lot of drugs in the community in a year and a half.

I check it here.
And thank you for everything you wrote. makes sense.

---

Members don't see this ad.

 

[Wickett]

"Innocent until proven guilty" only works when you have the power to get proof. You do not. You cannot suopena medical records. You cannot compel a urine screen. You can't interview a prescriber face to face. You can't even prove that the name on the prescription is a real person.

It should be more like, "Innocent until one red flag. Probably trouble at two red flags. Too much trouble at three."

By innocent until proven guilty, I mean innocent until you see a red flag/flags. My post says several times not to fill if you find a red flag.

 

[PikminOC]

Pharmacists call me. I talk to them about any questions they have

 

[FarmD711]

What is the rationale for all of these patients on 90-120mg adderall daily? Max recommended dose is 20-30 mg. I have psych docs who don't write any adderall rxs < 90 mg daily.


Sent from my iPhone using SDN mobile

 

[Dr Wario]

Something psyche doctors really need to understand is that almost all of them can come up with some justification for their prescribing habits, however, the DEA looks simply at a pharmacy's ratios of controls vs noncontrols when they decide to raid them. As a pharmacist, my life is much easier if I don't have to explain my justifications to the DEA at all, so if you are prescribing at too bad of a ratio I will deny your scripts regardless if you can justify it or not.

 

[doublehh03]

Something psyche doctors really need to understand is that almost all of them can come up with some justification for their prescribing habits, however, the DEA looks simply at a pharmacy's ratios of controls vs noncontrols when they decide to raid them. As a pharmacist, my life is much easier if I don't have to explain my justifications to the DEA at all, so if you are prescribing at too bad of a ratio I will deny your scripts regardless if you can justify it or not.

Pretty much. DEA also looks at your control ordering habits in comparison with pharmacies within your area.

 

[PikminOC]

If you see a flag, why not call the doc?

 

[PikminOC]

What is the rationale for all of these patients on 90-120mg adderall daily? Max recommended dose is 20-30 mg. I have psych docs who don't write any adderall rxs < 90 mg daily.


Sent from my iPhone using SDN mobile

There are medical conditions that allow for for than 30 according to product insert

 

[radio frequency]

If you see a flag, why not call the doc?

I do, but it's a mixed bag. Some are helpful, but some prescribers don't want to justify their clinical choices when a question comes up. Some don't return phone calls; some won't even engage in a conversation and instead command "just fill it!" I had a prescriber bark that at me for a patient with a very high dose of phentermine for weight loss (beyond prescribing guidelines). I was surprised at how rude they were about something I still can't find any clinical justification for.

The other issue is time. Calling on issues eats up a lot of time and if you aren't getting x number of scripts verified per hour, your manager starts mouth breathing down your neck.

 

[PikminOC]

I try to be nice. I even sent one an article before

 

[Drugsarefun2350]

I try to be nice. I even sent one an article before

It's unfortunate more prescribes aren't like you, but in all honesty when we call we get an MA that is oblivious to why we have concerns anyway and it's not worth the time or headache trying to get ahold of the actual doctor while these patients are in ur waiting room expecting a 15min rx

Sent from my SAMSUNG-SM-G870A using Tapatalk

 

[zelman]

It's unfortunate more prescribes aren't like you, but in all honesty when we call we get an MA that is oblivious to why we have concerns anyway and it's not worth the time or headache trying to get ahold of the actual doctor while these patients are in ur waiting room expecting a 15min rx

Sent from my SAMSUNG-SM-G870A using Tapatalk

MA's can be the worst. I know we've all called a thousand MA's and told them "this prescription doesn't make sense. The quantity to dispense is not enough to complete the taper directions." Or some other such obvious mistake only to be put on hold while she checks the EMR that printed the RX and read it to us as printed after waiting 5 minutes. If we could actually reach prescribers, I think everyone would practice better. But we can't.

 

[FarmD711]

There are medical conditions that allow for for than 30 according to product insert

Ok 60 mg for narcolepsy. Even given that, 90-150mg IR daily? And there is no way this psych doctor is treating all of these patients for narcolepsy.


Sent from my iPhone using SDN mobile

 

[PikminOC]

What are the doses for adult adhd? Look beyond the product insert

 

[beautifulrobot]

What are the doses for adult adhd? Look beyond the product insert

Even for off-label use for adult ADHD, Adderall IR 90-150 mg / daily seems pretty high. Once you start going up into those higher doses it's hard to argue the risks (psychosis, impairments in impulse-control, cardiovascular risks) outweigh the benefits. Are these doses that you see often in your clinical practice?

 

[FarmD711]

What are the doses for adult adhd? Look beyond the product insert

Certainly not >100 mg for every patient seen.


Sent from my iPhone using SDN mobile

 

[Apotheker2015]

I do, but it's a mixed bag. Some are helpful, but some prescribers don't want to justify their clinical choices when a question comes up. Some don't return phone calls; some won't even engage in a conversation and instead command "just fill it!" I had a prescriber bark that at me for a patient with a very high dose of phentermine for weight loss (beyond prescribing guidelines). I was surprised at how rude they were about something I still can't find any clinical justification for.

The other issue is time. Calling on issues eats up a lot of time and if you aren't getting x number of scripts verified per hour, your manager starts mouth breathing down your neck.

Well, did you fill the phentermine prescription after the prescriber barked at you?

 

[ldiot]

Kind of unrelated but when doctors change a CII from TID to QID and the patient has pills left from the TID RX, they should make the patient aware that they cannot fill it until they are out of the pills they already have. Just tell them to take them QID and document a "Do not fill before" date based on the new directions and how many pills they should have at the time of the dose change.

This drives me nuts when people picked up 120 Norco a week ago and demand their new script be filled because of a dose change and it happens pretty often.

 

[RxPreceptor]

My norco 5-325 (#120) from Dr. x that I filled yesterday is for my back. The norco 5-325 (#90) from Dr. y that I'm filling today is for my leg. You can't deny it I need this for my leg, they are for 2 different things!!! Also I need a refill on my Tramadol (#240) while I'm here.

Am I the only person that this happens to? Don't the physicians take a med list and check the state reporting system before prescribing narcotics? How can they not know that their patient has a back problem and takes narcotics? In these cases I don't even call.

It happens...1 or the other, not both unless it's a scheduled + a pro re nata. What's more troubling was a physician who was okay with Rx-ing Oxycodone/APAP to a woman who was literally off of buprenorphine-naloxone for just over 1 month after extensively titrating down. To be fair, it was only a few day supply but still, there are plenty of other options for analgesia (ketorolac would seem like a good alternative).

 

[ldiot]

It happens...1 or the other, not both unless it's a scheduled + a pro re nata. What's more troubling was a physician who was okay with Rx-ing Oxycodone/APAP to a woman who was literally off of buprenorphine-naloxone for just over 1 month after extensively titrating down. To be fair, it was only a few day supply but still, there are plenty of other options for analgesia (ketorolac would seem like a good alternative).

Some lady who was 30 years clean was prescribed oxys and ended up taking 90 pills in 3 days. The doctor realized what happened and then wrote a script for a percocet taper. I honestly felt bad for the lady but we didn't fill the taper; got the doctor to write something else to help.

 

[ldiot]

It happens...1 or the other, not both unless it's a scheduled + a pro re nata. What's more troubling was a physician who was okay with Rx-ing Oxycodone/APAP to a woman who was literally off of buprenorphine-naloxone for just over 1 month after extensively titrating down. To be fair, it was only a few day supply but still, there are plenty of other options for analgesia (ketorolac would seem like a good alternative).

I'm not sure what's more sad, the doctor writing it or that the woman was trying to fill it. I'd try to talk her out of it, where I live I've only seen maybe 1 or 2 people actually go off of buprenorphine.

 

[PikminOC]

I'm talking about 30 bid adderall. Any references for this for adult adhd?

And what was the high doses of phentermine? I use it for adhd.

 

[radio frequency]

Well, did you fill the phentermine prescription after the prescriber barked at you?

No. My PIC did, apparently not wanting to upset the doctor.

 

[radio frequency]

I'm talking about 30 bid adderall. Any references for this for adult adhd?

And what was the high doses of phentermine? I use it for adhd.

I can't remember the dose but it was either 37.5 mg TID or some other amount much higher than normal.

Any studies on phentermine for ADHD? That's news to me. Why do you choose that particular medication over other available ADHD meds?

 

[Apotheker2015]

No. My PIC did, apparently not wanting to upset the doctor.

I see. To each their own, I guess. I would not verify that under my license. Plain and simple.

 

[RxPreceptor]

Lexicomp online:
"Dosing: Adult
Note: Use lowest effective individualized dose; administer first dose as soon as awake.

ADHD: Oral:

Adderall: Initial: 5 mg once or twice daily; increase daily dose in 5 mg increments at weekly intervals until optimal response is obtained; usual maximum dose: 40 mg daily given in 1 to 3 divided doses per day. Use intervals of 4 to 6 hours between additional doses.

Adderall XR: Initial: 20 mg once daily in the morning; higher doses (up to 60 mg once daily) have been evaluated; however, there is not adequate evidence that higher doses afforded additional benefit. The Canadian labeling recommends a maximum dose of 30 mg/day."

Package insert sources from 2012 (IR) & 2015 (XR). Why 90+mg/day just seems like overkill. Same doses in Clinical pharmacology; I always cross reference databases just to be sure since some do include off-label doses/indications while others omit; seems to be drug specific. A problem with Epocrates I notices seems to be that they don't often include a MAX dose in the drug monographs. I'm rather in favor of some of the Canadian recommendations/labeling I have read about; while they certainly do bash some meds, they take into consideration the kinetics/pt parameters

 

[PikminOC]

Any other references? As a psychiatrist i see patients who are on above normal values of many meds, not just stims. I have to look at the person, not just the insert

 

[PikminOC]

Pt was on phentermine already, but we have been trying to change it to vyvanse or adderall

 

[Dr Wario]

Any other references? As a psychiatrist i see patients who are on above normal values of many meds, not just stims. I have to look at the person, not just the insert

The problem with this is that this justification goes around in a circle. You say you need to look at the patient not just the insert to determine dosing, but them the DEA comes to the pharmacy and says what the hell is doing on here, why are you letting all of these prescribers dose over the recommended maximums? It all just goes round and around until the pharmacist simply has to say they don't care what the doctor's justification is, they will not dispense over guidelines.

 

[FarmD711]

Any other references? As a psychiatrist i see patients who are on above normal values of many meds, not just stims. I have to look at the person, not just the insert

I can buy this for prescribing slightly above the limit recommended by the insert. Having more than 50% of patients at 3-4 times the limit however...




Sent from my iPhone using SDN mobile

 

[PikminOC]

More like 10 percent of my patients at 2 times the limit

 

[PikminOC]

Do you know how many patients the other doctor has

 

[PikminOC]

Not in Florida, but I've also seen some messed up prescribing locally. I feel like it's often from doctors or NPs who just don't have the backbone to tell pushy patients "no" or "that's not a good idea." Weirdly, I hardly ever see "bad" prescribing of controls from PAs.

With prodding over many months, I finally got an NP to change a patient's prescriptions from including scheduled tramadol and hydrocodone/APAP and "PRN" oxycodone (in quotations because the patient clearly took it four times daily, not four times daily as needed) to just tramadol and hydrocodone/APAP (possibly still questionable but maybe less so now?). The NP also prescribed this patient guaifenesin/codeine. As though the oxycodone and the hydrocodone had no antitussive effects....

Pa work under physicians. So it's the physician who sets the bar

 

[radio frequency]

Pa work under physicians. So it's the physician who sets the bar

I also think being held responsible to a physician whose license you work under leads to more careful prescribing as you don't want to let that person down. There's strong social pressure to not mess up.

 

[PikminOC]

There's also scope of practice. Psychiatrists get patients more complex than pcp

 

[PikminOC]

What if a person is going out of the country so the doc orders twice as much. How do you handle? Like Japan for 2 months

 

[zelman]

What if a person is going out of the country so the doc orders twice as much. How do you handle? Like Japan for 2 months

If they "double the dose" to really just double the duration, that's insurance fraud. If they tell me that, I refuse to participate. If their insurance won't pay for a 60 day RX or two 30 day RX's, then they should have gotten different insurance. Now they'll have to pay the (cash) price.

edit: BTW: if you have a patient taking stimulants to Japan, make sure they contact the consulate to get approval. They are really picky about what prescription drugs come in.

 

[drcrispmd]

In TN, prescribers are required to check the database before prescribing anything controls longer than 7 days. We are also required to do controlled substance prescribing CME every 2 years. In my clinic, we drug test everyone before starting any controlled substance and do random uds and random pill counts. They sign a controlled substance contact. If they are getting controls at another physician, we will not prescribe controls. I do not do benzos for anxiety. If the patient demands them, I explain that is not the best treatment and refer them to our counseling center and if they believe they need benzos, they get set up with the psychiatrist. Info not prescribe more than #90 of pain medicine. Only 1 patient on oxycodone, one on long acting morphine (cancer patient). I try to use other methods of pain relief (love the compounding pharmacy). We also watch the county arrest records and if any of our patients have been arrested for drug or alcohol related charge, they are tapered off. If they admit in office to sharing or trying someone else's meds, they are tapered off. Only 1 violation of the pain contract and that is it. C-2 come in every month for an office visit. Other controls, every 3 months. They have to be seen in the office to get a refill. I have worked hard these last 2 years to get the clinic like this. I have successfully tapered people off their Xanax and doing well on buspar or other med and counseling. I wish all offices were as strict/careful. There have been older doc who retire in the area and tell patients come to me and they are on the Xanax, norco 10 and soma. They are told when they make their appointment I would likely not continue. I do not prescribe soma, ever. I typically do not start anyone on pain medication unless it is one of my elderly that cannot take NSAIDs due to kidneys, then it is tramadol 1 a day as needed and Tylenol. I think pharmacist and physicians needs to work together on this. I use lexicomp for dosages and do not go over recommended max. I have 4 kids on adhd medicine and 3 adults (that I have weaned to a lower dose and still doing great). I guess I should add that I am family med.


Sent from my iPhone using SDN mobile app

 

[drcrispmd]

If they "double the dose" to really just double the duration, that's insurance fraud. If they tell me that, I refuse to participate. If their insurance won't pay for a 60 day RX or two 30 day RX's, then they should have gotten different insurance. Now they'll have to pay the (cash) price.

edit: BTW: if you have a patient taking stimulants to Japan, make sure they contact the consulate to get approval. They are really picky about what prescription drugs come in.

I have had several patients as me to prescribe 2 a day and them only taking 1 so their copay will last 2 months and I refuse.


Sent from my iPhone using SDN mobile app

 

[Apotheker2015]

What if a person is going out of the country so the doc orders twice as much. How do you handle? Like Japan for 2 months

This happened a few years ago. It's quite what you're asking but somewhat similar. The doctor did not prescribe more. Instead, the patient had a total of six prescriptions, each for a 30 day supply of Adderall. She was going to study abroad for 6 months and asked how she could go about it. The pharmacist-in-charge had her put a credit card on file and had her authorize someone to pick up a 30 day supply at a time every month; then that person would mail it to her abroad and her credit card was charged at every pickup.

 

[PikminOC]

Interesting. My patients who do the 2 month pay cash. It's extremely rare

 

[PikminOC]

I'd be worried about charge back in the stored card situation with no signature

 

[zelman]

I'd be worried about charge back in the stored card situation with no signature

CVS doesn't even get a signature for prescription charges under $51.

 

[RxPreceptor]

CVS doesn't even get a signature for prescription charges under $51.

My old store would have a composition book to pick up C2s or suspicious controls requiring documentation of driver's license #, state, DOB, & relation to patient.

 

[ldiot]

What if a person is going out of the country so the doc orders twice as much. How do you handle? Like Japan for 2 months

Usually when people say they are going on vacation it is in the country so I tell them to take the script to a pharmacy where they are going on vacation.

If they are going out of the country, as you described, the doctor will be contacted and the approval will have to be documented. From here there are really two options:

1) They pay cash for the second script
2) Pharmacy has to call insurance to see if the plan offers a vacation override

I would absolutely not fill for double the dose as a way around this. Calling for vacation overrides is also a pain.

Having a family member pick up the med, pay for it, and mail it might also be an option but I'm not sure what kind of regulations there would be on mailing CIIs out of the country...

 

[zelman]

My old store would have a composition book to pick up C2s or suspicious controls requiring documentation of driver's license #, state, DOB, & relation to patient.

Not relevant to the quoted text regarding credit card chargebacks.

 

[Apotheker2015]

I'd be worried about charge back in the stored card situation with no signature

I guess I do not know the rationale that went behind the manager's call but that's what he did. I can't imagine that having someone sign a form authorizing a pharmacy to charge a credit card once a month for 6 months for a pre-agreed amount is something that would cause a charge back. We do that every day with bills, car payments, etc.

 

[ldiot]

I guess I do not know the rationale that went behind the manager's call but that's what he did. I can't imagine that having someone sign a form authorizing a pharmacy to charge a credit card once a month for 6 months for a pre-agreed amount is something that would cause a charge back. We do that every day with bills, car payments, etc.

Would be easier to just have the friend/family member pay for it themselves and the patient can pay them back or give them money ahead of time. That being said I wouldn't really be worrying about a chargeback to begin with; especially if the copay is low enough that the register doesn't require them to sign.

 

[Apotheker2015]

Would be easier to just have the friend/family member pay for it themselves and the patient can pay them back or give them money ahead of time. That being said I wouldn't really be worrying about a chargeback to begin with; especially if the copay is low enough that the register doesn't require them to sign.

LOL, like I said.... I am relating what the PIC did. I never said that's what everyone should do when this situation arises.

 

[Deja]

No. My PIC did, apparently not wanting to upset the doctor.

I don't get it, the doctor didn't have any problem at upsetting you, why worry about his fragile feelings? esp if he barked at you, pharmacist should stand up for what they believe in, if you are not comfortable with a prescription then don't fill it