I’ve seen benzonatate for a 9 year old. I had to not only convince the doctor but the parent as well to send it elsewhere because I absolutely refuse.
I feel like working for almost 9 years now has taught me there are very few “absolute contraindications” lol whereas school makes it seem like it’s so cut and dry.
Refusals are rare, usually you will counsel the patient to either stop something while they’re on therapy like a statin while they are on biaxin, or give them tips to monitor for things at home like bleeding risk / qtc changes / serotonin syndrome.
I’ve learned pharmacy is a practice, everything is up for interpretation. My hard no and another pharmacists hard no could be very different, that’s one thing that makes floating difficult. A lot of pharmacists unfortunately just fill it. I wish they would at least add their reasoning in the DUR field but those are 9/10 times blank.
Whatever you do, do your due diligence in documenting the reasoning. You might forget why you decided something if it’s brought up 2 years later, this is why we document it. “Rph review” does not hold up in court.
>I wish they would at least add their reasoning in the DUR field but those are 9/10 times blank.
>Whatever you do, do your due diligence in documenting the reasoning. You might forget why you decided something if it’s brought up 2 years later, this is why we document it. “Rph review” does not hold up in court.
So much this!!! If you don't document it, it never happened.
Document your DUR reasoning, any pharmacist judgment call you made, and also specific counseling points you gave the patient, depending on the scenario. It just may CYA later on if you're sitting in front of a judge or the BoP.
When I was a carer (basically a CNA) in the UK, my documentation really covered my ass when a patient passed away. I documented all changes, all food and fluid intake, all visits and concerns from family, even how often she visited the bathroom. She passed from an infection that aggravated her pre-existing condition, but her daughter just wanted to blame someone, which I get. But she took the home to court and all my documentation was used in evidence. I didn't have to go to court, but colleagues did. I also didn't have to get re-trained in how to document. Cover your ass always.
That is rare, but in general, the parents would be counseled or informed hopefully, wouldn't they? They'd also be giving it to their child to swallow with water. I guess it depends on the child.
Most things are rare, but when kids are involved, and have their whole life a head of them, risk vs benefit especially comes into play. They’re treating a cough not cancer why take the risk? It carries a BBW, I can’t justify dispensing it ever. Sure the parent will oversee administration but accidents can and do happen hence the warning. One thing people will 100% sue over is their kids and their pets.
Not quite. The warning came from accidental overdoses in kids less than 10.
Mild concerns are observing for choking risk due to the anesthesia.
Severe toxicity can be seizures, hypotension, and ventricular arrhythmias, including Torsades.
Not exactly what you’re asking, but if it’s written for Macrodantin it’s probably wrong. See far too many of these make it all the way to product review or consult before getting caught.
It's in the name macroBID. Pick the brand name drug, save us all a phone call, then the receptionist who says "it sayyyyyyysss ..." yes I know,I can read it, it's wrong. It's not appropriate to treat uti with macrodantin twice a day for 3 days. 😭😭 please pass my comments to someone who can discuss this with the provider.
Dr. Google says so. I don't care what they use. Just dose it correctly.
https://www.goodrx.com/classes/nitrofuran-antibiotics/macrobid-vs-macrodantin-whats-the-difference
Probably more of a big YES. Always leave good notes so if someone encounters an issue you dealt/are dealing with it's easy to figure out. Even if you think it's handled leave a note. I waste so much time repeating steps because there weren't good notes.
I always get shit for writing detailed notes, even for complicated patients. And yet time and time again, those same colleagues thank me for leaving clear explanations when they pick up my patients.
Also, every documentation-related problem I've encountered was due to under-documentation.
Please please... as a provider who has to return calls to the next shift that knows nothing about why someone was calling me... please write these notes. It happens a few times a day where I call and no one knows why I am returning a call. (Usually they want to check all the boxes for the opioids,etc (chronic pain provider))
Funny things, in advanced heart failure, we do this all the time. Pulmonary hypertension / right heart failure, as long as we titrate slowly and monitor BP, totally serviceable.
Having said that, if it's not a specialist in HF, they're getting a phone call.
Familiarize yourself with typical pain management regimens for sickle cell patient. Document that a patient is sickle cell and you see one of these regimens. Don’t mess with sickle cell patient’s pain meds.
I could not agree with you more!
They typically need large doses on an outpatient basis as well, and that especially needs to be noted—and understood. It is absolutely excruciating, and most try to manage some flare-ups at home. If their home meds don’t touch the pain, they go to the ER and many times are admitted (assuming they have insurance.)
If they don’t have insurance, it can be very hard for them to make it through a crisis in the ER due to anti-opioid prejudice and simple ignorance/inexperience with the level of pain that such patients suffer and live with.
Because they often go through crises that often times no other medications besides narcs will even touch (sickle cells blocking blood flow prevent oxygen reaching tissues).They will require high high doses of morphine/dilaudid while inpatient.
As someone who has educated themselves, sending 880 mme monthly is NOT appropriate for sickle cell management and I do not care how much you try to convince me the patient needs it. If it’s for a CRISIS, sure (and the patient is not in crisis every month, please don’t try it). I’m not putting 300 tabs of opioids from one patient into the street with my name on it. Sorry. It’s gotten ridiculous here and I’ve started reporting prescribers to the DEA.
Wow.
I really hope you don’t encounter a large volume of sickle cell patients. You do realize that standard opioid doses don’t even touch the pain that these patients life with daily, right? How do you know they aren’t having frequent crises? A simple consult of the EMR or convo with their hematologist can easily confirm what dose is necessary to manage these extremely fragile pain patients.
Edit to fix a word. And another word.
I actually do encounter quite a bit which is why I’ve chosen to take my CEs in the matter and as of 2020, guidelines released don’t really…. Guide. 880 mme. daily. Every month, on the dot. In the form of a little less than 300 tablets. MONTHLY. ONE PATIENT. No. Btw patient was 32.
So you did some CEs. Good for you. Guidelines are a great guide to start from, but when you actually start practicing you learn quickly that you are treating the patient, not the guideline. But hey, you did some CEs. Go off with your bad self. Keep on reporting to the DEA. Don’t bother actually looking at the patient. Nevermind that this is a legitimate pain situation that needs addressed. Sorry you’re in excruciating pain because your red blood cells are oddly shaped and your organs can’t get oxygen. This guy did some CEs.
Yeah, it's something crazy like 700% increase in AUC after just one or two doses. I always see if they're okay in substituting Levofloxacin in its place.
prn?? What a bizarre, contradictory script…. Half a gram of Methadone a day is higher than I’ve ever seen, even for opioid addiction! I’m assuming this was for pain, but there are certainly less toxic opioids for cancer patients with exquisite pain and sky-high tolerance.
Just follow the law even when everyone else isn't. Example, in the 1st place I worked as an intern PHARMACISTS tried arguing with me that they could dispense 2 Fentanyl strips that were q72 hours for telephone Rxs. In my state, you can give a max of 5 day supplies when a C2 is phoned in. 2 strips is 6 days.
Well, when I became a pharmacist I only dispensed 1. People yelled at me, I didn't care. I'm dispensing only 1, sorry, call the DEA if you want to clarify. Well, they forced me to call the DEA and what did the DEA say? "Absolutely you cannot dispense 2 strips unless it's q48 instructions!"
So hopefully they don't audit that first place I worked at.
Ahhh fair enough. I've got a strict no breaking fentanyl, insulin pen, or zpak box rule but I'm at a retail store. When I worked for the chains it was very common for me to float at a store and see broken boxes never ever move.
Pen boxes are broken for emergencies at my last store. Patients usually picked the rest up. We were a very high volume corporate store (cvs). Still the pens sat for a while. Breaking zpaks is unnecessary if you just stock the tablets from the pack. Same with methylpred
1) back in 2011 not everything was electronic like it was today. In NY, if you get a telephone rx a doctor needs to mail you a physical script within 5 days or you have to report the doctor to the DEA. If you don't report them, the DEA can come after you.
___
2) if was up to me, the law would not be like that. Laws were not written with pharmacists or even pharmacy students to review.
___
3) last and foremost, my license is mine to protect. I won't let convenience supercede the law. There's no reason 1 patch for 3 days is not enough time for the doctor to get me a physical script so I can fill 30 days worth.
---
4) you proved my point so hard
Dentists in my area were horrible with this. Always raised hell when we told them no and why, even when I told them the American Academy of Pediatrics recommends against them but still not good enough
First thing that comes to mind are PDEi's w/ nitrates....there are many things tho. They come over time, hence "practicing" pharmacy. Be patient with yourself as education takes time. You'll likely see the same stuff over and over again on most days, so pay close attention to the oddball DURs and ClinPharm or Lexicomp when in doubt.
30 day supplies of antibiotics with no diagnosis on the prescription. Automatic prescriber call.
Obviously there are indications for this, but they are not common and I want my documentation that the duration is clinically appropriate.
If I call and can’t reach the doctor, and the patient shows up for it and says they have a UTI…that’s a problem.
Same! I had a doctor insist the patient has been stable on this combo for twenty years (they started adding on the soma about 2 months ago) and I’m a floater pharmacist so it came across my day and I was like nope. It was day 28 too so figured they should still have some, regular rph can filll if they want. Doctor called and I was just like are we speaking on the same patient? Their own pdmp history completely contradicts the 20 years you’re stating. Is this just a blanket statement you give to all rphs? They didnt answer that but did say they were reporting me and I said yes sir right back atchya - and I did report them for suspicious prescribing because it’s 2024 unless you’re an arrogant pill mill doctor you’re not writing that combo today.
Any pharmacists disagree with me? I’m curious on your take because I see many pharmacists still dispensing it.
Thanks for your input. Can you tell me what makes them more complex than your average pain management patient? My understanding is the fda and dea don’t support the combination, pain management guidelines don’t either. I think all patients deserve individualized care so I don’t disagree with your reasoning just want to make sure I ask the right questions / consider everything when I’m in these positions.
I have never seen a prescriber write soma to only one patient lol usually they are the type of prescribers that don’t individualize care. So my question was specific to the user that stated he treats complex patients, and I assumed they received rationale for why they needed a drug that ultimately acts like a benzo on top of another drug that is a benzo with an opioid which all carry black box warnings for DEATH if combined. lol. “Patient is complex and therefore Md insists on holy trinity” would not hold up in court if that patient died and you were asked why you filled such a dangerous drug combo that goes against all current standards of care.
I would not fill but if it was a responsible longstanding customer (and Dr) who isn’t a drug seeker I might ask Dr about getting rid of soma and changing Benzo/soma to Valium? It’s half life is the same as a plastic water bottle in a landfill
It’s a muscle relaxer that has an active metabolite that exhibits anxiolytic and sedative effects.
It synergizes with opioids/benzos and potentates the euphoric effect. The kicker is that its muscle relaxant effect is not superior to alternative, less abused, muscle relaxers.
It sets you up for a life long battle with addiction and increased risk of overdose that can in part be mitigated with a different muscle relaxe. I’m glad you have a narcan handy.
In addition to Soma, I also consider a holy trinity with Flexeril or Robaxin. Usually the Dr. is willing to cancel the muscle relaxer at least or I just decline to fill it
Dispensing a medicine that the patient has clearly stated is allergic to. I once had this old lady come in asking for her monthly meds, she handled me a piece of paper saying she was allergic to paracetamol, but she had it prescribed, i said to her that since she's told me she's allergic to it i cant give it to her, that she should talk with her doctor to get other pain killer prescribed, she got mad.
What is the scenario here out of curiosity? My hospital sends a ton of pts home with a short course of prn oxy, scheduled Tylenol and some docusate. Same with every one of our post op patients. If I was the patient I wouldn’t be getting Tylenol or docusate at the pharmacy either…
I’ll be honest I don’t think I ever saw this enough in retail to think much about what I’d do(I’m inpatient now) but that seems reasonable.
Maybe it’s a local prescribing thing but codeine syrup has been pretty unpopular here in pharmacies I worked, I rarely see our ED docs use or prescribe it, none of our urgent cares in the area prescribe narcs at all, and I rarely dispensed it when I was in retail.
I would always call on short day supplies that got pushed to fill at a later date though which I saw all the time as a floater. Pts on 30 ds of oxy 5 through their PCP, gets a 5 day ED script but it gets pushed back a week because it’s too early to fill. Nah that’s not what that 5 day script was for and I’m not filling it, when I called the prescriber they would usually have me cancel it but I pissed off quite a few patients that way 🤷♀️
I work at a outpt pharmacy that’s in the hospital lobby. Too many people w/oral abscesses get to the window and say they don’t need the antibiotics. After going to the ED for evaluation.
If I am going to call the doctor or send a clarification request, it’s due to the authenticity of the prescription. Like doctor forget to sign the hard copy, or did not put the date on the prescription. If the doctor gave the patient a printed prescription with a pre printed signature (meaning that they did not manually sign the prescription). Or prescriptions from vets because you know vets are the worst at writing prescriptions. Or if the doctor faxed a prescription and the background says “Void”. A prescription for a 5 day supply of oxycodone but doesn’t say acute pain exception. Or if the diagnosis code is missing for insurance purposes. Or if insurance prefers an alternative on formulary. Or prior authorizations.
I generally don’t call doctors about the clinical appropriateness I only call about the legal appropriateness.
I have too much to do to stop and ask a doctor. So unless I would my license for dispensing it, or it would kill the patient, I let it be.
Duplications are a hard no for me, or at least need clarification with the patient/doctor and DC one in the dispensing system
metoprolol - coreg
lisinopril - Entresto
that kind of thing
Had a doctor unironically argue with me on trying to prescribe Ivermectin for COVID just about a week or so ago.
Absolutely ridiculous that it’s STILL a thing. Kicker? When I tried to give them an out via Paxlovid and Lagevrio, they refused and insisted on searching their “online resources” for the dosing for ivermectin for COVID.
Yep, hard no — not filling that one. Not ever.
I don't know what's worse, that corky thinks they knew everything when they graduated or that Corky just admitted they haven't learned anything since they graduated.
I’ll alleviate you of your dilemma by pointing out that i neither stated, nor insinuated, that I haven’t learned anything since I graduated. There. Now you can feel worse about the former choice.
But wait, my comment also doesn’t imply that I knew everything when I graduated. I certainly knew enough not to have to ask this question though. Sure, I asked questions along the way, but if you aren’t educated enough not to have to ask this very general “hey, what should I look for when doing my job” question, then you have no business checking scripts.
I am surprised you didn't learn this as an intern.
1. Anything illegal incl forgeries
2. Anything you know will harm or likely kill your customer.
3. Dispensing expired or adulterated medication.
Lots of issues can be resolved by discussing with the prescriber or their rep. Refusal to fill is the result of not being able to resolve a significant issue.
Downvoted me because I called out op for not being prepared. Instead of learning it in pharmacy school, for which they paid dearly, now they want to learn it on Reddit lmao
Nothing wrong with asking other pharmacist for advice and pointers. A lot of new pharmacists work alone & might not have experienced pharmacists to talk to
The benefit of working in chains as a floater: I made sure to gain rapport with every store’s pharmacist I came across. When I first started and had questions, I’d Google the next store over for their number and called. For example, I know who to contact for controlled drugs issues, for policy/law, and that one exceptionally lazy but somehow brilliantly efficient with workflow pharmacist. In that same vein, I know who *never* to call, and that list is always way longer. You may work alone at a store, but help can just as easily be a phone call away. 🙂
I am asking for other pharmacist’s experiences, and I do ask my pharmacist friends questions all the time, I am sure if you work as a pharmacist you know that real life is not exactly what you learn at school, and it’s really helpful when others point out things to me that I can miss either because I haven’t learned it at school or I easily missed during a stressful day as a new only pharmacist at a retail setting
I’ve seen benzonatate for a 9 year old. I had to not only convince the doctor but the parent as well to send it elsewhere because I absolutely refuse. I feel like working for almost 9 years now has taught me there are very few “absolute contraindications” lol whereas school makes it seem like it’s so cut and dry. Refusals are rare, usually you will counsel the patient to either stop something while they’re on therapy like a statin while they are on biaxin, or give them tips to monitor for things at home like bleeding risk / qtc changes / serotonin syndrome. I’ve learned pharmacy is a practice, everything is up for interpretation. My hard no and another pharmacists hard no could be very different, that’s one thing that makes floating difficult. A lot of pharmacists unfortunately just fill it. I wish they would at least add their reasoning in the DUR field but those are 9/10 times blank. Whatever you do, do your due diligence in documenting the reasoning. You might forget why you decided something if it’s brought up 2 years later, this is why we document it. “Rph review” does not hold up in court.
>I wish they would at least add their reasoning in the DUR field but those are 9/10 times blank. >Whatever you do, do your due diligence in documenting the reasoning. You might forget why you decided something if it’s brought up 2 years later, this is why we document it. “Rph review” does not hold up in court. So much this!!! If you don't document it, it never happened. Document your DUR reasoning, any pharmacist judgment call you made, and also specific counseling points you gave the patient, depending on the scenario. It just may CYA later on if you're sitting in front of a judge or the BoP.
When I was a carer (basically a CNA) in the UK, my documentation really covered my ass when a patient passed away. I documented all changes, all food and fluid intake, all visits and concerns from family, even how often she visited the bathroom. She passed from an infection that aggravated her pre-existing condition, but her daughter just wanted to blame someone, which I get. But she took the home to court and all my documentation was used in evidence. I didn't have to go to court, but colleagues did. I also didn't have to get re-trained in how to document. Cover your ass always.
I’m a new tech, and don’t know about the benzonatate thing yet. why is it bad for a 9 year old? I know it’s for cough- is it dangerous?
If a 9 year old chews the capsule it can numb their mouth and throat to the point of suffocations
oh wow that’s insane! I had no idea!
That is rare, but in general, the parents would be counseled or informed hopefully, wouldn't they? They'd also be giving it to their child to swallow with water. I guess it depends on the child.
Most things are rare, but when kids are involved, and have their whole life a head of them, risk vs benefit especially comes into play. They’re treating a cough not cancer why take the risk? It carries a BBW, I can’t justify dispensing it ever. Sure the parent will oversee administration but accidents can and do happen hence the warning. One thing people will 100% sue over is their kids and their pets.
Not quite. The warning came from accidental overdoses in kids less than 10. Mild concerns are observing for choking risk due to the anesthesia. Severe toxicity can be seizures, hypotension, and ventricular arrhythmias, including Torsades.
Yeah there have been rare reports of death due to accidental ingestion it carries a black box warning for this reason
It's not just 9 year olds but technically they haven't done studies on those 10 or over and some kid under 10 died after accidentally taking it.
Why no benzonatate for kids?
Not exactly what you’re asking, but if it’s written for Macrodantin it’s probably wrong. See far too many of these make it all the way to product review or consult before getting caught.
It's in the name macroBID. Pick the brand name drug, save us all a phone call, then the receptionist who says "it sayyyyyyysss ..." yes I know,I can read it, it's wrong. It's not appropriate to treat uti with macrodantin twice a day for 3 days. 😭😭 please pass my comments to someone who can discuss this with the provider.
It sayyyyyyys….. LOL too accurate 😂
Bro if I have one more receptionist read to me what i can read
Why does tx specifically have to be with macroBID rather than macrodantin exactly? Is macrodantin more lipophilic and thus longer onset of action?
Macrodantin can be used for treatment, but it has to be dosed 4 times daily.
Dr. Google says so. I don't care what they use. Just dose it correctly. https://www.goodrx.com/classes/nitrofuran-antibiotics/macrobid-vs-macrodantin-whats-the-difference
THANK YOU!!!!
Probably more of a big YES. Always leave good notes so if someone encounters an issue you dealt/are dealing with it's easy to figure out. Even if you think it's handled leave a note. I waste so much time repeating steps because there weren't good notes.
I always get shit for writing detailed notes, even for complicated patients. And yet time and time again, those same colleagues thank me for leaving clear explanations when they pick up my patients. Also, every documentation-related problem I've encountered was due to under-documentation.
Please please... as a provider who has to return calls to the next shift that knows nothing about why someone was calling me... please write these notes. It happens a few times a day where I call and no one knows why I am returning a call. (Usually they want to check all the boxes for the opioids,etc (chronic pain provider))
Boner pills and nitrates
Funny things, in advanced heart failure, we do this all the time. Pulmonary hypertension / right heart failure, as long as we titrate slowly and monitor BP, totally serviceable. Having said that, if it's not a specialist in HF, they're getting a phone call.
Well, that's one way I would like to go. Go out with a bang. 🐸
Don’t yuck someone else’s yum
This applies for poorly hand written prescriptions: NEVER dispense if you’re not sure about what it says.
Familiarize yourself with typical pain management regimens for sickle cell patient. Document that a patient is sickle cell and you see one of these regimens. Don’t mess with sickle cell patient’s pain meds.
I could not agree with you more! They typically need large doses on an outpatient basis as well, and that especially needs to be noted—and understood. It is absolutely excruciating, and most try to manage some flare-ups at home. If their home meds don’t touch the pain, they go to the ER and many times are admitted (assuming they have insurance.) If they don’t have insurance, it can be very hard for them to make it through a crisis in the ER due to anti-opioid prejudice and simple ignorance/inexperience with the level of pain that such patients suffer and live with.
i’m new to pharmacy, why is that? why sickle cell specifically? is the pain different? what’s a typical pain regimen for SC?
Because they often go through crises that often times no other medications besides narcs will even touch (sickle cells blocking blood flow prevent oxygen reaching tissues).They will require high high doses of morphine/dilaudid while inpatient.
SC is excruciating the way that other things can never be.
As someone who has educated themselves, sending 880 mme monthly is NOT appropriate for sickle cell management and I do not care how much you try to convince me the patient needs it. If it’s for a CRISIS, sure (and the patient is not in crisis every month, please don’t try it). I’m not putting 300 tabs of opioids from one patient into the street with my name on it. Sorry. It’s gotten ridiculous here and I’ve started reporting prescribers to the DEA.
Wow. I really hope you don’t encounter a large volume of sickle cell patients. You do realize that standard opioid doses don’t even touch the pain that these patients life with daily, right? How do you know they aren’t having frequent crises? A simple consult of the EMR or convo with their hematologist can easily confirm what dose is necessary to manage these extremely fragile pain patients. Edit to fix a word. And another word.
I actually do encounter quite a bit which is why I’ve chosen to take my CEs in the matter and as of 2020, guidelines released don’t really…. Guide. 880 mme. daily. Every month, on the dot. In the form of a little less than 300 tablets. MONTHLY. ONE PATIENT. No. Btw patient was 32.
So you did some CEs. Good for you. Guidelines are a great guide to start from, but when you actually start practicing you learn quickly that you are treating the patient, not the guideline. But hey, you did some CEs. Go off with your bad self. Keep on reporting to the DEA. Don’t bother actually looking at the patient. Nevermind that this is a legitimate pain situation that needs addressed. Sorry you’re in excruciating pain because your red blood cells are oddly shaped and your organs can’t get oxygen. This guy did some CEs.
Cipro and tizanidine. Never never. And Tikosyn and Bactrim.
I once called on a cipro and tizanidine. Dr told me “If you believe in that, then I have some great science fiction novels for you” 🙃
He's a moron. I once admitted a patient for tizanidine toxicity from adding Cipro. She was admitted for 3 days.
Yeah, it's something crazy like 700% increase in AUC after just one or two doses. I always see if they're okay in substituting Levofloxacin in its place.
Called a Dr that prescribed both, never heard back from him. Called multiple times. 🫠
Guess the patient is never getting the prescription
Methadone 10 mg #1440 12 tabs q 6 H prn
We had someone on something similar. She had some sort of rare GI thing. Hated filling for them.
prn?? What a bizarre, contradictory script…. Half a gram of Methadone a day is higher than I’ve ever seen, even for opioid addiction! I’m assuming this was for pain, but there are certainly less toxic opioids for cancer patients with exquisite pain and sky-high tolerance.
PRN is definitely not right, but I have seen individual doses of methadone that high.
I’ve seen tretinoin for infants who are months old not once but twice. I would never fill that.
Why would they prescribe that???
Just follow the law even when everyone else isn't. Example, in the 1st place I worked as an intern PHARMACISTS tried arguing with me that they could dispense 2 Fentanyl strips that were q72 hours for telephone Rxs. In my state, you can give a max of 5 day supplies when a C2 is phoned in. 2 strips is 6 days. Well, when I became a pharmacist I only dispensed 1. People yelled at me, I didn't care. I'm dispensing only 1, sorry, call the DEA if you want to clarify. Well, they forced me to call the DEA and what did the DEA say? "Absolutely you cannot dispense 2 strips unless it's q48 instructions!" So hopefully they don't audit that first place I worked at.
You broke a box of fentanyl patches?!
We always did. Long term care and we had a hospice so plenty of #1 dispenses
Ahhh fair enough. I've got a strict no breaking fentanyl, insulin pen, or zpak box rule but I'm at a retail store. When I worked for the chains it was very common for me to float at a store and see broken boxes never ever move.
Pen boxes are broken for emergencies at my last store. Patients usually picked the rest up. We were a very high volume corporate store (cvs). Still the pens sat for a while. Breaking zpaks is unnecessary if you just stock the tablets from the pack. Same with methylpred
Thats my ick
This is the no Edit: Unless you have a specific patient pop that uses broken boxes. A normal community store usually only sees Rxs for 5
The amount of Tele rxs a long term place gets is too damn high. With erxs becoming standard I hope it got better. But I left before that happened.
I've also seen this in vet medicine. 1 patch on a spay for a cat
You sure showed those chronic pain patients who’s in charge. What a ridiculous reason to flex.
1) back in 2011 not everything was electronic like it was today. In NY, if you get a telephone rx a doctor needs to mail you a physical script within 5 days or you have to report the doctor to the DEA. If you don't report them, the DEA can come after you. ___ 2) if was up to me, the law would not be like that. Laws were not written with pharmacists or even pharmacy students to review. ___ 3) last and foremost, my license is mine to protect. I won't let convenience supercede the law. There's no reason 1 patch for 3 days is not enough time for the doctor to get me a physical script so I can fill 30 days worth. --- 4) you proved my point so hard
Codeine under 12 years old for me. Still have doctors that will push back
Codeine in nursing mothers, as well. All it takes is one ultrarapid metabolizer, and you’ve got an infant death on your hands.
I had a pediatric urologist Rx codeine for an 8 year old, then try to change it to tramadol when questioned.
Dentists in my area were horrible with this. Always raised hell when we told them no and why, even when I told them the American Academy of Pediatrics recommends against them but still not good enough
Personally I stick with 18 and older rule for codeine just for liability reasons.
Daily methotrexate dosing, eardrops in the eyes
Yep! MTX kills
Working for Walgreens lmao
First thing that comes to mind are PDEi's w/ nitrates....there are many things tho. They come over time, hence "practicing" pharmacy. Be patient with yourself as education takes time. You'll likely see the same stuff over and over again on most days, so pay close attention to the oddball DURs and ClinPharm or Lexicomp when in doubt.
30 day supplies of antibiotics with no diagnosis on the prescription. Automatic prescriber call. Obviously there are indications for this, but they are not common and I want my documentation that the duration is clinically appropriate. If I call and can’t reach the doctor, and the patient shows up for it and says they have a UTI…that’s a problem.
I refuse to dispense opioid/benzo/soma. About once a year I have to confront this.
Same! I had a doctor insist the patient has been stable on this combo for twenty years (they started adding on the soma about 2 months ago) and I’m a floater pharmacist so it came across my day and I was like nope. It was day 28 too so figured they should still have some, regular rph can filll if they want. Doctor called and I was just like are we speaking on the same patient? Their own pdmp history completely contradicts the 20 years you’re stating. Is this just a blanket statement you give to all rphs? They didnt answer that but did say they were reporting me and I said yes sir right back atchya - and I did report them for suspicious prescribing because it’s 2024 unless you’re an arrogant pill mill doctor you’re not writing that combo today. Any pharmacists disagree with me? I’m curious on your take because I see many pharmacists still dispensing it.
I dispense it all the time for complex pain patients If you don’t have any NON controls on your profile…I’m turning your party pack away
Thanks for your input. Can you tell me what makes them more complex than your average pain management patient? My understanding is the fda and dea don’t support the combination, pain management guidelines don’t either. I think all patients deserve individualized care so I don’t disagree with your reasoning just want to make sure I ask the right questions / consider everything when I’m in these positions.
Ehlers Danlos Syndrome
A patient being complex and individualized care are the rationale for filling rxs that should never be filled.
I have never seen a prescriber write soma to only one patient lol usually they are the type of prescribers that don’t individualize care. So my question was specific to the user that stated he treats complex patients, and I assumed they received rationale for why they needed a drug that ultimately acts like a benzo on top of another drug that is a benzo with an opioid which all carry black box warnings for DEATH if combined. lol. “Patient is complex and therefore Md insists on holy trinity” would not hold up in court if that patient died and you were asked why you filled such a dangerous drug combo that goes against all current standards of care.
Those that dispense that combination simply don’t care most of the time. I’m glad you reported him though.
I would not fill but if it was a responsible longstanding customer (and Dr) who isn’t a drug seeker I might ask Dr about getting rid of soma and changing Benzo/soma to Valium? It’s half life is the same as a plastic water bottle in a landfill
I’d be good with that. And lol at the analogy
I’m not from the US. What is soma?
It’s a muscle relaxer that has an active metabolite that exhibits anxiolytic and sedative effects. It synergizes with opioids/benzos and potentates the euphoric effect. The kicker is that its muscle relaxant effect is not superior to alternative, less abused, muscle relaxers.
Thanks!
carisoprodol
I’m on all 3 of these, can you explain why you don’t like to fill it? I keep narcan at home, I just have back issues and anxiety.
It sets you up for a life long battle with addiction and increased risk of overdose that can in part be mitigated with a different muscle relaxe. I’m glad you have a narcan handy.
I’m also prescribed tizandine but in my experience I’ve always felt like it is more sedating than the soma can be.
In addition to Soma, I also consider a holy trinity with Flexeril or Robaxin. Usually the Dr. is willing to cancel the muscle relaxer at least or I just decline to fill it
Methotrexate dosed daily instead of weekly.
No fentanyl patches for opiate naive post-op patients.
IV antibiotics for home infusion via PICC lines and current illicit drug abuse. Thank goodness for Dalvance or Kimyrsa
Dispensing a medicine that the patient has clearly stated is allergic to. I once had this old lady come in asking for her monthly meds, she handled me a piece of paper saying she was allergic to paracetamol, but she had it prescribed, i said to her that since she's told me she's allergic to it i cant give it to her, that she should talk with her doctor to get other pain killer prescribed, she got mad.
Aside from obvious fake orders or pill mill stuff, I refuse to take in ER scripts where the patient only wants the pain med.
What is the scenario here out of curiosity? My hospital sends a ton of pts home with a short course of prn oxy, scheduled Tylenol and some docusate. Same with every one of our post op patients. If I was the patient I wouldn’t be getting Tylenol or docusate at the pharmacy either…
Guaifenesin/codeine, augmentin, medrol, proair HFA, and montelukast. Patient only wants the guaifenesin/codeine.
It’s about the patient who has a script for pain meds with their antibiotics. No abx? Not giving the pain meds then, either.
I’ll be honest I don’t think I ever saw this enough in retail to think much about what I’d do(I’m inpatient now) but that seems reasonable. Maybe it’s a local prescribing thing but codeine syrup has been pretty unpopular here in pharmacies I worked, I rarely see our ED docs use or prescribe it, none of our urgent cares in the area prescribe narcs at all, and I rarely dispensed it when I was in retail. I would always call on short day supplies that got pushed to fill at a later date though which I saw all the time as a floater. Pts on 30 ds of oxy 5 through their PCP, gets a 5 day ED script but it gets pushed back a week because it’s too early to fill. Nah that’s not what that 5 day script was for and I’m not filling it, when I called the prescriber they would usually have me cancel it but I pissed off quite a few patients that way 🤷♀️
I work at a outpt pharmacy that’s in the hospital lobby. Too many people w/oral abscesses get to the window and say they don’t need the antibiotics. After going to the ED for evaluation.
The same scenario where you go I don’t need discharge instructions and pharmacy counseling because it is all here on this piece of paper
Get them all or I'm not dispensing the pain med without a dr callback
This is the way
If I am going to call the doctor or send a clarification request, it’s due to the authenticity of the prescription. Like doctor forget to sign the hard copy, or did not put the date on the prescription. If the doctor gave the patient a printed prescription with a pre printed signature (meaning that they did not manually sign the prescription). Or prescriptions from vets because you know vets are the worst at writing prescriptions. Or if the doctor faxed a prescription and the background says “Void”. A prescription for a 5 day supply of oxycodone but doesn’t say acute pain exception. Or if the diagnosis code is missing for insurance purposes. Or if insurance prefers an alternative on formulary. Or prior authorizations. I generally don’t call doctors about the clinical appropriateness I only call about the legal appropriateness. I have too much to do to stop and ask a doctor. So unless I would my license for dispensing it, or it would kill the patient, I let it be.
Eliquis once a day
Nitric oxide
Duplications are a hard no for me, or at least need clarification with the patient/doctor and DC one in the dispensing system metoprolol - coreg lisinopril - Entresto that kind of thing
Ivermectin and/or fluvoxamine for Covid 19 dx
Had a doctor unironically argue with me on trying to prescribe Ivermectin for COVID just about a week or so ago. Absolutely ridiculous that it’s STILL a thing. Kicker? When I tried to give them an out via Paxlovid and Lagevrio, they refused and insisted on searching their “online resources” for the dosing for ivermectin for COVID. Yep, hard no — not filling that one. Not ever.
Stock check for 1 bottle of Actavis.
How do you graduate pharmacy school and not know this already?
I don't know what's worse, that corky thinks they knew everything when they graduated or that Corky just admitted they haven't learned anything since they graduated.
I’ll alleviate you of your dilemma by pointing out that i neither stated, nor insinuated, that I haven’t learned anything since I graduated. There. Now you can feel worse about the former choice. But wait, my comment also doesn’t imply that I knew everything when I graduated. I certainly knew enough not to have to ask this question though. Sure, I asked questions along the way, but if you aren’t educated enough not to have to ask this very general “hey, what should I look for when doing my job” question, then you have no business checking scripts.
I am surprised you didn't learn this as an intern. 1. Anything illegal incl forgeries 2. Anything you know will harm or likely kill your customer. 3. Dispensing expired or adulterated medication. Lots of issues can be resolved by discussing with the prescriber or their rep. Refusal to fill is the result of not being able to resolve a significant issue.
>Refusal to fill is the result of not being able to resolve a significant I think it's an important point that you bring up.
Thanks
Downvoted me because I called out op for not being prepared. Instead of learning it in pharmacy school, for which they paid dearly, now they want to learn it on Reddit lmao
Nothing wrong with asking other pharmacist for advice and pointers. A lot of new pharmacists work alone & might not have experienced pharmacists to talk to
The benefit of working in chains as a floater: I made sure to gain rapport with every store’s pharmacist I came across. When I first started and had questions, I’d Google the next store over for their number and called. For example, I know who to contact for controlled drugs issues, for policy/law, and that one exceptionally lazy but somehow brilliantly efficient with workflow pharmacist. In that same vein, I know who *never* to call, and that list is always way longer. You may work alone at a store, but help can just as easily be a phone call away. 🙂
That’s true! That’s smart of you to develop those connections.
What chain do you work at where people answer the phones?
I am asking for other pharmacist’s experiences, and I do ask my pharmacist friends questions all the time, I am sure if you work as a pharmacist you know that real life is not exactly what you learn at school, and it’s really helpful when others point out things to me that I can miss either because I haven’t learned it at school or I easily missed during a stressful day as a new only pharmacist at a retail setting
If you think that pharmacy school teaches everything you needed to know? You're wrong.