The Pharmacy Chick

Flying the coup in retail

Ok. Lets let the Doctor speak about the subject…

Filed under: Uncategorized — pharmacychick at 5:14 pm on Tuesday, June 29, 2010

So, Pharmacy chick wrote a post about legit narcotics users being treated like second class citizens because their drug seeker counterparts make them look bad.  Because I implied that Doctors contribute to the problem by continuing to give narcs to seekers (cant seem to see thru their lame stories), one commenter added that it “wasn’t that easy” to deal with them.

I countered that a few phone calls to pharmacies around would garner enough info to determine the status on a sketchy patient.  Most would be more than helpful to provide dispensing information for the MD to make informed choices about servicing certain patients.

I don’t know how many PROVIDERS read my blog, but I am inviting you to comment.  Tell us why you give narcotics to people you suspect are scamming or lying to you and how  you stop,  when you finally have had enough, and finally, how often do you call pharmacies or other providers to see if the (said patient) is popping up there too.

Because…Pharmacy Chick really wants to know both sides!


Comment by provider

June 29, 2010 @ 6:05 pm

they may really be hurting. they may require a series of complex cares that require their cooperation. it may be very important that they show up for followup…it may be the only thing that keeps the critical caregiver linked to and committed to the patient. they may really be hurting. i can say no and a lot of patients feel i am a creep, and a lot of patients manipulate their misery to get narcs. even by intentionally making themselves worse clinically. we have a statewide prescription database, and it is still not easy, and i am sure i still make mistakes. in both directions.

Comment by provider

June 29, 2010 @ 6:18 pm

also, the person picking up the script may not be the patient, or may be the patient with a totally different presentation and attitude.
we know the difference between the patient and a patients agent. we have to make that determination at the onset.

Comment by Dr. Grumpy

June 30, 2010 @ 5:25 am

I try to give all the benefit of the doubt. If I am suspicious, though, I search the state database. And if I catch them, they’re toast.

Comment by JustADoc

June 30, 2010 @ 8:16 am

I have found the state database to be somewhat problematic at times. Is ‘Jason Smith DOB 3-16-1954’ the same as ‘Jason P. Smith DOB 3-6-1954′ and Jason T. Smith DOB 3-16-1954’ and ‘Jason Smith DOB 3-16-1953’. Could be. Maybe even probably is. But it could be different people. And the database only looks for the person you type in. It might not even catch the other 3 very similar names/DOBs. And some people travel a long long way to their various pharmacies and doctors. I caught one guy who used at least a dozen pharmacies over 100 miles from each other under at least 5 different name/DOB combos.
And then of course some people have legit pain AND are abusers as well. They can be very difficult to treat, but they still need treatment.
My experience is that eventually an abuser will mess up and be caught, but sometimes it takes awhile. And then they usually just move on. There are a million doctors and I have no idea how many pharmacies in this country.
And I will note that I get maybe 1 call a year from a pharmacist letting me know that they are concerned about someone potentially playing the system.

Comment by R. May

June 30, 2010 @ 10:58 am

Chick, do you have discretion to require ID? It might help control the similar names dob that pop up in a database.

I know when I go to the Dr, they put in my name based on how I fill out paperwork, and they don’t check my DOB. Same with the pharmacy.

Comment by Debbie

June 30, 2010 @ 10:51 pm

Hi PC. Thanks for responding, and I am glad to read that I am not the only provider to struggle with balancing the absolute necessity of adequately addressing pain and avoiding over-prescribing, avoiding feeding addicts, and helping legitimate pain patients avoid unnecessary side effects, habituation, rebound pain, etc. Provider reply # 2360 makes a couple of excellent points as well. When I can, I prefer to prescribe large numbers of “pills” very seldom, using longer-acting preps or patches, etc. And I ALWAYS appreciate hearing from pharmacists, talking with them personally about an individual, especially if there are doubts about the wisdom of filling a given amount or drug. Thanks for opening the dialog. Rest assured that we get just as frustrated, just from a different angle! WE also get angry with providers who are either lazy or negligent in their narcotic prescribing habits!

Comment by Sarah G

July 2, 2010 @ 12:04 pm

It’s definitely a good idea to avoid prescribing large amounts of pills. We recently had a home invasion in our area (central Kentucky) where the target was a bottle of recently-prescribed pain pills for a car accident victim. Pretty low.

Comment by Ellie

July 10, 2010 @ 1:43 pm

If I think I’m being scammed? Um, I don’t give controls, why would I?
OK, two exceptions, I admit it:
Acute injuries only: think compound fracture. Not flare up of longstanding injury, not usual musc-skel pain, not dental pain, not HA… and then I give them sparingly. Not “#60” as a reflex. I also write for 2-3 day supplies and require a trip to the office to get the refill rx if I think this is going to require more than 2-3 days’ treatment, which is usually unlikely (not always requiring an office visit, but come down to pick up.) We have had one (one) post-op patient who truly did not receive appropriate post-op analgesia from his/her surgeon, and we provided that coverage as well.
I also cc my note to the EDs when I do this. Small isolated area, so the pt can’t just drive 30 minutes. Most places don’t have that option, though.

And hospice situations – but even then I keep close tabs on the narcotics. I await enraged comments (Oh, no, teh mean lady does what?), but, guess what? Addicts can be terminally/painfully ill too, and their ‘friends’/families still steal/divert drugs. I will treat pain in that context even with known active drug abuse, but I will not feed the whole family’s habit. I try to make sure meds are given by home health/observed, I get away from prns (which I almost never give anyway), and, in a couple of rare, really grim situations, I’ve put the whole family on a behavioral contract that involves UAs for the family. With good reason, as it turned out. Because there ARE low-down people who will steal their dying relative’s pain meds – and I think that intervening in that situation did make the patient’s last months much more comfortable and safe.

I work in a clinic with a very high percentage of addicted/abusing patients right now, so it’s been easy to make the changes below system-wide. One of my other work settings is in a drug abuse treatment center. Therefore I’m probably going to come off as a bit paranoid to some of you. These are all lessons learned the hard way. Will be curious to see if the Chick thinks this is overkill or if I’m not going far enough.

We’re required to have ID on file for patients for our state’s Medicaid. It’s just clinic policy to have ID on file for everyone now. All the pharmacies in town check ID for whoever’s picking up a controlled substance, as far as I can tell…

Standard practice for every patient and EVERY controlled substance rx in our office: we write the pharmacy to be used that day on the rx – call us if you can’t fill, red-pen in the new one. And we note the insurance used in the office on the rx. Amazing how many scams we catch that way when the pt requests to pay cash instead.

My state doesn’t have a database. We need one, badly, but we don’t have one.
We DO have access to the larger hospital’s EHR, though, if we sign up for it. That’s very helpful.
I or my nurse routinely call the pt’s self-identified pharmacy for the last few fills. He knows to just call if the pt is here for anything pain related before I even go in the room. If the pt has filled at other pharmacies in our chart, we’ll call any ‘dominant’ pharmacies. And if the pt lives on the far north side of town and says that she or he wants to fill on the inconvenient/expensive south side of town, and doesn’t work there… we’re probably going to call the ONLY pharmacy on the north side of town and check with them. {May I say how nice everyone at the pharmacies has been when we do this? We try to not over-call, and we have our questions ready.}

My personal policy is to almost never phone in controlled substances. I will fax them in when possible. I will handwrite them as above. When the e-prescribing software changes to permit it, I will (with trepidation) do that. But I have phoned in 2 controlled substances in 12 months, and I have phoned them in personally, each time explaining why I was calling – stuck at airport, etc. – and leaving my pager number to confirm prn. I don’t delegate it to nursing. I have made it clear that I don’t do this. Again, small town, but… this meant that when someone DID get the Bright Idea of phoning herself in some Xanax under my name and saying she was my nurse… because she was, for that one week… the pharmacist thought that was kind of weird for me to have someone else do it and paged me. I do everything I can in writing and directly to the pharmacy when possible. Giving someone else the power to manage my narcotic rx, as in calling them in to a pharmacy on my behalf? Hahahahaha. NO.

My state has a fairly navigable court records system. I look up everyone on it. (I expect more outrage.) But – when I see a sweet young mommy with “back spasms” from carrying her toddler – and then see the history of 8 prescription fraud charges/convictions in the past 5 years – I have to think that perhaps there may be the possibility of substance abuse or diversion here. I will, of course, address her complaint – I will take it seriously, and I will evaluate appropriately. But I am unlikely indeed to give her any controlled substance, and no way am I giving her a written prescription to take with her.

There’s more. Those are the most basic elements, though.
Excellent comment Ellie, I can see that you take your prescribing seriously and I would bet that drug seekers probably figure that out right quick and steer clear. Thanks for sharing that insight. It clearly took some time to write that comment! and NO, the Chick does not think it is overkill. I am very impressed! Thanks for reading and THANKS for writing!

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