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





Today was a bit busier than yesterday. We had quite the Sunday rush, and the front store was short a person thanks to the stomach bug that’s been going around. So, all in all, I guess I got what I was wishing for yesterday, haha.

The major theme I came across today was people’s reactions to pain. It amazes me how different people are when they’re in pain vs. when they’re not. They are almost a completely different person. I personally know a few people who suffer from chronic pain, so I have known about this phenomenon for a long time. But still, the reactions I see in the pharmacy sometimes surprise me because they’re so over-the-top.

There was one woman who came in today. She had just had major abdominal surgery done and was in a great deal of pain. She brings in a script for a narcotic pain medication. When it was run through her insurance, I received a rejection message stating it was too soon to be filled until the following day. I told her this, and she asked if she could just pay cash for it. I refused because of what the medication was. Had it been a non-controlled maintenance medication, then I would have let her pay out of pocket without any problems. But, seeing that it belonged to the most controlled class of medications, I politely told her no.

She immediately started screaming about how much pain she was in and that the doctor told her she could get it filled early because the directions were changed. Because she had gotten it at another pharmacy the previous time, I could not verify this without calling them, and they were closed. I told her if she got a hold of her doctor personally, and he authorized the fill over the phone to me, I would fill it, otherwise, my answer remained the same. She banged her fists on the counter and continued yelling. She couldn’t understand why it was her responsibility to call the doctor and not ours. At our pharmacy, when a person insists a narcotic is allowed to be filled early, the pharmacy personnel do not call on it. We have quite a number of people that have had past issues with prescription drug abuse, so we choose not to cater to them for safety issues.

To make this long story short, the physician did end up calling me and verifying that it was, indeed, allowed to be filled early. He stated that he gave her a very limited amount of pills for this very reason. I filled them for her, wanting to just get her out because her carrying on was making some of the other patients in the waiting area nervous. I went to the register to start ringing her out. That’s when it happened–the words, “I’m sorry,” escaped from her mouth. It’s very rare that we hear apologies from the people that have two year old inspired tantrums over their medications. I was shocked. She apologized for her behavior; she was just in a lot of pain. After some more apologizing, she left.

Other similar things happened today, all of which were due to the patient being in pain. But, that was probably the best story of the day.


Image courtesy of http://i834.photobucket.com/albums/zz268/Sticher/pain.jpg




Today felt like national narcotic day in the pharmacy. It seemed like every couple of scripts was for a narcotic medication. It made for a very busy day. The most common complaint I got was, “Why does it take so long to fill my medication?” So, here’s my answer…

The normal filling process at the busiest hour of the day takes about 15 minutes, if all goes smoothly and there are three or less prescriptions. Why is this?

1.) The person that takes your prescription from you has to type all of the information on the script into the computer. If the prescription is easily legible or typed, the process will take about 1-2 minutes for each prescription, depending on how fast the person can type. Any questions or illegible handwriting means the prescriber needs to be contacted before it can be filled and dispensed. I can’t count how many times I have to verify the strength on prescriptions because decimal points are omitted.

2.) After that, the prescription has to be submitted to the insurance. If it’s accepted, this process takes about a minute. If it’s rejected, that can extend the time anywhere from 2 minutes to 2 weeks depending on what the rejection is. This is the step that aggravates most people, pharmacy staff included.

3.) After the insurance step, comes the actual counting and labeling step, which is the easiest part of the whole process. A good technician can count 30 pills out in about 45 seconds if they’re on a roll. But, add in 200 other prescriptions to fill during the busiest part of the day plus phone calls and ringing register, and you’ll have some back up in the production line. So, practically speaking, we allow them a few minutes to get through each person.

4.) The final step in the process before checking out is where I come into play. I need to double check each prescription that is filled, even if I was the one who counted out the pills. I have to make sure each script was entered right, billed correctly, and filled properly. If everything is straightforward, I can verify a prescription in less than a minute. But, between answering doctor calls, counseling patients, and correcting errors, the process takes much longer at the busiest hour of the day.

So, where does a narcotic come into play? In many pharmacies in the US, narcotic medications can only be counted by an on-duty pharmacist. So, this breaks up the normal production line. I have to make sure I am well caught up before filling a narcotic because I won’t be able to verify anything while I’m filling it. These medications have to be counted twice, and the remaining quantity in any stock bottles have to be counted and logged in a log book. There is more documentation that goes into narcotics prescriptions than other medications, and this can only be done by the pharmacists most of the time. The counting and filling of a narcotic alone takes a good five to ten minutes depending on how many tablets and if I receive any phone calls or questions during that time frame.

So, yeah, narcotics make for busy days. The more there are, the longer it takes for me to get medications out to my patients. I wish I could make people understand this. I feel like if they knew what went into filling narcotic scripts, they’d be a bit more understanding. Then again, maybe I expect too much out of people.


Image courtesy of http://i664.photobucket.com/albums/vv5/narcotic_photo/Logos/logodefausschnitt-1-2.jpg