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

Heist

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      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...
      Would you at least call the doctor to discuss? We are on the same team...you would or would not call the doc? I'm confused. Pt going to Japan for 2 months. If it was zoloft, there would be no issue
       

      Dr Wario

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        Would you at least call the doctor to discuss? We are on the same team...you would or would not call the doc? I'm confused. Pt going to Japan for 2 months. If it was zoloft, there would be no issue

        This would be very situational depending on the patient. In my area 95% are on some form of govt assistance so this would be an automatic no, but in a more well to do area with a problem free patient I would consider.
         
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        radio frequency

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          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
          I didn't fill it. I told the prescriber and my PIC I wasn't going to fill it. My PIC decided he wanted to check it and fill it.
           

          zelman

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            Do most stores keep credit card numbers and prescriptions? I tell patients to hold on to their prescription and bring it in when needed
            Most pharmacies hold prescriptions if a patient requests it. Many won't hold on to CII's since a missing RX can't be replaced via phone, but otherwise it's common practice. That way patients can drop them off after their annual physical and not worry about the exact day their old prescriptions expire.

            Credit cards are more variable. CVS won't keep them (per policy, but practice varies) and Walgreens will. Most independents will, but some still have internal "charge accounts" and send patients a bill every month.
             

            ldiot

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              Do most stores keep credit card numbers and prescriptions? I tell patients to hold on to their prescription and bring it in when needed

              When I type a script into their file and put it on hold, there isn't a way for me to schedule it to fill on a certain day (at least at my pharmacy). So the patient has to call us on the day it's due and tell us to fill it. 50% of the time they don't listen to us and just show up. It's annoying because they usually get mad and we have to prioritize the script since they are waiting.

              Maybe some stores keep a notebook or something to keep track of this stuff. I prefer that they bring it in on the day it's due but I if they want to leave the script at the pharmacy I tell them to call us when it is due to be filled.

              Most sores don't hold cc info but I know Walmart pharmacy will do it for quicker checkout.
               
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              Apotheker2015

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                Most pharmacies hold prescriptions if a patient requests it. Many won't hold on to CII's since a missing RX can't be replaced via phone, but otherwise it's common practice. That way patients can drop them off after their annual physical and not worry about the exact day their old prescriptions expire.

                Credit cards are more variable. CVS won't keep them (per policy, but practice varies) and Walgreens will. Most independents will, but some still have internal "charge accounts" and send patients a bill every month.

                As you said, it varies at CVS. I do know that stores that offer delivery keep credit cards on file.
                 

                ldiot

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                  Would you at least call the doctor to discuss? We are on the same team...you would or would not call the doc? I'm confused. Pt going to Japan for 2 months. If it was zoloft, there would be no issue

                  My post was indicating that I would call the doctor and document their approval on the prescription. I would call the doctor and make sure they are okay with me dispensing the extra medication if it is any sort of controlled substance.
                   

                  Ackj

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                    When I type a script into their file and put it on hold, there isn't a way for me to schedule it to fill on a certain day (at least at my pharmacy). So the patient has to call us on the day it's due and tell us to fill it. 50% of the time they don't listen to us and just show up. It's annoying because they usually get mad and we have to prioritize the script since they are waiting.

                    Maybe some stores keep a notebook or something to keep track of this stuff. I prefer that they bring it in on the day it's due but I if they want to leave the script at the pharmacy I tell them to call us when it is due to be filled.
                    We keep one of those "page a day" tear off calendars and put everything in there. In the morning you tear off the page, laugh at Snoopy, and process the rx that were on hold.
                     
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                    zelman

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                      As you said, it varies at CVS. I do know that stores that offer delivery keep credit cards on file.
                      ...which is a direct violation of policy. The policy says prior to each delivery the store must contact the patient and get the card info, then use it and destroy it. But that seems unreasonable to most humans with the power of logical thought, so I'd say it happens rarely to never.
                       
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                      BidingMyTime

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                        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).

                        ketorolac is a terrible choice for most people.

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

                        I agree, I have never heard of using phentermine for ADHD, while I could see that it might be theoretically effective for ADHD, the risk/side-effects would seem to outweigh any usefullness.

                        Would you at least call the doctor to discuss? We are on the same team...you would or would not call the doc? I'm confused. Pt going to Japan for 2 months. If it was zoloft, there would be no issue

                        FYI, this would be an issue in some states. In IL, it is illegal to dispense over 30 days of a CII, so it would be pointless to call the doctor (other than to let her/him know that it's illegal to fill a 60 day supply. )
                         

                        Heist

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                          ketorolac is a terrible choice for most people.



                          I agree, I have never heard of using phentermine for ADHD, while I could see that it might be theoretically effective for ADHD, the risk/side-effects would seem to outweigh any usefullness.



                          FYI, this would be an issue in some states. In IL, it is illegal to dispense over 30 days of a CII, so it would be pointless to call the doctor (other than to let her/him know that it's illegal to fill a 60 day supply. )
                          How are the risks and side effects of phentermine different from Adderall?
                           

                          6GodPharm

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                            Was counseling a patient on Belviq the other day and asked her if she has tried other medications before. She said "Yeah my Dr also has me on Vyvanse for weight loss". Not filling that one anymore.
                             
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                            FarmD711

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                              it would be nice. Son of us straddle two states like Wisconsin where two months is legal

                              It would be nice and I have no problem with pharmacists reaching out to inform.

                              At the same time, it is not a pharmacists responsibility to make you aware of the laws around prescribing in states where you practice.


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                              Apotheker2015

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                                If pph is post post partum hemorrhage, why would that be somethingI'd be concerned about in most of my patients? Any effects that are more generalized?

                                Bidingmytime meant Primary Pulmonary Hypertension, I am pretty sure. It's also known for Valvular Heart Disease. Phentermine is a dirty drug, plain and simple. It gets in everywhere. If you read the mechanism of action you will see that it does not do 1 thing; instead, it gets in everywhere and it happens to cause appetite suppression like any other sympathomimetic would. So if the desired effect is ADHD management, there are much cleaner drugs that can achieve that. Because it is a dirty drug, it is only indicated for the short term treatment of exogenous obesity. So there you have it. ADHD is a chronic condition. You manage it. It never quite goes away. So you would not want to treat it with something that is not indicated for long term use. That's what Bidingmytime meant to say, in a nutshell. Just a hunch...
                                 
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                                Digsbe

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                                  Would you at least call the doctor to discuss? We are on the same team...you would or would not call the doc? I'm confused. Pt going to Japan for 2 months. If it was zoloft, there would be no issue

                                  I've been to Japan and it's illegal to bring any stimulant drugs into the country. It doesn't matter if it is prescribed and dispensed in the US legally or not. Adderall and other stimulants are illegal in many countries (particularly Asian countries) and not approved to treat psych conditions. This may be a tangent point, but any patient going international absolutely needs to check the the country's laws they are visiting to make sure the meds they want to bring in are legal, in the right quantity, and bring any necessary documentation as well. If a patient needed extra supply for vacation I'd have the patient contact their physician and explain their situation directly to their prescriber so everyone is on the same page and then work with them in ways that are legal and ethical to cover them on their trip. I always tell patients to check the country's customs laws or embassy website for information regarding bringing medications there first.
                                   
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                                  Apotheker2015

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                                    I've been to Japan and it's illegal to bring any stimulant drugs into the country. It doesn't matter if it is prescribed and dispensed in the US legally or not. Adderall and other stimulants are illegal in many countries (particularly Asian countries) and not approved to treat psych conditions. This may be a tangent point, but any patient going international absolutely needs to check the the country's laws they are visiting to make sure the meds they want to bring in are legal, in the right quantity, and bring any necessary documentation as well. If a patient needed extra supply for vacation I'd have the patient contact their physician and explain their situation directly to their prescriber so everyone is on the same page and then work with them in ways that are legal and ethical to cover them on their trip. I always tell patients to check the country's customs laws or embassy website for information regarding bringing medications there first.

                                    With all due respect, it's nice that you tell patients to check the country's customs laws, etc, but that really isn't part of what we do. If a patient is going to Japan and needs a two month supply of a C-II, then you check your state vs. federal law and you either fill it or not because whichever the stricter one of the two laws, either allows it or not. That's all you are concerned with.
                                     

                                    beautifulrobot

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                                      With all due respect, it's nice that you tell patients to check the country's customs laws, etc, but that really isn't part of what we do. If a patient is going to Japan and needs a two month supply of a C-II, then you check your state vs. federal law and you either fill it or not because whichever the stricter one of the two laws, either allows it or not. That's all you are concerned with.

                                      Shouldn't you also be concerned with the well-being of your patient, and particularly in this case, their ability to adhere to drug therapy? Counseling patients that they should check the other country's customs laws seems like a reasonable thing to do. Not saying you shouldn't fill the two month supply of a C-II until you confirm the other country will allow the patient to take it in with them, but giving the patient a heads up that they might have problems bringing their medication into another country seems like it is well within our duties as a pharmacist. Most patients would probably appreciate it, although I can also imagine some patients will then demand you check the country's customs laws for them because they don't know how to... So there is that...
                                       

                                      Apotheker2015

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                                        Shouldn't you also be concerned with the well-being of your patient, and particularly in this case, their ability to adhere to drug therapy? Counseling patients that they should check the other country's customs laws seems like a reasonable thing to do. Not saying you shouldn't fill the two month supply of a C-II until you confirm the other country will allow the patient to take it in with them, but giving the patient a heads up that they might have problems bringing their medication into another country seems like it is well within our duties as a pharmacist. Most patients would probably appreciate it, although I can also imagine some patients will then demand you check the country's customs laws for them because they don't know how to... So there is that...

                                        @giga

                                        We already have a lot to do. Sure, bringing that up would be a nice thing to do and yes, I probably would if I get a sense that the patient has never been abroad and is clueless. However, it is not part of our responsibilities as pharmacists. Our license as pharmacists does not encompass that. It is the responsibility of the patient to check all of that as travelers. Here's how you know if something is a responsibility outlined by your pharmacist license. Do you want the Board of pharmacy to be able to get back at you requesting a hearing because Ms Jones was unable to adhere to her C-II therapy and her supply was confiscated by customs? Should patients be able to turn around and blame it on the pharmacist? No, the answer to that is no. It is the responsibility of the patient.

                                        I would likely think of immunizations before mentioning customs. But then again, that is also their responsibility. It is their responsibility to check the immunizations they need before they travel to any country. They come to us and tell us which ones they need. Our job is to evaluate the appropriateness of the requested immunizations and then administer them. That's that.
                                         

                                        Digsbe

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                                          With all due respect, it's nice that you tell patients to check the country's customs laws, etc, but that really isn't part of what we do. If a patient is going to Japan and needs a two month supply of a C-II, then you check your state vs. federal law and you either fill it or not because whichever the stricter one of the two laws, either allows it or not. That's all you are concerned with.

                                          I'm not going to look up customs info for them, but if they are asking me for an extra fill for vacation I'd drop the sentence that they should also check with the country they are visiting regarding customs and bringing in medicine. Mentioning it is just a 10 second sentence. If it's legal in the US to fill it and ethical to do so then I'd have no problem with it.
                                           

                                          Apotheker2015

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                                            I'm not going to look up customs info for them, but if they are asking me for an extra fill for vacation I'd drop the sentence that they should also check with the country they are visiting regarding customs and bringing in medicine. Mentioning it is just a 10 second sentence. If it's legal in the US to fill it and ethical to do so then I'd have no problem with it.

                                            That's fine. It just isn't our responsibility. That's my point. I do not care if you like to sing to your patients. I just don't want them coming to me asking me to sing to them. That's all.
                                             
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                                            Rukn

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                                              Do you guys fill stuff like Adderall 30 mg take 1 tid? The maximum daily dose that I'm aware of is 60 mg.

                                              I've seen pharmacists reject these scripts and I've seen some fill them.

                                              90 mg of amphetamine a day does sound ridiculous but I've seen patients on it.
                                               

                                              HelpfulPharmer1

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                                                Do you guys fill stuff like Adderall 30 mg take 1 tid? The maximum daily dose that I'm aware of is 60 mg.

                                                I've seen pharmacists reject these scripts and I've seen some fill them.

                                                90 mg of amphetamine a day does sound ridiculous but I've seen patients on it.


                                                Per Database Clinical Pharmacology:
                                                Amphetamine; Dextroamphetamine|
                                                Adderall
                                                Maximum Dosage Limits
                                                •Adults
                                                60 mg/day PO for ADHD or narcolepsy for immediate-release tablets;

                                                30 mg/day PO for obesity using immediate-release tablets.

                                                20 mg/day PO using extended-release capsules for ADHD.
                                                 

                                                doublehh03

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                                                  Do you guys fill stuff like Adderall 30 mg take 1 tid? The maximum daily dose that I'm aware of is 60 mg.

                                                  I've seen pharmacists reject these scripts and I've seen some fill them.

                                                  90 mg of amphetamine a day does sound ridiculous but I've seen patients on it.

                                                  This is where you take a patient's history into account. Have they slowly been titrated on Adderall? You have to take a patient's history into account with these kinds of meds. I've seen a patient on concerta 54mg bid. Very rare and it surprises you but I try to look at the patient's history before anything.

                                                  A lot of doctors go above max doses on many different meds, not just controls.
                                                   
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                                                  beautifulrobot

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                                                    Do you guys fill stuff like Adderall 30 mg take 1 tid? The maximum daily dose that I'm aware of is 60 mg.

                                                    I've seen pharmacists reject these scripts and I've seen some fill them.

                                                    90 mg of amphetamine a day does sound ridiculous but I've seen patients on it.

                                                    I would generally question/reject these scripts unless I could confirm that the patient is being closely monitored and that both the prescriber and the patient are aware that the dose is above the max approved dose, and are also aware of the associated risks, and still want to proceed. Going above the max FDA approved dose of a CII stimulant isn't a benign thing... If the patient ended up stroking out, having a heart attack, or had a psychotic break and attempted suicide (usually because they did something stupid in addition to taking high doses of a stimulant, but that won't usually matter in the context of a lawsuit), and you didn't document that you covered your butt... lets just say that it wouldn't be hard for a lawyer to find a pharmacist to testify that a reasonably prudent pharmacist in the same situation wouldn't have dispensed that medication.

                                                    ETA: Here's one example of a time I came across an order for Adderall that was above the max dose. This was in an institution where I had access to the patient's EHR. I was able to see that the patient was already tachycardic with their current Adderall dose of 60 mg/day. I called the doc, a resident at the time, to confirm if he really wanted to increase the Adderall dose considering the patient was already tachycardic on their current dose. The resident admitted that he didn't notice the patient's heart rate, and agreed that it wasn't a good idea to increase the dose at this time, and said he would follow-up with the patient to let them know. #savinglives
                                                     
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                                                    BidingMyTime

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                                                      Bidingmytime meant Primary Pulmonary Hypertension, I am pretty sure. It's also known for Valvular Heart Disease. Phentermine is a dirty drug, plain and simple. It gets in everywhere. If you read the mechanism of action you will see that it does not do 1 thing; instead, it gets in everywhere and it happens to cause appetite suppression like any other sympathomimetic would. So if the desired effect is ADHD management, there are much cleaner drugs that can achieve that. Because it is a dirty drug, it is only indicated for the short term treatment of exogenous obesity. So there you have it. ADHD is a chronic condition. You manage it. It never quite goes away. So you would not want to treat it with something that is not indicated for long term use. That's what Bidingmytime meant to say, in a nutshell. Just a hunch...

                                                      Yes, thank you Apotheker, for explaining it better than I did. I thought in the context of the drugs we were talking about, it would be obviously that PPH meant Primary Pulmonary Hypertension, but PPH is ambiguous and I hadn't considered other interpretations of it.

                                                      Shouldn't you also be concerned with the well-being of your patient, and particularly in this case, their ability to adhere to drug therapy? Counseling patients that they should check the other country's customs laws seems like a reasonable thing to do. Not saying you shouldn't fill the two month supply of a C-II until you confirm the other country will allow the patient to take it in with them, but giving the patient a heads up that they might have problems bringing their medication into another country seems like it is well within our duties as a pharmacist. Most patients would probably appreciate it, although I can also imagine some patients will then demand you check the country's customs laws for them because they don't know how to... So there is that...

                                                      I don't have web access, or time, to look up every country's customs laws.....not to mention, maybe the patient is going to one country where there drug is legal and while there, they decide to add another country to their itinerary where their drug isn't legal. Or maybe the parent will send the drug with their child to school, instead of checking in with the school nurse, and then their child gets expelled (maybe the child previously went to a private school where they did this, then transferred to a public school and didn't realize the new rule.)

                                                      Maybe car seat sellers should have to warn people that while a particular model meets the laws in their state, if they go to such and such other states, that car seat won't meet that states laws. Or someone selling a gun, do they have to inform the purchaser about all applicable laws concerning that gun in any neighboring states?

                                                      Seriously, at some point people have to take responsibility for themselves. There is no way a pharmacist could, or should, be responsible for anything other than the laws in their own locale. (Although I agree it would be nice to mention to the patient that they should check out the laws in the area they are traveling to.)
                                                       
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