PHARMACIST STEVE

Inside a Pharmacist’s mind concerning the filling of controlled meds ?

8 Responses

1. 

   Walgreens Hater, on October 27, 2015 at 11:53 pm said:

   For me I wish I could do the same thing you did but Walgreens is the only game in town for me at present. There pharmacist,people and whole attitude is SUBSTANDARD in my opinion. I would love to flip the pharmacist the “bird” but that would be a guaranteed detox for me. I hate being locked into one pharmacy(DEALER).

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2. 

   Jbwilliams, on October 27, 2015 at 11:44 pm said:

   I purchased a medication reduction card at wallgreens 3 years ago, and after using it for three months, they told me I couldn’t use it for controlled drugs due to their new policy. I have never shopped at wallgreens since, and now they are purchasing rite-aid pharmacys, I will stop doing business with them. Walgreens can go to hell.

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3. » Another Pharmacist’s point of view… PHARMACIST STEVE, on October 27, 2015 at 11:29 pm said:

   […] Inside a Pharmacist's mind concerning the filling of controlled meds ? […]

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4. 

   lespaul1963, on October 27, 2015 at 1:58 pm said:

   RSD_Lady…Some of us pharmacists do have considerably more training in the are of treating chronic pain than others. In my home state of California, there are Hospital groups that have pharmacists managing chronic pain and cancer pain patient’s pain medication regimens under the supervision of a board-certified physician. One of the conditions of employment is that the pharmacist issued a DEA Registration number like the various classes of prescribers. That’s indicative of a collaborative practice agreement that allows the pharmacist to make significant changes in the patient’s regimen in a semi-autonomous fashion.

   In addition, in my own practice experience, I worked for a closed door operation that serviced Skilled Nursing Facilities as it’s core business. Most of the day to day care was driven primarily by nurse practitioners (NP) and a handful of physician assistants (PA). There was an MD that “supervised” these mid-levels, but that supervision seemed questionable at times. In any case, many of the NP’s were fairly inexperienced. Often enough, in doing the mandated DUR for a given patient, I’d see a poorly designed chronic pain regimen. When I called to question it with the NP who wrote the orders, I’d often encounter an NP who’d admit that he/she was unsure as to how to design a better regimen. The issue would be one of under treatment or poor utilization of the appropriate long acting opioids for baseline control with an immediate release opioid for breakthrough pain. I recall one regimen that had Acetaminophen 625 mg four times daily routine as baseline control ans oxycodone 5 mg every three hours as needed for break through pain. The patient was going through the as needed medication as though they were Skittles. To make a long story short, I very quickly learned to assess the germane written documentation and assessments, as well as getting the best current picture of the patient’s pain level by talking with the the nurses taking care of the patient. I ended up designing the regimens and the NP would sign off on what I suggested (I don’t have prescriptive powers).

   After a while, I ended up being one of the go-to-pharmacists for this kind of thing. It was a constant experience, because as soon as the NP had garnered enough experience to be able to land a better paying job with better working conditions, they’d be gone and I’d have another handful of newly-minted NP’s who I would have to teach how to design chronic pain control regimens. I can honestly say that my suggested designs resulted in patients whose pain was better managed, quality of life was improved and in some cases, went from non-ambulatory to ambulatory or ambulated to an improved degree from where they were. I never had any complaints and no one suffered bad outcomes from the suggestions I made, to the best of my knowledge.

   My point is that some of us do know what were doing in this area. I can say that many of the pharmacists that work in retail chains do not have my kind of practice experience; some do have similar to experience to mine and hopefully they are able to pass some of that on to their retail-chained colleagues (pun completely intended). There are some pharmacist’s that come out of school and do a one or two year residency that also pick up this experience. A residency provides the kind of selected, focused training that it might take one years to get in the real world. Keep in mind that the residency programs are relatively new. The residents are getting their training and information from pharmacists like me that have garnered the experience, knowledge and wisdom from day to day work experience. In my case, I had picked up enough experience to do what I was doing from seeing the same kinds of orders day after day and knowing the patient’s clinical states from chart records, lab records, nursing notes and MAR’s that I had access to. I also picked up some things here and there from particular co-workers who were specialized in a given area. Total Parenteral Nutrition (TPN) was one such area.

   As t having the right to challenge the prescriber’s order…in the practice setting I mentioned above, that challenging the prescriber was a day-to-day affair. Some of the orders I saw would have injured or killed a patient had they not been challenged and a more reasonable order suggested by us, the pharmacists. For me, the Law is simply the lowest metric that I use to judge what I do in pharmacy practice. It is the minimum. The item that drives the highest order of my decision-making process is what is in the best interest of the patient, from an objective, defensible stand point. The truth is, using that higher metric, I never once encountered a conflict where i would have to worry about my license being disciplined for a decision that I made. Perhaps the basis for pharmacist decision making is what you need to consider and address, as opposed to the fact that we do decide to challenge a prescriber’s order. To do otherwise, RSD_Lady, I fear will result in you tilting at windmills.

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5. Another Pharmacist’s point of view… | Pained Lives Matter, on October 27, 2015 at 12:27 pm said:

   […] is a comment on this blog by another Pharmacist/reader on this post https://www.pharmaciststeve.com/?p=12316  and points out the legal requirements of a Pharmacist in processing a prescription. A lot of […]

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6. 

   RSD_Lady, on October 27, 2015 at 1:00 am said:

   Can somebody please explain to me how a pharmacist can possibly believe that he or she has the right to challenge the doctor regarding the prescription of controlled medication? You cannot challenge something unless you are educated about that topic. When pharmacist want to go to medical school and specialize in pain management, then perhaps they would be qualified to challenge a doctor regarding the prescription he or she has written. But even being qualified to challenge the prescription does not give the pharmacist a right to challenge the prescription. I am dumbfounded by what this jackhole has to say on the topic. You have a person who is unqualified to make a call regarding pain management dosing and on top of that he doesn’t even have the right to challenge the doctor it is not his role. His role is to ensure that the prescription is not a forgery that it is a legitimate prescription written by a doctor whos DEA license for writing control prescriptions is active. Then the pharmacist has the responsibility to fill that prescription correctly with the right medication and the right dosing and that’s it. So as Bugs Bunny would say it: that’s all folks!

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   • 

     RalPh, on October 27, 2015 at 4:27 am said:

     Maybe the pharmacy practice acts and rules need to be modified, or if not, clarified so as to not leave a pharmacist feeling as if she is open to malpractice for just going along with doctors. Doctors are not gods and they are not always right. But pharmacists need to know that duty to collaborate and document does not necessarily mean a pharmacist has a right to refuse any prescription.

     Pharmacy, as defined in one state’s statutes, is “Pharmacy practice is a dynamic patient-oriented health service that applies a scientific body of knowledge to improve and promote patient health by means of appropriate drug use, drug-related therapy, and communication for clinical and consultative purposes. A pharmacist licensed to practice pharmacy by the Board has the duty to use that degree of care, skill, diligence and professional judgment that is exercised by an ordinarily careful pharmacist in the same or similar circumstances.”

     Here is what one state’s Pharmacy Board rules say about what is called drug utilization review. It is a REQUIREMENT that pharmacists perform it in most states. What is it?

     (17) Participation in Drug Selection and Drug Utilization Review:

     (a) “Participation in drug selection” means the consultation with the practitioner in the selection of the best possible drug for a particular patient.

     (b) “Drug utilization review” means evaluating prescription drug order in light of the information currently provided to the pharmacist by the patient or the patient’s agent and in light of the information contained in the patient’s record for the purpose of promoting therapeutic appropriateness by identifying potential problems and consulting with the prescriber, when appropriate. Problems subject to identification during drug utilization review include, but are not limited to:

     (A) Over-utilization or under-utilization;

     (B) Therapeutic duplication;

     (C) Drug-disease contraindications;

     (D) Drug-drug interactions;

     (E) Incorrect drug dosage;

     (F) Incorrect duration of treatment;

     (G) Drug-allergy interactions; and

     (H) Clinical drug abuse or misuse.

     SOOOOOOOOO…. one can understand how a pharmacist might feel as if drug abuse or misuse is a concern, because their own rules say so.

     It’s not as cut and dried as the pro-pain advocates would like it. The point of change is new laws that require any pharmacist who wishes to refuse a prescription first reach the prescriber and inform them of such denial. If the prescriber cannot be reached immediately, the pharmacist must actively find a pharmacist who will take over care of that patient so that the patient is served in a reasonable amount of time.

     And RSDLady, pharmacists are well educated on classes of medications. But like any general practitioner, deference must be given to specialists such as pain management doctors. BUT often in daily practice, family practice doctors (who treat ear infections and thyroid conditions) are trying to manage complicated cases with too quickly increasing doses of narcotics. Or with no safety nets for patients whose case becomes even more complicated. Not to mention, nurse practitioners and naturopathic doctors can prescribe in many states, and because of DEA interference they have started whole practices of pain relief, but they also are not specialists and a reasonable pharmacist would at least consider the legitimacy vs. misuse equation. But again, collaborate with prescriber or complain to the naturopath board…don’t PUNISH patients. Pharmacists cannot allow anyone to leave hurting without a treatment plan of action or they have shirked their duty.

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7. 

   kenneth, on October 26, 2015 at 9:14 pm said:

   The DEA are just glorified COPS. They can’t even catch el chapo. They should leave the business of Doctors to Doctors. IMHO

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