The practice of pharmacy is regulated at the state level by the Board of Pharmacy (BOP)
The entities that are licensed by the BOP are:
Wholesaler, store permit holder, Pharmacist.
The wholesaler’s only function is to sell medication to a legally licensed pharmacy.
The store permit holder is licensed to operate a pharmacy, unless the store permit holder is also a licensed Pharmacist.. the permit holder has no legal right to “practice pharmacy”. Each pharmacy has to have a licensed Pharmacist that has agreed to be PIC ( Pharmacist in Charge) for the permit holder.
Licensed Pharmacist… In a independent pharmacy (Mom & Pop) the PIC and the store permit holder may be one and the same. With a chain pharmacy, the corporation that is the permit holder… since it is not a person.. can’t be a PIC.
The BOP looks to the PIC as the responsible party that the Rx dept complies with all applicable rules/laws/regulations.
The basic function of a Pharmacist is to make sure that the correct medication & directions, that was ordered by a prescriber, are provided to the pt and to make sure that the pt understands how to take the medication and be aware of any potential side effects.
Legally, the only reason that a Pharmacist can decline to fill a pt’s prescription is that the pt has a known allergy to the newly prescribed medication, there is a major adverse drug to drug interaction with other medications that the pt is currently taking and/or the dose is outside of the FDA guidelines.
Generally, when one of those situation presents itself, the Pharmacist will contact the patient , to confirm the allergy. Then contact the prescriber to verify or change the prescribe medication to one that will eliminate all the contraindications for the patient. It is high unusual, pretty much unheard of, for Pharmacist to just tell the pt that the medication can’t be filled as is.. or tell the pt that “they are not comfortable filling the Rx “.
About ten years ago, Plan B (morning after pill) became available. Some Pharmacist claimed to have a personal “moral objection” to dispensing this medication. Some refused to the fill prescription(s), some even confiscated these prescriptions and refuse to return the prescription to the patient.
BOP and legislatures got involved in this issue and they came down on both sides of this debate.. some claimed that the Pharmacist had a “moral conscientious clause” that they could invoke and decline to fill the prescription… confiscating the Rx was not acceptable… others .. demanded that Pharmacists fill these Rxs.. regardless of which way their “moral compass” pointed.
Some Pharmacists came away from this debate with the opinion that they could refuse to fill any Rx… for any reason.. or no reason… The Pharmacist’s Oath that they took… became seemingly otherwise worthless… or a “promise broken”
The DEA in early part of this decade decided that they were going to have enhanced enforcement of a concept in the DEA laws called “Corresponding Responsibility”.. which the interpreted to mean that a Pharmacist has the legal responsibility to no know determine if the prescription presented has been written by a legally licensed prescriber… but.. that the prescriber is actually writing the prescription for a valid medical necessity. Thus the DEA has told Pharmacists that they are expected to be able to give a “second opinion” of the pt’s subjective disease and the severity of their disease… WITHOUT access to all the pt’s medical records nor the appropriate amount of time to evaluate them.. if they did have access. AND.. Pharmacists have little/no training in being a diagnostician…
So the DEA has basically told Pharmacists that if you allow controlled drugs to get in the wrong hands… we are coming after you.. BUT.. if you fail to get the correct drugs into the right hands.. THERE ARE NO CONSEQUENCES …
One of the major chains has established their “good faith filling policy”.. which is your basic… twenty questions to find a reason NOT TO FILL A RX.
Then a couple of the other chains… have implemented what are covert reason why their Pharmacists should not fill controlled medications.. Historically, a Pharmacist’s bonus and allowed tech man hours were determined by the number of prescriptions filled per day/week/month/year… What has reportedly happened is that these chains have taken the controlled meds Rx count out of the determination of the Pharmacist’s bonus.. .but. they have also taken those numbers have also been removed from calculating the allowed tech man hours… The typical store will fill 15%-20% of their total Rx count as controlled meds…
So now the average chain Rx dept is 15%-20% short on allowed tech man hours.. BTW.. allowed tech man hours have never been overly generous to begin with. So these Pharmacists are faced with to trying to fill more Rxs than they have ancillary staffing hours that would considered marginally safe before the lower tech hours were implemented.. or just turn down controlled meds prescriptions.
So these Pharmacists believe that they are well within their “rights” to turn down Rxs.. for any reason or no reason.. Which is true.. except those people with subjective diseases are generally covered under the ADA.. and declining a legit/on time/medically necessary Rx is considered discrimination and a civil rights violation under the ADA.
Some also falsely believe that as long as a pt can get their Rx filled somewhere else.. they are in the clear of violating the ADA… that would be a MAJOR… I DON”T THINK SO ! If the pt files a ADA complaint, the investigator is going to “Monday morning quarterback” the Pharmacist’s reason to not fill a pt’s Rx.. and if the Pharmacist is found in violation of the ADA.. the fine imposed.. the pt will get the lion’s share of the fine… and the Pharmacist may be charged with unprofessional conduct by the BOP. Which would also put the Pharmacist in violation of their company’s P&P… which could be a sufficient reason to be discharged.
Also, the pharmacy that these Pharmacist work for.. have a contract with your insurance company which they are obligated to fill/bill covered Rxs for their policy holders and failure in doing so.. is probably a violation of their contract with the insurance company and refusing to fill a pt’s Rx could cause the pharmacy to be fined and/or have their contract revoked.
All things considered… all too many Pharmacists are more focused on reason(s) to “Just Say No” to filling a controlled prescription. As long as the legit pt doesn’t file complaints with the respective bureaucratic agencies… there are no consequences for the Pharmacist.
Here is a article that I wrote that was published in DRUG TOPICS. I am being told of Pharmacists who are calling up a pt’s prescriber and telling the prescriber that the dose is too high. I suspect that these Pharmacists are using FDA dosing guidelines for OPIATE NAIVE pts… which has not relevant to a opiate tolerant pt. IMO, a Pharmacist using these FDA dosing guide lines when referencing opiate tolerate pts.. clearly demonstrates that they are clearly operating outside of their skills set. It could also, be considered practicing medicine without a license.
AMA warns RPH’s about inappropriate inquiries about pain med prescribing
When it comes to controlled meds and opiates in particular.. the upper (lethal ) limit of these meds, becomes totally dependent on the pt’s tolerance and length of therapy they have been on… There are now even tests that can determine if a pt is a “fast metabolizer” of opiates.. which would require higher/ more frequent dosing to compensate for this biological oddity.
Pharmacists have little/no training as a diagnosticians and even with access to the pt’s total medical records.. it is highly unlikely that a Pharmacist will be competent in making recommendations for dosing or dosing limits when it comes to opiates.
Filed under: General Problems
[…] Standard of Care & Best Practices – Pharmacy […]
I’ve filled four complaints against the pharmacy in general. The last complaint which was made because the main pharmacist in charge was on vacation so, of course there was another “temp pharmacist”. I came in 1 day before my refill was due and as the pharmacy technician like always has to ask the pharmacist “temp” at this moment and its a C2 controlled substance. I know that They have the medicine in stock but after the temp pharmacist looked at my prescription, without even looking by checking the safe where the regular full pharmacist has to go to fill it. He bluntly lied to my face and informed me that he didn’t have that prescription in stock and like the majority of pharmacist assumed I’m some drug seeking addict.. But, anyways I first informed him that sir, you do I fact have it in stock as the main pharmacist keeps it in stock as I get it filled every month. I then continued to direct him to please actually open the safe under you and actually look. Guess what…? He has it!!! Go figured right. Then, as I’m still standing there with people other customers behinde me, he looks at my prescription and looks at the bottle of medicine that he said he did t have then looked at me and loudly asked from the middle of the pharmacy area ” WHAT ARE YOU GETTING TREATED FOR??” He DID NOT ASK ME TO come to the CONSULTANT DESK and I was already embarrassed by the way he was treating me then I had to loudly answer back where everyone else in line and also picking up their rx in another line could hear and know all of my medical problems and personal health and private information. After I told him what I was getting treated for he finally filled the rx..of course I had to wait over 30 minutes as I’m sure he wanted to verify the rx whih is TOTALLY fine with me and should have either done that in the first place and or ask to see me at the consultation desk and ask me what I’m getting treated for. I’ll never forget this and nener forgive cvs for this..Tim the temp pharmacist was in the wrong, violated my
Hippa rights, and treated me unjustly. After I left I was mortified, embarrassed, depressed that I had to go through this. I looked up if there was anything I could do and I got advice from pharmacist Steve stating to file a complaint regarding CVS ciolsting my hippa rights and also I filled s complaint with the Louisiana board of pharmacy. Well, after CVS got a call from a compliance officer and spoke to the main pharmacist Jessica … I got an email from the compliance officer stating he spoke to Jessica and asked her to cal me and try to resolve the issue. About an hour later I do get s call,but Jessica just says she no longer feels comfortable filling ANY of my prescriptions.
I will continue to tell my story regarding I was treated, labeled, and punished for filling s complaint. The point of complaints is to be able to provide feedback and the store or company to better themselves and their customer service.. But, now I have to drive about over an hour round trip to get my prescriptions now. Lawyers tell me that it would cost me more money to possibly just slap them with a fine. The compliance officer and to the companies that I have submitted s legit complaint did nothing to help the consumer.
I hope that And know I’m not the only one out there and I pray and hope that something can get done to this pharmacist and temp pharmacist along with cvs.
Thanks for your time in reading this
Sincerely,
Ronnie M
Please support your local pharmacy sand not these big chains as they don’t give a two craps about your health or you as a human being
Re
Cvs store
70550 LA-21
Covington LA 70433
United States
+1 (985) 893-7681
Coonhound,
I just started to titrate down starting on June 12, today I’m now at 45 mgs a day down from 150 mgs and doing good. My feelings only , I think these medications can be a psychological thing thinking if I don’t get them my life will fall apart. I’ve learned the basic way to get by with a lot less pain meds, I just have to keep my hands busy at all times. I will have chronic pain no matter what, but its time for a change things have become ,,, I don’t know the word to use,,, OLD and DOUBTFUL now that pharmacies cant fill a legit/ on time/ medically necessary opioid script. Then its time to move forward and forget about these medications, it will make my life a lot more pleasant. I mean all this stress for what, I don’t need it, I can do without it and didn’t know it. So soon I might just take myself off this all together. I wish everyone well, meantime, Don’t Cold Turkey Methadone it took my legs out from under me , literally.
Did these long lasting pain meds help me, yes they did at a certain point in my life when all this began , I was in really bad chronic pain and didn’t know what to do, I didn’t know how to move forward. I lost my job and company car all in one day after 23 years with this company I worked for. This changed my life and I lost lots of things. Now its time for a change and I’m finding I’m able to deal with my chronic pain pretty darn good as I titrate down.
Blessings and Much Love for all chronic pain sufferers,,,
I’ll keep you all in my prayers.
Me ,
PC2014 and Coonhound,
Your posts are interesting and I read into them frustration with the problems obtaining your medications rather than lack of need for them. I felt the same way and in 2009 I made the same choice with regret. I decided that I could no longer go 3 months on my medications then go 30 days without because of pharmacy denials so I quit taking the 120 mg of methadone and 320mg of Oxycontin daily. I was very sick, but I was determined to do it one time and stop. After about 45 days I was starting to feel a little better, but the pain was unbearable. I decided to see surgeons for possible options and when I was sent for current MRI’s I was told that I was not a surgical candidate or at least the doctors I saw would not assume the liability for my required surgery. I would need at least 6 different surgeries over several years in all three spine levels, cervical, thoracic, and lumbar and many devices installed. I gave up and went back on the meds again as I could not take the thought of having the pain at the level I was at for the rest of my life much less more pain. I did work with my PM doctor to return to much less pain meds which has been working well. However, even with a much reduced medication therapy pharmacists still think I am taking way to much medication which is rediculous considering my medication history. I am taking less than the amount of both pain medications than my medicare plan D allows without doctor intervention. This should be a reasonable amount you would think especially since my plan D has no problem with the amounts. But, that is not the case it seems not to matter to pharmacists today that you are taking less than your insurance plan allows. Time to move away to a country that cares about its elderly and disabled.,
Coonhound,
Pretty good story of you being treated like dirt while addicts are being treated better from abusing drugs ,doesn’t make any sense does it. I to had the same problem getting methadone filled the past 2 months and not 4 months ago I was getting 450 a month with no problem. Then BOOM this thing got a hold of me like it did you and nothing has been the same. I have to admit 50 mgs 3 times a day was a lot and I have titrated down to 20 mgs 3 times a day, at one time I was at 90 mgs 3 times a day back in 2010. My spine is basically destroyed, slowly collapsing like the domino affect that started in my neck. It slowly jumped from my cervical spine to my thoracic spine now my lumbar spine. I’m a spineless bastard so to speak literally or should I say physically. Anyhow I wanted to tell people in pain methadone in my opinion is the strongest pain pill a person can get per milligram. I didn’t realize this at first when my chronic pain came about and I went thru A to Z on different long acting pain meds and my body would become tolerant requiring a increase in dose to achieve the same pain relief. To my surprise methadone worked better than the expensive time released pain meds. My body has never become tolerant on any given dose of methadone it seems to work the same but a lower dose just does not last as long and wears off faster than a higher dose . And another thing for me no break through medication works because I think the methadone is blocking it from working, filling in the brains opioid receptors making other opioids pass by. That’s the whole idea behind using methadone for people who abuse other drugs ,correct me if I’m wrong. It gives them relief of their addiction but its not want they really want but helps a lot, I feel bad for those that abuse, addiction is a disease and should be treated as one. Its not always the abusers fault ,it could be from abuse as a child that led them to this addiction.
Now its been 18 years and as I titrate downward and I’m finding my body has became so use to pain its not as bad as when all this first came about.
To my surprise I’m able to get by with less and less of this really bad medication called methadone and my chronic pain is still the same but not as problematic as when it first started. Its kind of like getting use to a spouse after the good times wear off. That person you love is still there but the real good sex has passed and their in your life and you become use to them if you decide you want sex again ,or something similar to that.
I think a lot of people in chronic pain and I mean real chronic pain and no psychological thinking the pain is there when its not, can eventually get by with less pain medication if not stopping it all together just to see how bad your chronic pain really is after many years have passed. I found my chronic pain is still there , maybe not as bad as when this first started because it changed my life and it sucked at first, but I’ve become so use to it , like part of my life that will always be.
This thing about the DEA playing doctor and detective of all pharmacies is sick and all that suffer from chronic intractable pain should have the right to be as pain free as possible. This will pass in time ,like things in life always change .
To get this reply out of the way, all of you that have been suffering in chronic pain for say 10 years or more step back and take a inventory of your life. Is the pain as bad as it use to be, slow down and see what the pain is really like now that all this time has passed. Do you really want to be on pain medication for the rest of your life ? I was asked this question just 2 months ago and I thought “HELL NO” I don’t want to be on this crap for the rest of my life, something just clicked in my head after being asked this question by my pain doc.. This thing with getting the pain medications filled just kept going and going and now this crap with pharmacies not having certain pain medication we need in stock has put me in a position to decide what to do next. Deep down I think a new chapter needs to begin in my life now because this one has gotten to a point to where I just don’t have the patients to argue with pharmacist because the DEA is hassling them. This is ridiculous what these pharmacist are forced to do with chronic pain sufferers, but in time it will change.
Hey PC2014. I agree, methadone is by far the best medication for pain that I have tried and I have tried quite a few over the years. When I expressed exasperation at the mg that addicts in MMT were receiving I didn’t want you or anyone to think that I would judge them for being on a dose in that range or higher, like you were until recently. Everyone is different and if that’s what worked and you needed it then I am glad you received the care you did.
I merely wanted to contrast a legit patient w/ pain and the hurdles we face w/ the ease at w/ which addicts can go up and down on their meds w/out so much as a stubbed toe. I would also like to tip my hat to you for such a rapid taper. My goodness, going from 150mg/day to 60mg/day in 4 months? You sir are a trooper! That is simply amazing IMO.
As far as the ‘blocking’ of other opioids goes there seems to be a lot of different opinions (from Drs and patients and addicts) on this issue both in MMT and in treating CP. I was under the impression that anything over 80-100mg would block out any euphoria experienced by those not in pain if they tried to shoot up heroin oxycodone or whatever it is they are using. Up to 80-100mg (lets say 40 or 60 you or I take) there is only a partial blocking effect (not really important in CP as much as in MMT because our pain ‘eats up’ the medication and any chance at feeling the ‘high’ so sought after by those addicted to opioids. I think the time frame used in dosing plays a part as well as most in MMT take all of their methadone at once where we space ours out over the course of the day.
I will have to admit that after reading your post I set out on a mission of sorts to try to get some concrete answers regarding a ‘blockade dose’ and be able to get a definitive answer one way or another. Personally my rescue med (Norco 10/325) helps out fairly well, esp on those ‘ugly’ mornings at which time my pain is usually at its worst.
Check this link out. Though it addresses those on methadone for MMT, some of the information can be gleaned from it in regards to treatment of pain while on higher doses of methadone (that can be useful for those of us taking it for CP). It seems that while many/most BT or rescue opioid’s euphoria/dizziness/etc are successfully blocked by higher doses of methadone, their pain relieving qualities remain. SO, since those on higher methadone doses might not ‘feel it’ they get the impression that the med is not working or is blocked.
SO, the way I understood it, in order to treat acute pain or BT pain while on a high dose of methadone it seems that higher doses of a BT or short acting opioid may be needed along w/ more frequent administration. They explain it better so here it is:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1892816/
I am glad that you are able to tolerate your pain better of late and with less medication. I hope that you are able to realize your goal of being free of medication. I think most of us would gladly give up our meds if we could just have our old life back.
I got that opportunity one time when my AI disease went into remission.
I went from Ms Contin @ 145mg per day to not so much as a baby aspirin from around 2003-late 2008 when I became sick again. I was particularly naïve about my illness and wish I wouldn’t have taken so much of what I got back for granted. I was able to transition fairly well from PM to zero opioids (amazing enough I had no inclination to become a drugstore cowboy or start frequenting open air drug markets ‘downtown’ to get ahold of some heroin).
This is what pisses me off about the DEA, the media, ‘concerned citizens’, and especially those who earn their living by hounding the decent citizens and doctors of this once great land of freedoms. We are all adults here. We don’t need some agency to babysit adults, they can make their own decisions. I agree that addiction is an illness and not a criminal offense but
this wholesale repression and cut in supplies of opiates nationwide is NOT the answer. Until one becomes ready to give up the life of addiction they are going to find a way to fuel their obsession new laws and regulations or not.
The scary thing is that once these laws and regulations get put on ‘the books’ it will take an act of god to repeal them. SO, unless this battle turns, and soon there are going to be a lot more suffering. My main qualm is that so much has been done to curb the outrageous behaviors that were once given carte blanche I want to scream out HELLO!!! Lets just give them some time to work for crying out loud. Making PMDPs mandatory to use could be one step to take.
I mean for 1-we have PMDPs in every state but 2 now and many are cooperating across state lines.(I personally don’t feel like there is enough of an epidemic big enough, even if 50,ooo OD’d and died each year to allow the state and federal govt agencies to operate a database on everyone who needs pain treatment. It runs against everything this country is supposed to be about, freedom and a certain expectation to privacy w/out fear of an intrusive government (but here again another database is ‘needed’)
BUT, It seems every damn time I turn around there is another reason for the govt to pry more and more into our private lives and private information. No need for warrants anymore for LE to listen in on phone calls. No reason needed to send in SWAT teams to raid a house (no knock raids usually) just someone to call LE and give a tip that the owner had illegal contraband. Hell it could be a neighborly feud for all anyone knows and the next thing you know someone is dead, usually the home owner. AND……
The reason is always to protect us/them/society from some boogey-man whether it be pill mill operators, terrorists, the ice cream man, the list goes on ad nauseum..
IMO, I say we are all adults here, if someone wants to play w/ fire give ’em a lighter and let ’em have at it. If they want to slam oxycodone in their veins for kicks why the hell not, you can’t cure stupidity w/ laws its been proven time and time again. Education is the only way. It worked w/ smoking and now it seems to be making some headway on obesity, why the over-reaction w/ drugs. (saved for another post but I believe it is due to the citizens having enough of the war on drugs, at least its apathy towards one of the DEA’s, state, and local LE, and the prison system’s main cash cow, the funding to battle illegal marijuana).
.
They realize that many citizens think there is no need for all these agents so they have to prove we need them. I say let them stand in the unemployment line, we spend too much on enforcing laws that only empower criminals and encourage corruption and erosion of civil liberties by govt agencies.
We have REMS now. With more and more primary physicians refusing to treat pain, IMO we haven’t seen nothing yet wait ’til hydrocodone is a schedule II, it will be pain management or bust. With the shortage of PM docs and the rising cost of being a patient in PM it will be mostly bust. One will have to shell out major cash for all these new abuse deterrent (not abuse proof mind you) opioids big pharma is gearing up for release. Add to this the cost of UDTs (my clinic gives one EVERY MONTH NOW to every patient!). Add to this the fact that many w/ chronic pain, including myself, pain is but one symptom of their disease. We/I still have to be able to afford to see other specialists (I have a team of 6 doctors and WELL over a dozen meds to fill each month) and treat other issues. There is no way on gods green earth I could afford to have my pain treated w/out being on Medicare, even now I would most likely be destitute if it weren’t for a caring and helpful family.
They are pricing pain management out of reach of the average American citizen and it is really sad because these medications are some of the cheapest on earth.(or should be at least).Got off on a tangent there sorry, at any rate, between the UDTs, PDMPs, REMS, Drug Task Forces, (say that 10x fast) rescheduling meds, opiate contracts, pill mill bills, red flagging, etc etc, there are more than enough hoops in place to deter diversion! We do NOT need any more. Let’s give these actions some time to work before we continue to stir people up into a such a frenzy. Be well friends.
Coonhound
Thank you for your speedy reply! You are a true godsend to those of us novices to the workings of pharmacies, regulators, distributors, and the medical system in general. It seems like the chronic pain community could swamp the system if a complaint was filed for every legit Rx that was turned down, is that what you had in mind in order to draw attention to the matter of pharmacists refusals and DEA meddling?
My question about a pharmacy being out of a given schedule II med is basically for future reference. I recently was turned away from 2 pharmacies located on the grounds of a certain medical center in Jax FL of which I have been a patient of since Oct 2009. (I shared this story on Dr Fudin’s blog some time ago). After much back and forth between pharmacists from the two (less than 2 blocks away from each other in separate medical buildings one being the main hospital) my Rx for methadone (a whopping 120 pills) was filled almost as if they were doing me a favor despite the fact that I have filled the exact same med @ the same dose for there for 3+yrs w/out a problem. Reason given, I went two months w/out filling there and since I am from GA they didn’t know what I was ‘up to’ up there. (I thought we had a working PMP in GA now[?])
After calling patient services I was directed to the DIRECTOR of pharmacy at the hospital who treated me like the gestapo! Then after telling me she would call me back after speaking w/ the pharmacists she proceeded to dodge my calls for the next 3 wks. I end a rounded her w/ a call to her assistant who said, oh she’s right here let me transfer you. 3 days before 3oth day and still in limbo. I gave her all the info on the pharmacy in GA that filled my Rx (angels-despite the killing of my liver issue on the hydrocodone) and he vouched that I wasn’t a scammer that I filled 3 DMARDS, 3 hormone replacements, heart med, PPIs, 2 inhalers and neb meds, heart med, etc, etc at his pharmacy for years and was legit. [I’m only 42]
She stated that she was very sorry for the inconvenience but the DEA is out there watching us like hawks (I had a strange mental image of Leslie Neilson in their parking lot w/ pistachio shells surrounding his undercover clunker peering through binoculars!) Anyhow the verdict, AFTER requesting names of all my physicians seen at the medical center (pulmo, neuro, rheumatology,cardiology, and PM doc) AND talking to the PIC at my GA pharmacy was that I could fill at ONE of their pharmacies, the one located in the building housing my rheumy and PM doc (not in the main hospital which I usually used to fill as they are bigger and better stocked). I was told HOSPITAL patients were first priority and they needed to make sure that meds would be on hand esp after surgery. I asked her since her position required knowledge of meds just how often was methadone Rx after surgery? She admitted sheepishly not very often. Thinking NO SH**. AND what was I chopped liver since I was only an OUTpatient of the hospital for 5 yrs now? Well that was the best ‘DEAL’ I could get, she chimed in that the pharmacy in GA agreed to and would be more than willing to fill for me if the hospital’s one pharmacy was ‘out of stock’ which usually was sometime after the middle of the month. Reason given they were under no obligation to fill my PM docs Rx since he was only affiliated w/the hospital and did it as a favor (never mind I was referred there by the hospital’s rheumatology dept located on the floor directly above the PM clinic no less. Since this time I have had my methadone filled, twice two days early, balanced out this coming visit by a 31st day fill. When I thanked the pharmacist, she said no problem (seemed like a MAJOR problem for me).
This disturbing experience along w/ my being turned down for a hydrocodone Rx 5/325 on the day of my throat surgery in GA w/out so much as a call to the surgeon or PM doc and given nothing but lies by the PIC until the I dragged the truth out of her: the real reason she told me was that I was already on too much pain medication w/ stress on METHADONE and I didn’t need any more! Yes day of THROAT surgery over the PHONE when I was told don’t talk for 3 days and bed rest. These 2 issues are what got me to jump on the advocacy train pronto. I am sorry that I waited so long as I just didn’t believe that legit patients were being affected, just the dopers I thought, how wrong I was.
Your 28 day schedule would have come in handy as the reason I hadn’t filled there at the hospital in 2 mos was because my PM doctor’s availability didn’t coincide w/ my rheumatologists, trying to save a trip as I did not have a vehicle at the time and my GF uses hers for work. The days didn’t line up correctly so I had it filled in GA. I had done this several times and was given the ok to use 2 pharmacies by my PM clinic (also located on the grounds of the medical center but not technically hospital doctors [only AFFILIATED w/ the hospital] but their smiling faces are there for all to see on their website and I was referred to them by the medical center’s rheumatology department. A lot of ins, a lot of outs to this one. Sorry but you seem to be the one to ask these complicated questions regarding Rx for controlled medications. I am waiting for the refusal to use the main hospital pharmacy comes as soon as the smaller pharmacy is ‘out of stock’.
Where do I stand on this? I think my complaint would line up perfectly if the main hospital pharmacy was not out of stock too (hard to imagine a major medical center being completely out of methadone or any single prescription med for that matter but what do I know Im just the village idiot according to these jokers).
I cannot write to my congressman (I did in GA and signed several petitions going around now) but not much help in FL I would think) Let me state that when I went to my first appt @ this medical center I lived a mere 45 min drive from Jacksonville FL and the only rheumatologist in MY town was NOT covered under my insurance plan so I went just over the state line. NOT in a car full of dopers from Ohio or WV.
I am currently now disabled on SSDI and on Medicare so the ADA should apply despite being an out of state patient no? So confusing.
Where the heck has the ACLU been at all this time this crap has been going on?
I’ve read they are fighting against welfare recipients being drug tested what about PATIENTS? I get tested EVERY MONTH NOW despite never having one failed drug test, not one missed appt, not one pill count off, or lost Rx! I get Occiptial Nerve Blocks, Euflexxa for knee, TENS, Depo-medrol shoulder injects for chronic bursitis and rotator cuff issues, etc, etc not just opioids. I was told by the PM nurse it was standard now to weed out the addicts. HELLO but one or two calls per year during the middle or first week of the month to report in 48 hrs to a Lab Corp for a UDT should suffice much better than a UDT at every appt, any idiot can pop a couple pain pills before his appt and stop using cocaine/meth or whatever else they are doing for a couple of days. They tested me for PCP FOR CHRISAKE! Its a racket, I got a bill for $990 for just one test and another for $730! I called the lab and they said oh sorry we didn’t file the claim w/ Medicare. No wonder we cant insure anyone it takes half the federal budget just to run UDTs on legit Medicare pain patients!
Trying to learn years of info on these issues in a couple months time.. I am a quick study but admittedly way behind here. I started reading up on methadone, its use in PM, its higher OD rates, its usefulness in certain neuropathies (of which I can attest) and its social stigma due to its use in MMT. Not trying to make this the longest post ever here but it led me to one last thought I wanted to share.
I read a few sites [doper sites] where addicts shared their experience with methadone in the maintenance treatment centers. It seems there that these guys can get increases in their maintenance dose by telling their counselor that their current dose isn’t ‘holding them’ too well they are getting cravings. This is WAY past the initiation stage where one would think this would occur. I thought maybe it was a bit of bravado or pride in gaming the system but there were just too many of them. Apparently some of these jokers are on 150-200 mg of methadone a DAY just for showing up w/ a smiling face while I get treated like I’m breaking the bank at 40 mg a day and my whole body is falling apart here. What is wrong with this picture?
Its the Harrison Act part II IMO. Listening to Kolodny addressing the dunces at the congressional caucus recently and he and the other experts are trying to paint all who use opioids daily as addicts all the while Kolodny was purporting the benefits of suboxone not only for addiction but for PAIN *no mention of its ceiling or even the fact that it was also an opioid, just that it was much safer. It didn”t take too much to impress Dianne ‘the brain’ Feinstein that SOMETHING has to be done and soon (she said so we need to go after these pain doctors it seems; absolutely sickening, god knows where this train will take the disabled citizens of this once great country of ours but it aint lookin good.
Coonhound
First off I want to thank you Steve for all that you do in advocating for those of us w/ chronic medical illness/injuries. My question has to do with ADA complaints and pharmacist assertions. IF the pharmacist tells me that they are out of a certain medication is there a legal way to verify this? If so, who can check to see if the pharmacy filled one for that same medication later in the day for another customer? I know that on schedule II meds at least, extensive paperwork is required to keep track of them so I assume it would not be difficult to determine if the pharmacist was trying to escort you out of the store w/ an excuse or if they were truly out of the medication requested.
*For Paincare2014: You stated that an increase in pain is usually due to tolerance but also is possible if it is caused by acute pain.
I just wanted to add that patients like myself can have exacerbations in their chronic disease(s) (in my case MCTD/mixed connective tissue disease/lupus overlap and systemic sarcoidosis) otherwise known as a ‘flare’. OR it can be caused by changes made to another medication the patient is taking as I recently experienced during a tapering of prednisone (increase in inflammation and pain). Even under ‘normal circumstances’ I may not need a ‘rescue’ or breakthrough dose for a week or so then there are times of a couple days to a couple weeks when I use all 3 doses given for this type of pain. I wish there was a way to trust the patient’s judgement and allow more leeway in the use of these ‘rescue’ meds OR more willingness on the part of the prescriber to escalate (or decrease) doses to deal with situations such as these.
*Other issues discussed here on this thread. Changing doses and filling a new Rx.
My physician changed my dose of modafinil from 1 to 2 per day. As my appt was over a week or so before my Rx was due to be filled I inquired if I started the dose change the day after my appt could I fill ‘early’ as I would run out before 30 days.
I was told by insurance company and Rite-Aid that there would be no problems w/ this and I brought it in 4 days (or so) early and it was promptly filled,
As far as expiration dates go: A few mos ago I was told by my pharmacist that I needed to fill my rescue med (hydrocodone) that I had on file/ as a ‘hold’ as it would expire (6 mos on hydrocodone in GA). When I inquired about receiving the newer formulation 10/325 I was told that since it was written before the new changes were made on acetaminophen (original Rx was written in OCT for 10/650) that they ‘must’ fill with that med if they still had it in stock despite my request for the version w/ less APAP.
Coonhound
It would be rather simple to determine if a store had a particular C-II on hand on a given day. First you need to document the date/time that you were denied because of “no inventory”.. All stores are mandated Fed/State laws to keep a perpetual inventory for C-II. All prescriptions have a date/time stamp on them somewhere.. when the label was printed and when it was rung out – at the register. An investigator would only have to see the date/time before you were told that there was no inventory and was the last time a Rx for a particular med was dispensed and the date/time the next time that a Rx was filled for the same med. If necessary, they may have to look at invoice from wholesaler as to when additional inventory was received. Rxs for C-III or C-IV .. against a daily report of what was filled date/time compared against the date/time you where denied and again – if necessary – invoices when additional supplies were received from wholesaler. Depending on the computer system.. this may only show when the label/receipt was printed.. more elaborate system would have a date/time stamp of final quality check/scan and then a date/time stamp when it was rang out at the register. I suspect that someone filing a complaint.. unless there are a bunch of complaints.. that the complaint will get “blown off” because they don’t want to open an investigation and spend the 15-30 minutes to review the documentation at the pharmacy. Of course, a failure to investigate would give the pt reason to contact the AG’s office and State/Fed legislator for agencies failing to uphold the law(s).
Steve,
Do some research on a Writ of Mandamus I think it may help someone with the time and money to force government agencies to perform their required duties. I can not afford either time or money.
It would be simple to solve the 10/650 issue.. the Pharmacist only has to call the doc’s office and ask to provide the 10/325 in place and treat it as a new Rx and void the refills on the existing 10/650. SO.. the Pharmacist would rather continue to put your liver at risk.. than make a phone call ? IF SO.. the only word(s) that comes to mind is LAZY ASS !
I have watched all the clips. Thank you for sharing this wonderful man.
I had a good friend named Terry Lee Bovina that was a hospice nurse.
This guy was very caring to do the work he did over the years.
He found out he had stage 4 prostrate and bone cancer back in 2011.
Terry Lee decided to tell his most memorable stories of people helped over that 12 year period he was a hospice nurse. He passed away January 31 of 2012.
Please watch all 11 videos he made ,this is excellent the way he told his stories.
I will line these up 1 thru 11 for you but am missing one. Watch his face as he gets more sick with each video. This is sad, but its needs to be watched by someone who will appreciate it.
It called “ A Life Worth Living” .
1.
http://www.youtube.com/watch?v=CkpujvONT4U
2.
http://www.youtube.com/watch?v=-GCGTHxwbbs
3.
http://www.youtube.com/watch?v=jg29FvtvrN4
4.
http://www.youtube.com/watch?v=sb1yhaR1h0M
5.
6.
http://www.youtube.com/watch?v=dub5PaFVXSA
7.
http://www.youtube.com/watch?v=LjW6rIP8ZBo
8.
http://www.youtube.com/watch?v=bNHAwyHu9WE
9.
http://www.youtube.com/watch?v=mfE7Iwxu1GU
10.
http://www.youtube.com/watch?v=WwDfEuSE5V0
11.
http://www.youtube.com/watch?v=oHAKkKYFLo4
12.
Boilerrph87
Usually its tolerance to the opioid as to why you would increase the dose.
Then again increase in pain is possible if its acute pain. Its pretty easy to gauge a persons pain and what would best help them. Everyone thinks a person has to have years of experience but this is not true, I learned from my own chronic pain what opioid best kept it under control, and what dosage and how many times a day best helped my chronic pain. After years upon years of chronic pain eventually these opioids will lose their effectiveness and a person needs to titrate down and off. If a person can go without then all the better for them but usually the pain will be too much to handle and the process starts all over again.
That’s great you where able to help those people with their pain, did you ever know a hospice named Terry Lee Bovina.
With regards to opiate dosing, having worked hospice, hospital and LTC, I feel pretty comfortable in ASSISTING the physician in determining an opiate dose after a patient has been started on them and due to initial underdosing or increasing tolerance their pain is getting out of control. Purdue Pharma was always helpful in providing dosing charts to assist with calculations. I only made the recommendation, it was up to the physician to take it or leave it. And it was only for opiates that had no ceiling doses. Several times patients would come back and thank me for my assistance in the recommendations. The physicians I worked with appreciated it because they didn’t have a whole lot of time to sit and figure out the calculations.
I agree with you.. but.. what I am hearing from pts is that RPH’s are calling up prescribers and demanding that they lower the prescribed dose and/or cancel a drug for the RPH’s perception that it is not needed. It has been my experience that there are all too many RPH’s who base decisions on the published FDA dosing guidelines for opiates for NAIVE pts… and/or they don’t understand that addiction with opiates is a POTENTIAL ADDICTION not an absolute fact. Otherwise, everyone who got a couple of dozen doses for an acute issue would be an addict. IMO.. the RPH’s position is to seek a resolution..with the prescriber… to a drug allergy, major drug interaction or dosing issue… We may be the “drug experts” we are not – and never have been – the final authority. IMO.. the DEA stating that we are the final authority.. they are exceeding their authority
@Starwood500..I want to clarify a bit of my above comment. My OWN procedures for a dose change are when you get a fill for say (and I will use brand for ease of typing) Norco 5/325 #90 and then 3 days later come in with a script for Norco 10/325 #90 or say oxycodone 10mg and come back with a new rx for oxycondone 20mg. Maybe it’s the same doctor, maybe it’s a different doctor. This would prompt ME to contact to speak with BOTH you and the prescribing physician(s). In the case of the Oxys, I would WITH the physicians APRROVAL counsel you to double the oxy 10mg until they were finished and then fill the 20mg which I would hold for you and you and I would calculate the date. I would fill the Norcos because it’s a combo product with acetaminophen and to double the dose would risk overuse of the acetaminophen. On the Oxys, the insurance may or may not reject refill too soon in which case I would call and let them know it was a dose change and ask for an override and that I had spoken with the physicain. Generally for some reason insurance does not pick up duplicate Norco/Vicodin dose differences while our computers will pop up a DUR warning on all of these. I don’t know about individual states, But in Indiana, unfilled written CII scripts expire ONE YEAR from date written unlike a C III (vicodin) CIV (Xanax) which are 6 months from date written. I’ve double checked with our state BOP with this as I had an Adderall Rx for my son written in October and he ran out and his others were being mailed back from his college. Yes I argued with the filling pharmacy. Vindicated when the called the IBOP and they know I’m a duly licensed RPh. The 72 hr rule is for partial fillings on CIIs.
PLEASE GIVE OPINION ON THE DOSE CHANGE. Sorry for the caps. Just read another refusal to fill post. I appreciate your information and links to protect the patient that requires scheduled medication. I honestly can’t see how judgemental people can sleep at night. I certainly am not. So easy to pick up the phone to verify any prescription but why are they not?
I found there are plenty of chronic pain patients who never turn down a pain script from the dentist which is usually “Vicodin or Percocet’ based and is pretty much identical to what they are already taking. Some of them forget to tell the dentist of their pain meds. I always called the dentist and the physician to discuss a plan and make sure everyone was on the same page. Would be nice if it already isn’t included that a discussion with the pain doc cover… if major dental work is done, the chronic pain patient probably does NOT need a pain med script from the dentist. Responses I received were always..”tell patient to stop meds for chronic pain, take dental meds only, then resume chronic pain meds. OK…so how do I know this was really happening. I always documented the coversations on the back of the scripts. Not sure if that would cover me, yet maybe the extensive dental work would create breakthrough pain, I wouldn’t know because I’m not in their shoes. You counsel on risks and wonder if they even listen sometimes. Script refusals for me were based on INSPECT ( got 90 Vicodin 2 days ago at another pharmacy) and refill too soon. …too bad the insurance companies computers don’t pick up on the duplicate therapies when its a different dose, same ingredient to prompt a call the the doctors office for a PA or an explination from him to them..leave us out of it because we don’t have the chart.
Just had this discussion with my pain specialist and she stated that hydrocodone is the preferred med and the pain meds I take would be less beneficial in relieving dental pain. Always discuss these issues with your pain specialist and dentist.
Steve, I see your point, but I believe a pharmacist is supposed to use “judgement and discretion” when deciding whether to fill or not fill a prescription presented to them. Obviously “I didn’t feel like it” may not be acceptable, but “had 90 Hydrocodone 7.5/650 filled at another pharmacy 2 days ago” or “this prescription came from a storefront pain clinic two states away that would never answer the phone during business hours” or ” 16 ounces of promethazine vc with codeine for each member of the party(with 5 refills,no less)” should be acceptable reasons, right?
I had a article published in DRUG TOPICS about Filling prescriptions for controlled substances: Establish a protocol http://drugtopics.modernmedicine.com/drug-topics/news/filling-prescriptions-controlled-substances-establish-protocol#sthash.c61qkPwg.dpuf.
All too many miss the important part of my statement(s) legit/on-time/medically necessary..
I hear from all too many chronic pain pts.. that the RPH seems to look harder to find a way to say no.. or just doesn’t want to say yes.. so the easiest way to deal with a control med is to say NO…
Part of that protocol is that a pt is assigned a day every 4 weeks ( 28 days) which they can fill their 30 day Rxs.. work out issue with prescriber so that all refills are due on Tues-Fri .. no weekend refills or requests. IMO.. 30 day quantity/refilling only causes problems because of weekends… Educate/train the pts that this is the rules… if pt keeps coming in early.. then prescriber needs to get honest with directions or ban the pt from the store. Using multiple prescribers or pharmacies – RED FLAG the pt – don’t deal with them..
Most pts have their Rxs filled < 5 miles from prescriber, work, office.. RED FLAGGING a prescriber that writes the same meds for everyone.. is justified. Any pharmacy that stiffens their back with "frequent flyers" and cultivates the pts that are legit.. will have more legit business than they know what to do with... and after a couple of months.. the "frequent flyers" will go and take up someone else time. I think that if RPH tried to look at averages.. that "problem pts" take - on average - twice as much time as a compliant/legit pt. By and large, Pharmacy has failed to train/educate pts on what they should expect from us.. so.. each pt has established their own expectations and protocol and we find ourselves trying to accommodate all those "special rules " or exceptions to the rules.. and in the end.. we will continue to fail some of these pts.. because we have forgotten how we need to treat one of them special.
Steve,
Please differentiate between pharmacists refusing to fill a prescription because there is some need to verify and the pharmacists that are now refusing to fill any C2 prescription no matter what the reason. I understand where you would agree that it is sometimes necessary to verify some info on a prescription, but do you feel that it is ok for a pharmacist to refuse to fill any C2 rx? I am actually seeing signs at many pharmacy’s in Florida that they refuse to fill any controlled prescriptions and I don’t see how that can be legal. Those pharmacists with the signs are admitting that it doesn’t matter to them whether the prescription is legitimate or not. IMO the Florida statutes only allow refusal when the rx info is not complete or in error, medical safety (contraindications, etc.), or not in the course of legitimate medical practice. I have not read any other reason for a pharmacist to refuse to fill an rx. Please let us know what you think we should do when we encounter such a sign at a pharmacy. Thank You for your interest in our plight.
Steve,
I have a question, when my chronic pain first started hydrocodone was the only medication I could get for my chronic pain. This one pharmacy that filled 90 hydrocodone 5/ 500 said it was too soon to fill this new script but this new script was hydrocodone 10/500 . I told the pharmacist this is a new script from the same doctor because the last script was not helping my pain at all. I asked her to give it back to me and she wrote all over that script to not fill till the date she wrote on it.
Is this against some pharmacist law to deface a script by writing all over it.
I was so angry I whited out what she wrote and got it filled at another pharmacy.
This was a long time ago 1995. She wrote all over the top and sides and the bottom of the script where there was room ,DO NOT FILL TILL JUNE 18, 1995.
I like the way you explained things here, it gives me better understanding how to go about things during this “Pharmacy Crawl Epidemic.”