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patient leaves promptly. Patient: nervously my doctor is going away on vacation next month so he wrote 2 months supply for the one month Rph: That's illegal.
I watched him suffer when he ran out one month, so I'm always slow to judge on this kind of thing. My wife's brother has a genetic disease that puts him in chronic, severe pain if he doesn't have his painkillers.
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300 mg qid methadone.
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wish_i_was_in_CO 0 points 1 point 2 points 10 months ago (0 children).
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overrule 1 point 2 points 3 points 10 months ago * (1 child).
The other sad part is the total mismanagement of his pain. However, I only see his family members and they appear less than reputable in terms of character. I feel for the guy as I am sure he is in a lot of pain and presumably compley dependant on his pain meds. It's a moral dilemma for me. I am no pain management specialist but I do understand that optimizing long acting opiates with breakthrough medication is the standard.
Other than that, anything is fair game. The only real regulations are on the format of refills (whether the MD must write a total quantity with part fills or can write refills with intervals) and if they can phone it in.
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kameltoe P3 2 points 3 points 4 points 10 months ago (0 children).
kuzinrob 11 points 12 points 13 points 10 months ago (0 children).
Was rotating at a community independent and saw a script for OxyContin 80 mg 3 tabs TID. Guess it was just years of opioid tolerance at least that's what the pharmacist said. I've never seen more than 1 TID before. I thought it was time for a med change.
pizy1 CPhT 4 points 5 points 6 points 10 months ago (0 children).
I've worked in hospice and certainly understand. This just seemed odd to me. I've seen patients on infusions that maxed out the pumps parameters.
One time we made a switch from the light green round oxy 15's to the white ovals. I work for a small independent so we switch around generics often. Suddenly, a lot of our suspect patients reported that the new generic didn't work for them; all with very different reasons.
Come to find out his daughter gets #135 30mg tabs every 15 days. I don't buy it. This patient fills regularly every 11 days along with a similar rx for 360 15mg tabs. Did the math the street value is close to $30000 a month! Who would have done the same?. Sarcoidosis is genetic but I still find it a bit ridiculous. I found we have a MD note stating his condition and medical need. I refused a prescription the other day written for oxycodone 30mg tabs #360 for a 12 day supply.
Interestingly enough, they were both in pain from the same disease.
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How do they not go into respiratory failure?
b1u3 CPhT 4 points 5 points 6 points 10 months ago (5 children).
fritosinpeanutbutter 2 months to PharmD 2 points 3 points 4 points 10 months ago (2 children) http://i.imgur.com/CIwOO4z.jpg?1.
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demargination PharmD, DABAT, BCPS comment score below threshold -6 points -5 points -4 points 10 months ago (1 child).
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What is the highest daily dose of oral opiates you have seen? ( self.pharmacy ).
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oomio10 4 points 5 points 6 points 10 months ago (1 child).
The last retail place I worked had someone taking 22 methadone 10 mg a day. We were pretty sure she was selling it, but the doctor had everything documented and the pharmacy just kept filling it. Plus 6 oxy/apap 10/325, plus 3 cyclobenzaprine, plus 4 tramadol. Not to mention xanax and ambien.
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Ranger33 4 points 5 points 6 points 10 months ago (2 children).
Short term: Hydromorphone 8 mg 5 tablets QID. It was legit too.
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iamadoubledipper 3 points 4 points 5 points 10 months ago (0 children).
So 30 a day is not out of the question. She was a bit tired and constipated and that's about it. She is now on oral dilaudid, fentanyl, and we are working on getting the pump back to the point where we can get rid of the fentanyl. My wife was taking something like 16 8mg dislaudid a day and in great pain with that level of medication. I think that is about the same as 16 30mg oxycodone.
overrule 2 points 3 points 4 points 10 months ago * (3 children).
And one 100mcg patch every two days is pretty much on par for an opioid tolerant pt. It's not insane to be on that many opioids. If you have chronic pain for decades, you build quite the tolerance.
digikari4691 4 points 5 points 6 points 10 months ago * (0 children).
If this patient was reliant on this 30k + revenue a month, this simple substitution would probably be the equivalent of being "fired," and I would expect bricks to be shat.
This is by far the most disappointing response in the thread.
I think if you follow up with the doctor and document then you are fine. If you were filling that many for multiple people all the time it might be a different story.
2400 for 30 days ??? That's 80 tablets a day.
Sell some, use some. It's one thing to have large quantities of opioids administered directly to the patient and another to dispense from an outpatient pharmacy these ridiculous immediate-release combinations prescribed from some quack PCP (who most likely isn't doing any drug screening to see if this person is abusing other substances) repeatedly and excessively early in aggregate.
lynxnloki 0 points 1 point 2 points 10 months ago (1 child).
Biggest was a patient on 2.5gm of morphine equivalents/day of Oxycontin alone. Also had methadone and oxy IR.
Look up the cost on that! Patient copay = $40.00. She's down to 4 boxes monthly. Before the dosing was lowered, we were dispensing 7 boxes of BRAND Actiq 1600mcg.
I'll preface that I'm an auditor, so I don't know anything about the patient, but the script and the way it was billed was fine.
That being said, it is unusual for this patient to not be on a long-acting opioid at 900 mg oxy immediate release per day. That is the puzzling part.
ekeg15 0 points 1 point 2 points 10 months ago (0 children).
There are so many red flags for abuse/diversion. I would not be comfortable Filling something that is likely Not being used as "intended".
jesus I think that's still more than the amount my store has filled in the 5 years its been open. Who even has 2400 Oxycontin 80s on hand.
iamadoubledipper 9 points 10 points 11 points 10 months ago (5 children).
SkyCaptOfYesteryear 0 points 1 point 2 points 10 months ago (0 children).
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10 months ago (2 children).
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Tolerance develops to the analgesia & those side effects as well.
Long term: There's this old lady who gets 1200 ish Oxy-IR (brand) every 42 days.
Mayrewen 4 points 5 points 6 points 10 months ago (0 children).
2min2mid PharmD 1 point 2 points 3 points 10 months ago (2 children).
Sine_Cures 4 points 5 points 6 points 10 months ago (0 children).
My god, I can only imagine the GI problems this person has going on.
Sine_Cures 3 points 4 points 5 points 10 months ago (2 children).
Oxy-IR 10 mg tabs take 3 to 4 tabs every 3 hours when needed (max 32 tabs/day) 5,376 tablets, dispense 1,344 tabs every 42 days no sub by MD Dx: CRPS.
b1u3 CPhT 1 point 2 points 3 points 10 months ago (0 children).
I didn't base the judgement on street value, just something that came to mind as oxycodone 30mg are known for being a hot ticket due to high strength and no abuse deterrent.
We gave him for free the patch covers, I forget what they're called, but they go on around the patch like tape but they're one piece. He was also on two 100 mcg patches every two days and couldn't have possibly had decades of opioid use as he was 26.
Tonight I saw a patients profile where he is taking 2 Oxycontin 80 mg tabs BID plus 3 30mg oxycodone tabs every 3-4 hours.
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Mayrewen 0 points 1 point 2 points 10 months ago (0 children).
Still and all, that's quite a prescription.
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This is the patient's rx:
Can you run a test script to see if his TP covers OxyContin? He may not have the money to cover 2 $100 copays a month or even worse - 10 or 20 % of that OxyContin bill ($1000+ for #60 OxyContin 80...he would need 180 + tablets).
Where can you fill a script for a 43-day-supply of Oxy? And who even has the brand anymore? So many questions.
iamadoubledipper 4 points 5 points 6 points 10 months ago (3 children).
Wow that's an entirely different method that in the states. Also CRPS is no joke, spent a lot of time with a couple of patients with it while on my rotations.
I work closely with our palliative care department. We routinely have patients requiring daily oral morphine equivalents in the thousands of mgs.
Possibly 789.0 (abdominal pain).
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WarriorBeard6 Hospital Tech 2 points 3 points 4 points 10 months ago (0 children) Holy shit.
Ahh, the old days. Used to fill five-hundred-something methadone 10s monthly for someone.
ScriptPro PharmD -3 points -2 points -1 points 10 months ago (0 children).
Edit: just to be clear, I did explain to the doctor I would be willing to fill on the exact date of supply written on the rx. However, this patient fills early every time. I calculated from the beginning of the year and with all of the fills this current fill was 37 days early.
7xx could be a corn, an intestinal problem, or non-specific findings on examination of urine. But wow. Or a ton of other, rather more serious things. Acute pancreatitis is well beyond "unpleasant". Would love to know what the other code I can't see is.
It just doesn't make any sense to me why there would be two prescriptions." http://www.deadiversion.usdoj.gov/fed_regs/actions/2012/fr1012.htm. Now one might speculate that the reason for that is that pain can vary throughout the day and it may be that the individual is suggested to take the 15 when the pain is not so great and the 30 when it is so great. But 30 milligram tablets are scored right down the middle, and it's quite easy to break them in half. According to the DEA's expert witness against CVS regarding the pharmacies in FL that dispensed controlled substances despite red flags that were not resolvable (in the government's view), "Well, from a clinical pharmacist perspective that combination of drugs is what I would call a red flag because alprazolam and oxycodone are commonly diverted to nonmedical use. It also, from my perspective, makes no sense at all that there would be two prescriptions for oxycodone, one in a 15 milligram strength and the other in a 30 milligram.
jaygibby22 PharmD 0 points 1 point 2 points 10 months ago (0 children).
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sloppy_lobster 2 points 3 points 4 points 10 months ago (2 children).
No long acting abuse deterrent opiates. Just the two scripts above.
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Would have been smart to recommend some clear tape patches from the med supply store. Those patches are notoriously hard to keep on. They start coming off naturally after a day, add two showers and some tossing and turning throughout the night, and it falls off right away (and doesn't restick).
Sine_Cures 2 points 3 points 4 points 10 months ago (0 children).
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Rph: Can I ask why you're getting prescribed these quantities?
digikari4691 4 points 5 points 6 points 10 months ago (0 children).
Mayrewen 3 points 4 points 5 points 10 months ago (1 child).
They on an ER? you know the doctor?. work in florida so we see stuff like that from time to time, usually followed by a newspaper article about the DEA shutting down the doctor.
I am terrified of my wife running out and I am not the one in pain. It is entirely possible this patient is scamming. Pain is really really horrible stuff. Or that she was just afraid of running out. It is also possible her pain is not actually under control.
He was also on oral pain meds that kept switching around, I think he was on 6 or so hydromorphone every day when I left. There was also the guy getting fentanyl patches 100 mcg 2 patches every two days. And he'd STILL try to get them early because he "sweat too much" and had to keep replacing them.
2min2mid PharmD 0 points 1 point 2 points 10 months ago (0 children).
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What it boils down to is that for narcotics like opioids, as long as the physician writes some in the format of total x tabs authorized, may dispense x tabs every z days, and the rx is ed/written, there are no other restrictions. The Great White North, Canada. Seriously our narcotic laws are so nice to deal with.
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I've always thought it was strange the doc chose Percocet over plain oxycodone. Not that crazy, but a couple of times we've filled 720 Percocet 10-325's for a 90 day supply for a regular who's a cancer patient.
pinfamy 0 points 1 point 2 points 10 months ago (0 children).
I'm sure there's a placebo effect, probably some minor PK and dosing issues, etc. But one thing is for sure - they weren't recognizable on the street. This is absoluy an awful thing to base clinical decisions on - but when are looking for more information to inform our "gut feeling," the patient will get the white ovals.
kameltoe P3 9 points 10 points 11 points 10 months ago * (0 children).
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Showed it to my rph and he shakes his head and whispers " -- the fuck." He walks up to the patient and the conversation goes:. Cant remember the sig but it was basically a "no effing way" from me right off the bat. I had a young patient come in with 2 scripts, one for oxy 30s #600 tabs, and oxycontin 10s #480.
pharmprophet PharmD (Retail) 2 points 3 points 4 points 10 months ago (0 children).
He's a pcp. Only two patients of his I know and they are family getting oxycodone 30mg.
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WarriorBeard6 Hospital Tech 0 points 1 point 2 points 10 months ago (2 children).
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Brext 0 points 1 point 2 points 10 months ago (0 children).
Patient has been on it long term and built up med resistance. I didn't like sending out that order, but based on the previous dosage it made sense.
sloppy_lobster 0 points 1 point 2 points 10 months ago (0 children).
SkyCaptOfYesteryear 0 points 1 point 2 points 10 months ago (0 children).
ER definiy seems the best for this patient...having ER covered and not using it, when your popping 30 mg tablets hourly, would be a huge red flag for me.
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The DEA would see this as an outright failure to "exercise professional judgment." No documented diagnosis or "medical necessity" nor verification of patient identity would redeem this crap. The disturbing part is that you mention this garbage was filled "regularly," meaning the pharmacists there should have rejected this shit before it got out of hand.
Mayrewen 3 points 4 points 5 points 10 months ago (0 children).
zardwiz 2 points 3 points 4 points 10 months ago (1 child).
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I work in hospice and the numbers would floor you. I had someone getting $6000 in oxyfast every week.
Mayrewen 1 point 2 points 3 points 10 months ago (0 children).
cookiesfly PharmD 7 points 8 points 9 points 10 months ago (1 child).
Those numbers don't surprise me in my current position, but I would give the doctor a call in a retail setting. Ha fun timing, just sent out 50-100mg PO dilaudid every 2 hours as needed. I know that when I worked for WG any plain OxyIR script we had to talk to the MD list diagnosis code and basically cover walgreen's ass in case of abuse.
Everything checked out on the script. 2400 Oxycontin 80mg for a 30 day supply.
Is the 15 mg script for "breakthrough pain"? LOL. Oxycodone 30 mg #360 + oxycodone 15 mg #360 for one patient is pure garbage. There is no reason for one patient to get multiple scripts for oxycodone IR.Highest dose of oxycodone ir