Drug Topics Voices 05-10-2014

Document the Dx

Re: ‘Filling prescriptions for controlled substances: Establish a protocol’ [Steve Ariens, April 8; http://bit.ly/ariens2]:

There is one thing I also use ... the actual diagnosis, which I document. With electronic prescribing, more scripts are coming in with ICD-9 coding.

Also, I get into a dialogue with patients, asking questions about details that an honest patient on chronic medication should be able to answer, regardless of their educational level.

It kills me that too many pharmacists (and technicians doing input) fail to document the medical conditions for which we are dispensing and about which we are educating the patients.

Marc L. Rubin, RPh
Crystal Lake, ill.

That D word again

I have never met Steve Ariens, but his article about filling controlled Rxs is excellent, and he is to be commended for his passion to make pharmacy better.

Remember, everything you do behind the counter can put your license at risk. If you are a chain pharmacist, check the central database to see if the person presenting the Rx is getting it filled at your other stores. Don’t be afraid to call up the competition to see if that prescription is geting filled elsewhere. As Steve clearly says, DOCUMENT everything. If you are taking all the proper steps, there is no need to fear the DEA, ADA, or the state board.

On a lighter note, here’s a true story: I was coming in for my shift one day and two cars down from mine I saw this individual put on a neck brace and take out a cane. He didn’t see me, but five minutes later he tottered into the pharmacy and put on an Academy Award-winning performance, trying to convince me that he needed 100 Vicodin. When I asked, “Aren’t you the guy with the blue car?” he ripped off the neck brace, picked up his cane, and bolted out of the store.

One more note: I have gotten prescribers to write out the quantity (ten, twelve, twenty, etc.) rather than the number, which can be altered all too easily.

Robert S. Katz, RPh
Stamford, Conn.

No dilemma for this doc

”Which is the better alternative? To let a few doses of a controlled substance go? Or to cause a chronic pain patient to go into elevated pain, withdrawal, a possible hypertensive crisis, stroke and/or death?”

There are emergency rooms built to help the latter. There are pharmacists in jail for the former. I know what I’d pick.

Dr. Zelman
posted at drugtopics.com

Here to help

In my opinion, we, as pharmacists, should altogether abandon the whole “questionable patient” mentality.

Far too many DPhs graduate with the requisite white coat and a God complex to boot. If a patient walks through my door wanting help, I’m going to help - that’s what I signed up for.

There is no room in healthcare for judgment. If you wanted to be a judge, you should have gotten a JD, not a DPh.

Justyn Williams
facebook.com/DrugTopics

Don’t forget the AMA

[Steve Ariens] did not even consider one extremely important newer aspect of our conundrum as pharmacists: the resolution passed by the AMA last year, basically telling us to quit interfering with their practice of medicine by our phone calls to verify legitimacy and necessity of controlled prescriptions. And on the other side, the DEA is warning us to verify, verify. And now a third side is after us with the ADA. What’s a poor pharmacist to do????

Anonymous
posted at drugtopics.com

And there’s the D word again

I’m not sure of the reasons for the vehemence of replies to this constructive article. We, as pharmacists, often have experience in characterizing the person presenting the prescription. Sometimes, it’s a patient’s representative handing the piece of paper over to the technician.

Sometimes, it’s the unknown voice on the other end of the phone. But there’s just ‘something’ about the anticipated transaction that doesn’t seem right. Out-and-out refusal as the only option in response to that hunch presents risks to legitimate patients. Development of a protocol for handling situations that are not clear-cut seems very reasonable. Especially for pharmacists who might not always work the same shift at the same site.

Documentation of inconsistencies in a factual manner when receiving the script is not only an appropriate safeguard, but a professional courtesy to the pharmacist following, the physician questioning, and others. As for photocopies. All pharmacies should have ready access to a photocopier if there is not a way to log comments by the pharmacist on a prescription.

Pharmacists should already have a habit of noting unusual situations by the time they are licensed. It is only reasonable.

Anonymousposted at drugtopics.com

DEA, do your duty

What constitutes “valid”? Seeing three doctors for oxycodone 30 mg? “Seeing” a doctor in Florida and traveling from state to state trying to get some fool to fill it?

The DEA should enforce special restrictions on oxycodone 30 mg. Before Oxycontin was reformulated, you never saw it prescribed. What percentage of oxycodone 30 mg prescriptions seems “valid” to most pharmacists? The DEA says it’s our duty to make sure there’s a valid medical purpose.

With so many notorious pill mill doctors in certain states, fake x-rays, etc., why does the pharmacist become the enemy? We shouldn’t have to be policemen, but that’s why we have PMPs now in almost all states. To help curb abuse. The DEA needs to help close the floodgates by first of all shutting down the “pill mill” doctors.

I don’t want someone to be in pain. But addiction without pain is not a valid medical purpose.

Judy Rector Fulton
facebook.com/DrugTopics

Red flags, green flags

Re: “Diversion of opioids: Red flags and green flags” [Ken Baker, Ethical decisionmaking, April; http://bit.ly/diversionflags]:

Red flags! Green flags! At the moment all I see is the white flag I feel like waving in desperation. MAC pricing issues, mandatory mail-order prescriptions, and PBMs forcing patients to use major drug chains (blocking contracts with the independent pharmacies that have made our profession great) are very much involved in my decision as to which patient I am able to service in pain management.

Even though no federal entity or supplier will take responsibility for the quotas that have been placed on our control purchases, those same forces inform us that if we exceed our quota we will lose our ability to purchase any controls. We are being treated like criminals for even attempting to service these patients after considering all the red and green flags.

My quota is 20% total control purchases according to dollar value, and manufacturer price increases destroy that figure in two seconds. I don’t have to worry about buying any opiates on an average day, because a bottle of Lunesta for an insomniac or Concerta for an ADD child will eliminate any ability to purchase for pain-management patients.

I just want my profession back and not be told by politicians, PBMs, or non-medical personnel how to practice appropriate pharmacy. I am a legacy pharmacist, female, having practiced for over 40 years in East Tennessee. The profession I entered as a calling is now becoming just a job.

The patients who enter my business deserve respect and service, not excuses for my inability to serve them. At the end of the day, I want to be able to put the key in the door with no regrets. After enjoying my family and friends in what is left of the day, I want to rest my head on my pillow and hear that voice inside say, “Well done, good and faithful (pharmacist) servant.”

How many flags do we have to check ... how many patients do we neglect ... which flag do I wave in this battle?

Anonymous
posted at drugtopics.com

Amen to that

[In response to the above post]: I feel your “pain.” This is a serious issue that the DEA needs to address at the pill mill level - how these prescribers are allowed to practice in the first place. Not much I can add to your post except “AMEN.”

Anonymous
posted at drugtopics.com

Got their number

Regarding Mark Lowery’s “CVS sued for suspected fraudulent Rx reimbursements” [April 18; http://bit.ly/cvsreimb]:

As much as I dislike CVS and am not a fan of CVS, in all fairness I have to ask, “How is it any more profitable to fill a controlled substance prescription without electronically submitting the physician’s DEA number, than electronically submitting the physician’s DEA#?”

This article does not specify the particulars of filling without a DEA number. Most pharmacy computer systems will not allow the prescription to complete without that information, so I doubt that the DEA number was not verified before filling the prescription.

My guess is that it was not electronically submitted because the insurance company was requiring the NPI number to be submitted electronically and not the DEA number, and now the insurance company is stating that because the DEA number was not submitted to them, CVS is guilty of processing a claim without the DEA number. What hypocrisy. Yet another example of how insurance companies are allowed to accuse anyone of wrongdoing without anyone being able to accuse insurance companies of wrongdoing.

At least it happened to CVS, the company that everyone praised for terminating the sales of cigarettes, despite its continuing to sell alcohol.

Ben Benoit
facebook.com/DrugTopics

Correction: “Iowa Medicare program costs pharmacists ‘thousands’” (Up Front in Depth, March 2014) incorrectly stated that Daytrana patches expire two weeks after the box is opened. The actual duration is two months. Drug Topics regrets the error.