Would you fill this?

[Pharmacy1999]

Just curious...
If you were presented with the following script, would you fill it?

-Rx is for a CII pain medication, total daily dose ~ 4 times higher than you have ever seen
-Rx is written a couple hundred miles away
-Verified prescription with MD
-State database shows no controls being filled elsewhere

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[awval999]

What's the drug, dose and freq?

 

[pharmalt82]

Oxycontin >2000mg maintenance daily split into QID dosing

+ prn IR for breakthrough pain q 2-3 hours

Fill it.
By the way - cash or insurance?

 

[owlegrad]

I cannot imagine filling that. Oxycontin >2 grams?!

 

[MindOverMatter]

Oxycontin? 2000mg? QID? And PRN?

 

[pharmalt82]

Oxycontin? 2000mg? QID? And PRN?

But, but, in school they told us that there is no max.

 

[WhiteSnows]

No way I fill this ****.

 

[cdhoward]

-Verified prescription with MD
-State database shows no controls being filled elsewhere

Did this verification determine that the patient has been taking this chronically and has been needing more and more medicine to obtain the same relief from pain? As someone else mentioned, there is no max dose.

It is a crazy high dose - is this a pain specialist?

 

[rph3664]

The most I've seen is 240mg in a day. But TWO GRAMS?!? I don't think so.

 

[PriorAuth]

Daily dose of 2,000+ mg of OxyContin?

That's at least 25 tablets of 80 mg per day, which leads to at least 750 tablets of Oxy 80s .

Do you even have that much in stock?

I definitely won't fill that.

 

[mangopulp]

I would also try to find out what type of pain are they treating. ...malignant bone marrow are painful! !!

 

[boriqua]

on a scale of 1-10...
no

 

[BenJammin]

You guys need to understand that the statement "I called the doctor and he verified the script" means ABSOLUTELY NOTHING. The state board of pharmacy doesn't respect that and the DEA doesn't respect that. I would only fill if: the doctor doesn't have the reputation of being a pill mill AND there is evidence that they have filled a script like this somewhere else with a similar or slightly smaller dose AND they aren't a cash paying customer. The fact that it is an out of state doctor and that pain docs are all around your area is completely irrelevant. Nobody is required to use a doctor in state as long as out of state controls are legal in accordance with your SBOP.

 

[genesis09]

You shoud contact a pharmacy closer to the prescriber and see what his/her reputation is. That is not proper dosing for Oxycontin. I wouldn't feel comfortable filling it.

 

[boriqua]

You guys need to understand that the statement "I called the doctor and he verified the script" means ABSOLUTELY NOTHING. The state board of pharmacy doesn't respect that and the DEA doesn't respect that. I would only fill if: the doctor doesn't have the reputation of being a pill mill AND there is evidence that they have filled a script like this somewhere else with a similar or slightly smaller dose AND they aren't a cash paying customer. The fact that it is an out of state doctor and that pain docs are all around your area is completely irrelevant. Nobody is required to use a doctor in state as long as out of state controls are legal in accordance with your SBOP.

I think documenting that you spoke with the MD and verified the script plus what it is for means more than doing ass nothing and just filling it.
but in this case, I wouldn't fill it even if it was verified. the amount is ridiculous.

 

[zelman]

What's the drug, dose and freq?

...more importantly, is the doctor in Florida?

 

[BenJammin]

I think documenting that you spoke with the MD and verified the script plus what it is for means more than doing ass nothing and just filling it.
but in this case, I wouldn't fill it even if it was verified. the amount is ridiculous.

In theory? Sure but try telling that to the DEA.

 

[Estrace]

There is no way I'm filling that. that's ridiculous!

 

[MatCauthon]

We are not obligated to fill this rx. It is already a red flag that is from out of state. At the recent DEA/pharmacist meeting, the DEA told us we can deny anything that has red flags on it. Send it other to another pharmacy that doesn't have tight restrictions on C-IIs, that is what I do.

Verifying that it is a valid script from the MD is no longer defensible by the DEA. They expect us to do much more digging than that. The drug monitoring database is a good start, but what good is that if the rx is from out of state?

Ever since the 80 million dollar settlement with Walgreens this is a very serious issue. I know that DEA took away the license of one our pharmacies not to long ago for over-dispensing.

 

[Star30z]

Just curious...
If you were presented with the following script, would you fill it?

-Rx is for a CII pain medication, total daily dose ~ 4 times higher than you have ever seen
-Rx is written a couple hundred miles away
-Verified prescription with MD
-State database shows no controls being filled elsewhere

The simple fact that it's written a couple of hundred miles away is a huge red flag and a definite no. It's so bad in Florida with the pain meds. I've worked in pharmacies that will only fill a CII if the pt's ID and doctor are in the same city. I've worked with other Rph's that won't fill anything over #120 and MD and pt must be in the county.
Personally, I'm not that strict, but 4x the normal dose is alarming, does that pt have cancer? And if a statewide search resulted in no fills for controls that means he is more than likely opioid naiive making such dose lethal. I wouldn't fill it even after talking to the MD.

 

[xiphoid2010]

We are not obligated to fill this rx. It is already a red flag that is from out of state. At the recent DEA/pharmacist meeting, the DEA told us we can deny anything that has red flags on it. Send it other to another pharmacy that doesn't have tight restrictions on C-IIs, that is what I do.

Verifying that it is a valid script from the MD is no longer defensible by the DEA. They expect us to do much more digging than that. The drug monitoring database is a good start, but what good is that if the rx is from out of state?

Ever since the 80 million dollar settlement with Walgreens this is a very serious issue. I know that DEA took away the license of one our pharmacies not to long ago for over-dispensing.

Agreed, while everything might check out with the doc and narc database, I would still not dispense just to safe guard my license should something unforeseen happen. Just tell they him you don't have enough in stock and logistically difficult/impossible to partial fill a C2. Let some other more cavelier pharmacist fill it if they dare.

 

[OmiPharmD]

I've never seen a dose anywhere near this high in our cancer or hospice patients.

 

[awval999]

With no official ceiling dose, I find it hard to draw the line. Is there an unofficial max dose anyone knows of that has literature support?

There is no official or unofficial max dose of opioids.

However......

I've never seen a dose anywhere near this high in our cancer or hospice patients.

This.

 

[owlegrad]

So I guess that means the OP has seen >500mg daily dose of Oxycontin? Does that sound really, extremely high to anyone else?

I don't know the exact highest dose I have ever seen but I doubt it is much higher than maybe 160mg.

 

[FlavyFlav]

The highest I've seen prescribed to, or what I presumed to be, a legitimate patient was Oxycontin 80 QID with oxycodone 30mg up to 8 times a day for breakthrough. This guy had multiple surgeries and was slowly scaling upwards for a long time. That dosage floored me at the time, so I don't know how this patient is actually taking that much opiate in a day, no ceiling limit be damned.

 

[Ackj]

How can the database show no controls filled? You're not taking grams of oxy as a starter dose. IF (and it's a big if) it is legitimate, the pt would be taking the stuff for a long time to hit that dose. I would like to talk to their previous pharmacist and get the scoop, as maybe they dispensed 1g, 1.5g, etc. and can confirm a titration. Still no way any store I've been through would have this in stock. Highly doubt an insurance would approve that many, and you could not afford to pay cash for that every month. 750 tabs? Come on, even wholesale price would be sky high.

 

[PharmdA07]

Just curious...
If you were presented with the following script, would you fill it?

-Rx is for a CII pain medication, total daily dose ~ 4 times higher than you have ever seen
-Rx is written a couple hundred miles away
-Verified prescription with MD
-State database shows no controls being filled elsewhere

I do have my time practicing in hospice and palliative care. NOOO WAYYY in HE*L will I fill this. The max I've seen was a guy with last stage of Colorectal cancer which mets everywhere and he was on 120 mg PO q4h with alternating PRN MS IR liquid. This order was done with a reputable hospice service that my pharmacy contracts with and even with that, I still verified and talked with RN and MD on the case to discuss the process of care with this high dose of opioid; and this case is a retail walk-in script...No way!

For retail, if I see a C2 Rx from out-of-state, I will refuse it right away (and tell them to go somewhere down the street to get it) even though my state law allows filling of such Rx. I have friends dealing with DEA before and they emphasized "only calling and verifying with the prescriber is usually not sufficient to justify the normal course of practice of a reasonable pharmacist" !! CYA, please!

 

[boriqua]

. I have friends dealing with DEA before and they emphasized "only calling and verifying with the prescriber is usually not sufficient to justify the normal course of practice of a reasonable pharmacist" !! CYA, please!

so what is sufficient enough to justify the normal course of practice of a reasonable pharmacist?

 

[PharmdA07]

so what is sufficient enough to justify the normal course of practice of a reasonable pharmacist?

I think it's case-dependent. For me, I was told by my supervisor to do more nowadays such as using the Dispensing Database, Call the board to ask about the reputation of the clinic, ask the prescriber for a diagnosis code on the chart etc. like others have said. I even have a coworker pharmacist ask the clinic to fax him a copy of the chart page indicating the drug prescribed and the notes for that visit. That's quite a lot of work in my opinion, which is why when I see something fishy I usually refuse right from the beginning

 

[pharmalt82]

I've never seen a dose anywhere near this high in our cancer or hospice patients.

But, but, God switched livers with this ptn.

 

[boriqua]

I think it's case-dependent. For me, I was told by my supervisor to do more nowadays such as using the Dispensing Database, Call the board to ask about the reputation of the clinic, ask the prescriber for a diagnosis code on the chart etc. like others have said. I even have a coworker pharmacist ask the clinic to fax him a copy of the chart page indicating the drug prescribed and the notes for that visit. That's quite a lot of work in my opinion, which is why when I see something fishy I usually refuse right from the beginning

how do you check the database?

 

[thephoenician88]

if you were sent to court because this pt overdosed and died, would you be able to defend 2g of oxycontin a day?

NO

 

[Ackj]

if you were sent to court because this pt overdosed and died, would you be able to defend 2g of oxycontin a day?

NO

Reevaluating after the update from OP. If you have seen on your own computer that the patient has been getting this filled at your pharmacy for several months, you can probably argue that it's a continuation of therapy. How the hell they arrived at that point, no clue. But the fact that it has been going on at the same store makes me feel a slight bit better, since you could ask your coworkers what the deal is.

 

[thephoenician88]

Reevaluating after the update from OP. If you have seen on your own computer that the patient has been getting this filled at your pharmacy for several months, you can probably argue that it's a continuation of therapy. How the hell they arrived at that point, no clue. But the fact that it has been going on at the same store makes me feel a slight bit better, since you could ask your coworkers what the deal is.

I still wouldn't fill it. Just because "someone else filled it" doesn't mean it's OK to fill

 

[ethyl]

Refuse, patient should consider a second opinion and be placed on a morphine pain pump.

 

[BidingMyTime]

Reading the first OP, my answer was no, I wouldn't fill. However, knowing that the person has been regularly getting it filled at your pharmacy, I would consider it. Because if a person is really on that high of a dose, the withdrawal could about kill them if they suddenly stopped & its not like any other pharmacy would have that much in stock, so its not a simple issue of passing the buck. If the pharmacy has been filling it before, I can see problems from just cutting the patient off. However, I would want to talk to the prescriber and verify the dosage, condition being treated, get a reason why their condition requires such a huge dose, what to know the doctor's specialty, if this is a GP or worse yet a NP prescribing this, I would hesitate filling it.....and then talk to the patient, verify that he's not a walking zombie, that he has the condition the doctor said he did, etc. But it surprises me that anyone could be on such a high dose and have any quality of life whatsoever.

People have said they automatically wouldn't fill from an out of state doctor, but I can see a patient that requires this high of a dosage of Oxycontin would need to be seeing a specialist at a research hospital, not just a regular local pain doctor. So the out of state doctor in and of itself really isn't a reason not to fill, just to get further information.

 

[zelman]

Reading the first OP, my answer was no, I wouldn't fill. However, knowing that the person has been regularly getting it filled at your pharmacy, I would consider it. Because if a person is really on that high of a dose, the withdrawal could about kill them ...

Opioid withdrawal is not fatal. Just horrible. Alcohol or benzodiazepine withdrawal can kill.

 

[Carboxide]

No way. Besides the out of state thing, I'd think any patient on 2000 mg Oxycontin per day would be MUCH better suited for an intrathecal pain cassette.

There is no way this is safe. If it is, the patient should have a pain contract or something with a specialty pharmacy.

 

[HelpfulPharmer1]

.....talk to the patient, verify that he's not a walking zombie, that he has the condition the doctor said he did, etc. But it surprises me that anyone could be on such a high dose and have any quality of life whatsoever.

I thought the same way until one day, I learned that some patients buy a lot and sell most of med, keeping just some pills for personal use.
They buy high dose but don't use high dose, still have quality of life.

 

[owlegrad]

I thought the same way until one day, I learned that some patients buy a lot and sell most of med, keeping just some pills for personal use.
They buy high dose but don't use high dose, still have quality of life.

Ha! I had an intern ask me once about someone on a high amphetamine dose (he was concerned it was unsafe), I told him not to worry about it, that the patient only took a normal dose and sold the rest.

 

[Old Timer]

Just calling and verifying is NOT enough. You would need to document what the diagnosis and it better make clinical sense. Sometimes it does. As I have shared here many times before I once got an Rx for MS-Contin (No generic then, I know I'm old) 1800mg q12h. I called the doctor and was informed the patient was a heroin addict and normal doses of MS-Contin would not touch his pain which was due to prostate CA with extensive bone metastases. We filled it several times before he died, of the cancer, not the drug. Unless you have something like that to hang your hat on, don't do it.