Tighter Control on Vicodin?

A widely prescribed painkiller


So, before reading this blog post, take a peek at this article:  http://www.latimes.com/news/local/la-me-0126-vicodin-20130126,0,4066484.story

I’m not going to comment on whether or not this is a good move because, truthfully, there’s a lot to be said for both sides of the coin. There would be patients–legitimate pain patients–who would suffer from this being approved. But, there would also be a lot less abuse (or so we would hope). Regardless, I’m not going to comment on whether this is good or bad. I can tell you one thing, though:  this would make life in a big chain retail pharmacy a nightmare. Can you imagine having to be the only one allowed to count out every hydrocodone-based prescription? I don’t know where we would store it all to be honest. But, I digress.

The real thing that should be focused on here is how we, as a health care community, look at “chronic pain”. There are so many chronic pain sufferers out there, and each is different. My thoughts are that instead of reclassifying the most commonly prescribed medication in the US, we should reclassify how it is prescribed. No primary care physician should be the main person writing for a chronic pain medication. Chronic pain patients should be going to a pain specialist. This should be required. This is not only to insure the prescribing is done correctly, but to help the patients find the best possible relief. Now, I’m not saying there aren’t pain doctors out there that give out narcs like candy, but they are better equipped to be writing for these patients. I feel like writing for chronic heavy duty narcotics is out of a primary care physician’s realm of practice. Primary doctors are too quick to write a chronic lower back pain patient a script for Percocet many times. Shouldn’t they be trying out other options, such as Cymbalta or gabapentin first before going to a potent opioid medication? I think people should exhaust all other options first before starting with meds like that, including things like acupuncture and physical therapy. It’s very difficult to get off opioids once you’ve been taking them for a while. You can always go forward if it’s not working, but it’s hard to go back.

The other thing that makes the world of opioids so tough is the lack of communication between physicians, sometimes due to the patient not telling the whole truth. We had a patient who is taking both Suboxone and Percocet on a daily basis. She stopped coming to our pharmacy because we questioned why she was on both and asked if we could contact her physicians about therapy modification. There is no reason she should be on both. I wonder if her two doctors know that she is on both medications. How it ever went through her insurance is beyond me. Usually, that kind of interaction requires a prior authorization, so either one of the doctors did the prior authorization without thinking or the insurance let a major drug interaction slip by. Whichever it is, it truly points to a problem with the way this nation treats chronic pain and opioid dependence/addiction.

It really saddens me. I wish that the FDA would focus on where pain killer abuse starts instead of where it ends. We need to be proactive about health care, not reactive. If we can prevent opioid misuse by better regulating how and by whom the medications are prescribed, then we won’t need to restrict them in the pharmacy as much. But, that’s just me, a lowly pharmacist who receives multiple 7 to 10 day early fill authorizations from the same primary doctors every few weeks. Who am I to argue?


Image courtesy of http://www.latimes.com/news/local/la-me-0126-vicodin-20130126,0,4066484.story


Out of Control



Hello everyone! Long time, no post. I had been in the midst of moving my pharmacy. It took lots of planning, cooperation, and teamwork, but it went smoothly and now I can relax again. I will probably go on another hiatus in the upcoming months to study for a law exam. I am in the process of transferring my license to another state, and as soon as I get my authorization to test, I’m going to go back into student mode and study my buns off. But, for now, I am going to return to regular blogging. =)

So, today’s story is one I encountered a few days ago. It was the end of the night, and we were getting ready to close. A woman comes in, and one of my techs goes over to help her. She had some medications to pick up and she had requested print outs of last year’s medications for both her and her husband over the weekend. The policy at our store (in compliance with HIPAA) is that the person for whom the print out is for must be present to receive it. They also have to show ID proving they are who they say they are. The only exceptions are 1.) parents may pick up for children aged 17 & under and 2.) people who have power of attorney over another person may pick up for that individual (in which case, we ask them to bring in the POA paperwork once as proof and we mark it in our system). If the individual is not present and does not fall under one of the exceptions, we are required to mail it in our super spiffy confidential envelopes. All of our techs have been informed of this, but our newest tech dropped the ball and told this women she’d be able to pick up both hers and her husband’s.

Not surprisingly, the woman was upset. I apologized, as it was the fault of our technician’s. As sorry as I was, though, I was not about to break our HIPAA abiding policy. It’s there for the protection of everyone’s privacy and is a good policy. I offered to have it mailed first thing in the morning, letting her know I would personally ensure it got mailed. The woman kept ranting (again, not surprisingly), and I kept apologizing. Up to this point, this is a normal upset patient scenario and one I’ve dealt with several times. I take the brunt of the anger and apologize for a tech’s mistake. Usually, they either calm down after yelling a bit or storm off. This is where things got interesting and where the patient turned from angry to out of control.

She asked to speak with my manager. My manager happened to be standing not far away when the situation started, so I called her over. She also knows this print out policy, as she used to be a tech before becoming a manager. She attempted to intervene and calm the lady down. She offered her a gift card for her trouble (yay, retail store policies of feeding negative behavior!). The lady refused the offer and started to yell louder. She turned back to me, walked towards me, and got right in my face (we’re talking less than six inches from me). She started banging on our counter, and I became scared she would get physical with me and grab me by the collar of my jacket. Her yelling also started to scare the other patients in the pharmacy area. A good ten minutes go by, and this woman has not calmed down (she was actually yelling more) nor accepted any form of apology, telling us instead that we weren’t sorry. She’s still banging on our counters and is now pacing the length of the pharmacy. She kept returning to get as close to me as possible (at this point, I had stepped back a bit so she couldn’t grab me). Those shopping up front could hear her across the store and suggested to the girl working up there that she call the police. Just as my manager decides it may be a good idea to call the police, the woman finished her rant and left, continuing to yell all the way out the doors.

This was one of the few times I was actually scared of a patient. At first, I felt really bad for her. She was misinformed and had every right to be upset and angry with us. But, there is a point that most people reach when they’re yelling where they realize their carrying on won’t fix anything, so they either calm down or leave. I have never had anyone get right in my face like that before. She is one patient I hope never returns and transfers everything elsewhere. Being outright abusive to our staff is uncalled for and does not fix things. You have the right to be angry; you don’t have the right to be out of control like that. When you start scaring other patients and customers to the point where they tell our employees to call the police, that’s when you’ve gone overboard and need to stop. In the end, I still didn’t break HIPAA, and she still left without her husband’s print out. I did mail it the next morning, and it should be at their house by now. But, man…what an experience that night was.

The ironic part of this whole thing is that her husband’s print out contained five items from all of last year. She was out of control over a piece of paper with five items on it. *shakes head*


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Quick, off topic post today. I am very excited tonight. A few other pharmacists and I have just submitted a paper for review to the Journal of the American Pharmacists Association (JAPhA). The project it entailed actually began when I was a student. A then fellow classmate (now fellow graduate) of mine has piloted a lot of the study. We’re all very eager to hear if it’s accepted or not. I’ll let you guys know if it’s published! ^_^


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A New Endeavor


Hello everyone! I’m back from vacation! I’ll be back to posting pharmacy entries soon enough, but I wanted to let you guys know about a little side project of mine.

A fun fact about me is I have been involved in long distance running since I was 10 years old. I have always enjoyed the endorphin rush I get from pushing my body to its physical limits. I haven’t been actively running or training for the past few years, but recently decided to get back into it. I set a goal of completing a half marathon (13.1 miles) this fall. I am going to be documenting my progress on another blog (RPharrier). Check it out if you want. Hopefully, I will continue to train for longer races after this one. If I do, I will continue to use that blog. This will be my only little advertisement of my other blog I will post on here, but a link to it will always be on the sidebar.

So, here’s my question to you guys. It seems like every pharmacist out there has his/her own way of dealing with the pent up frustration and stress that accompanies our profession (regardless of what area you practice in). What is YOUR personal stress reliever? Leave me a comment letting me know. =)


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Today, I dealt with several transfers from other pharmacies. There were more than most days, and the common factor seemed to be confusion as to why it would take longer than 15 minutes to fill their prescriptions. Try as I may to explain why, there were just some people who didn’t understand and, therefore, were annoyed and irritated. So, here’s a step-by-step list of what has to happen in order to transfer refills from one pharmacy to another. This list does not include transferring within a chain (ex. transferring a prescription from one Walgreens to another). That process is less cumbersome.

For ease of explaining, Pharmacy A will be the pharmacy you last had the script filled at, and Pharmacy B will be the pharmacy you want the prescription to be filled at now.

Step 1

The pharmacist on duty at Pharmacy B must gather as much information about the prescription(s) you need as they can. When people have their bottle(s) from Pharmacy A with them, it’s a blessing. The more information the pharmacist has before continuing past this step, the faster the transfer will be made.

Step 2

The pharmacist at Pharmacy A must be called by the pharmacist at Pharmacy B. This can only be done by pharmacists and, in some places, pharmacy interns (those studying to be pharmacists).  Therefore, both the pharmacists at Pharmacy A and B must be available for a few minutes per prescription. Depending on the workflow at either store, it can take a bit before the pharmacist from Pharmacy B can make the call and the pharmacist from Pharmacy A can answer the call. I once sat on hold with a mail order pharmacy for 20 minutes before I got a hold of someone.

Step 3

The following information must be documented on prescription pads by the pharmacist at Pharmacy B:

  • drug name
  • drug strength
  • medication quantity
  • directions
  • number of refills remaining
  • prescription number from Pharmacy A
  • date the prescription was written by the prescriber
  • date the prescription was first filled
  • date the prescription was most recently filled
  • the prescriber’s name and credentials
  • Pharmacy A’s address and other information
  • the name of the pharmacist at Pharmacy A

The pharmacist at Pharmacy B must then share his/her name and Pharmacy B’s information with Pharmacy A.  Pharmacy A must document this in their system before continuing. This must be done individually foreach prescription that is transferred. This is why it takes a few minutes per prescription.

Step 4

Pharmacy A inactivates the prescription(s) in their computer, and Pharmacy B fills the prescription(s). That’s where the regular filling process kicks in. See the steps in my entry entitled “Narcs” to see what that entails.

Some important things to know about transfers:

  • Narcotic prescriptions cannot be transferred.
  • Some places do not allow for controlled medications of any kind to be transferred, even if they have refills.
  • Prescriptions can only be transferred if the prescription has refills and is not expired.
  • If you are transferring from a mail order service to a retail pharmacy, you may not be able to get the same amount of medication in the store as you do through the mail. A lot of insurance companies (in the US) allow for 90 days’ worth by mail but only 30 days in the pharmacy.
  • The prescription cannot be transferred if the pharmacy it was originally from is closed.

So, that’s my spiel for today. Hopefully, this entry wasn’t too confusing. Hope your days are all going great! =)


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Routes of Administration


Today, I ran into an issue that should be shared with all patients. I saw one of my favorite wife/husband patient combinations during my shift. I met them not long after starting at my current pharmacy, and I was able to help them save some money on prescriptions. They have sought me out for advice ever since.

Today, they came into the pharmacy to return a steroid cream. I asked them why, and the wife responded that the list of side effects on the medication guide scared her. She said she had decided not to use it. I asked her if she has discussed not using it with her physician, and she told me she had not. So, I started to go through the medication guide with her sentence by sentence to see what was the most troubling for her.

After some explanation, I realized the side effect she was most worried about was the immunosuppressant effect steroids can have. I explained to her that this adverse reaction was not one that should concern her too much. I told her that this effect happens after months of therapy and is more likely to occur with oral steroids. She calmed down immensely afterwards. She ended up taking the medication back home with her. I encouraged her to call or come back if she had more questions.

I have come across this situation a few times before. A patient has a non-oral therapy. They decide to read the warnings and other patient information, and they come across side effects that are mainly related to the oral form of the drug. It scares them, and they stop taking it. Once they realize there is no reason to worry about side effects A and B, though, they calm down and become more adherent.

One thing patients need to realize is that the medication guides that print out with the prescription labels at the pharmacy are required to include everything under the sun for that drug. It will include the side effects for the oral form, as well as other routes of administration (topical, rectal, vaginal, etc). So if you are picking up a prescription for a non-oral medication and are concerned or unsure, ask the pharmacist which side effects are the ones most likely to happen while you’re on it. Try not to scare yourself out of using the medication before you ever use it. As a general rule with many medications, you will probably never experience most of the side effects listed on the medication guide, especially if the prescription is for something non-oral. They are there to tell you all the possibilities for every person who might ever use the medication, not to forecast what will definitely happen when you use it.


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