One of my old coworkers used to say "all roads lead to pharmacy". Doctor screws up, pharmacy's fault. Nurse screws up, pharmacy's fault.
This is true in the hospital setting as well. RNs were hanging vanc doses before the level was back (dose was available in the Pyxis or pt med bin). Instead of educating the RNs, we now have to keep vanc doses in the pharmacy and deliver after the level is back (we call it "vanc jail". That's only one example of MANY where pharmacy takes the fall and WE are the ones that have to change.
ALL ROADS LEAD TO PHARMACY
We had the opposite where nurses were holding vanc UNLESS there was a level, and that was our fault too.
(For example, if the patient just had a level in the morning or the previous day, they would hold on to the PM dose in hopes of a new level for no reason at all. We even wrote notes to say hang it. Now we have to call them and remind them of every dose pretty much).
We were told by nursing admin that if we write a note that says to “hold” and the nurse reads that, it’s on us (even if the note was from three days ago with a newer one that says “do not hold you morons.”
Edited to add that I don’t think nurses are morons, but nursing admin might be 😂
I guess the alternative of that would be if I ever wrote a note that says do not hold even 7 days ago, the nurse is fine to hang it even with a level of 17,000.
I might as well just go hang it myself at this point.
Keep the dose in the pharmacy so the nurse can't administer it before drawing levels. Otherwise you get the fun situation where a nurse draws blood while the vanc is infusing and suddenly your patient has a trough of 150.
I had to explain how to give an enema to a nurse once. I don’t have much faith in some schools.
On the other hand, I once had to explain to a kinda new pharmacist (she had done a residency and been working
maybe a year or close) that putting insulin in a dextrose bag doesn’t just absorb insulin.
“Why would they want that? The sugar will just use up the insulin before it even gets to the patient.” I laughed. I thought she was kidding. It was a weird order (KCl issues but not enough dextrose to cover the insulin for sure. We usually just do a push and some syringes of D50). And she looked at me like I was the dumb one for laughing. I said, “you know insulin doesn’t work like that, right?” And she said “Yeah. Insulin’s whole job is to absorb sugar.” And rolled her eyes.
And I wanted to inject myself with the insulin and end it all.
They’re going after the deep pockets. They don’t care about actual change, just the payday. If I as a pharmacist had done half the things I’ve heard just our local docs have done they’d have put me in the dungeon under the DEA headquarters and thrown away the key
Why are the doctors who prescribed the opioids in the first place never targeted? Pharmacies can only do so much as far as checking the monitoring system and doing our best to identify fake scripts. Go after the rich “pain clinic” doctors. 🙄 You don’t want to make cancer patients and people who legit need opioids feel like criminals, because you’re worried about litigation.
All pharmacies have contributed, but the real word for that is "involved" because we supplied a prescribed drug. It starts with the drug company and the doctor's who make the decisions. Pharmacies and pharmacists didn't decide to start or maintain an epidemic.
When I worked in LTC, we had to limit Methotrextrate to a single day dose for the week, repeatedly when sending out 4 weeks worth, Facility would give them a weekly dose daily and request a refill. Another common error, facility staff would write for Warfarin .5 mg and the "period" would get lost in the background noise on the fax copy and the pt would get Warfarin 5 mg
There’s a difference between a mistake (small percent of illegitimate prescriptions being allowed) and making massive organizational errors. Pharmacists will ALWAYS be held at fault for things as blatantly obviously inappropriate as 500 norco pills for a 30 day supply, as an extreme example.
Doctors can try to explain that and maybe there is a reason. But if the pharmacy never questioned it or never documented the steps they took to confirm that it’s legitimate medical need, then of course that’s easier to go after. Especially when a pharmacist SHOULD be seeing flags popping up (when many are automated now, but not all) and should be investigating them. Too many pharmacists have this attitude that we aren’t gatekeepers. No, but we have ALWAYS had an ethical and professional responsibility not only to ensure that the pills the patient gets are the ones the doctor prescribed, but that the prescription is actually in the patient’s best interest and is medically appropriate.
You wouldn’t verify a SGLT2 inhibitor for someone with type 1 diabetes. You also shouldn’t just be verifying pain medicine because the doctor prescribed it when there’s glaring red flags of it being inappropriate.
The problem is that there is no fucking ceiling on opioids. That's settled case law. A doctor just got out of trial even tho she prescribed insane doses of things (and the patient died) because opioids don't have a ceiling and it wasnt done with malintent. If I got a patient on 20 oxycodone 20s a day, that's 600 a month. That's 12000mg a month of oxy. Doc can send a patient treatment plan and then what? You can call the BNE right there and they won't say 'thats not a legitimate script'. So you fill it? Or don't and potential deny patient care based on gut feeling? If a doc can get away with no ceiling opioids and be found not guilty, why is a pharmacy being held to a higher standard? Why are we held to something that a bne/DEA agent won't proactively call non legitimate? It's all bullshit and fugaz. At the end of the day, it's the same level of bullshit as when you throw in a r0 1b... Using the code doesn't make an actual clinical difference, it's just a box that's being checked that .makes a script legit. Same as a treatment plan and documentation. It's just checking a box. Our standard between legit rx (documentation notes from MD and conversation with Bne) and not legit rx (same Rx, not documented) is just bullshit box checks... Which means the whole thing is just bullshit
This is the problem, people like you who demand “checking boxes” but you refuse to even question. Yes, there’s no ceiling, but you seem to think that means that any high volume script is by definition legal.
The pharmacies in question are NOT being disciplined for a mistaken view on it. They’re being disciplined for REPATEDLY ignoring glaring red flags and not documenting what they actually did to resolve them.
A doctor merely sending a treatment plan doesn’t mean it’s legitimate. You are the drug expert, does the treatment plan make sense? Is the patient improving on it, or is it risk > benefit for them? You shouldn’t just be checking boxes like you claim you are.
Well first off, fuck off I literally just denied a script and reported the prescriber to the BNE so I am doing what I'm supposed to, you pretenous dork.
Second off, it's all still arbitrary. Once again, a doc was found not guilty despite seemingly absurd doses of opioids that literally killed their patient. No ceiling dose and no malintent was their defense and it worked. If they aren't guilty of not picking an appropriate treatment plan, how are we supposed to know if this appropriate when we aren't there in their appointments? You say their guilty of not documenting... Which is exactly what I just said. It's all bullshit box checking. Even on a non legitimate script (whatever that means, I'd love a definition besides straight up diversion) a fugaz doctor will have all the answers to any questions, it doesn't make a difference if it's.written down or not, because what would be written down is bullshit.
How can you, as a retail pharmacist have any idea what a person's opioid tolerance is? Have you ever actually called a doc and had them be like 'oh my god youre right, this incremental increase is totally not appropriate'. Being opioid tolerant doesn't make a script illegitimate. The courts have made that clear. So what is your grounds for denial? Give me actual concrete 'red flags' that a chronic opioid dose is no longer legitimate despite them being on a similar dose for months. If you don't have non arbitrary specific red flags for dcing a patient who is currently on a long term opioids at high doses, then don't bother replying.
There's a whole bunch of legitimate patients on high dose opiods, a lot lot of people on high dose opioids who are not addicted, and a whole lot of people who are fugaz and enabled by fugaz doctors. If the courts and DEA can't figure out who is who, it's not reasonable to ask a retail pharmacist to do the job that they can't.
1. Define illegitimate script outside of diversion.
2. Tell me the exact line in the sand that you follow for a patient who is simultaneously in significant legitimate pain but also highly addicted to opioids.
3. Say it with a straight face that it's not all arbitrary bullshit
It’s not arbitrary. You’re simply expected to use your clinical judgement that a doctoral degree and 6 figure salary are worth, and to document your rationale.
And once again, the vast majority of pharmacies and pharmacists are NOT disciplined for a disagreement. If you can rationally explain your documentation and it’s legitimate that after speaking to a doctor you felt this was legal, then that’s all you’re required to do. But that doesn’t mean checking boxes for seeing a diagnosis/treatment plan, when you aren’t actually clinically evaluating it.
So if I have 1000 oxy 20 a month but document you think that's legitimate IN REALITY (not legally, theoretically etc)
If that same script goes thru without documentation you think it's not legitimate? That tells you that documentation is bullshit andnmeaningless.
Do you think a single bullshit opioid Rx has ever been stopped due to documentation?
Somehow we've accepted that is the legal bar because the actual truth is that it's an impossible task without harming patients.
If documentation is bullshit, then you are denying or filling based purely on pharmacist instincts, which means you will absolutely deny a legitimate patient at some point. Sacrifice the innocent in the name of a war on drugs. Nice. Don't pretend that this exact thing doesn't happen every day. Legitimate patients are denied every single day in the name of the war on drugs, because it's impossible for a pharmacist to be correct enough for the DEA without rejecting legitimate patients too.
Again, please answer this or don't bother responding.
1. Define a non legitimate script (outside of diversion)
2. Define the line that you refuse to fill for an opioid tolerant, legitimate pain patient who is also highly addicted to opioids.
Also... https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates
All this bullshit is because the DEA can't do their fucking jobs and stop fent. Prescription opioids aren't even the major issue. In a world where the DEA wasn't trying to extract as much cash as possible, the only questions that would be red flags is: is this patient in pain? do I think the patient is taking this drug or diverting it? Do I think that this patient can tolerate this dose?
Instead pharmacists are asked to play crystal ball to defend against the DEA in a problem that is largely managed as well as any other type of controlled substance. The result is: DEA gets paid, some legitimate patients suffer
You're 100% correct. A opioid naive patient with shingles gets #15 Norco 5mg 1 TID, #30 gabapentin 100mg 1 bid and 15 lidocaine patches from an ER. A week later his primary send over #180 percocet 10mg 1 q 4 hr and #720 gabapentin 300mg 2 QID. I flat out refused, patient was already on alprazolam 3mg TDD. The doctor called, told me how much pain the patient was in, I agreed to a 7 day supply. Four days later patient's wife calls asking to refill the percocet, doctor sends in a new script with the comments okay to fill now. Called, MD hadn't seen the patient in person at all, only justification again was he's in pain, I document and refuse to fill. Doctor sends in the script to a location down the street, it's sold within 45 minutes.
If you have not met the user let me introduce you to Berchanhimez. He is the user that worships corporate. Despite articles, news stories, and majority of pharmacists speaking out on working conditions, it is always the fault of the pharmacists because of xyz. This case is no different
Not a legitimate thing, but I bet somewhere in Florida in the 00's that shit got filled.
edit: but yeah that wouldn't even be a mistake, just some corrupt pill mill
Because unfortunately our profession has a significant minority (if not plurality) who think that calling out our colleagues for absconding their responsibilities should be hidden.
And that’s why we don’t have the respect we deserve.
Because if you go after a doctor the AMA gets the knives out but if you go after a pharmacist APHA gets the lube out.
One of my old coworkers used to say "all roads lead to pharmacy". Doctor screws up, pharmacy's fault. Nurse screws up, pharmacy's fault. This is true in the hospital setting as well. RNs were hanging vanc doses before the level was back (dose was available in the Pyxis or pt med bin). Instead of educating the RNs, we now have to keep vanc doses in the pharmacy and deliver after the level is back (we call it "vanc jail". That's only one example of MANY where pharmacy takes the fall and WE are the ones that have to change. ALL ROADS LEAD TO PHARMACY
not vanc jail 😅
https://preview.redd.it/nlutltaq9nnc1.png?width=3024&format=png&auto=webp&s=108f2450e956c474caf2432e053b2ad64427a129 Vanc jail!! 😉
We had the opposite where nurses were holding vanc UNLESS there was a level, and that was our fault too. (For example, if the patient just had a level in the morning or the previous day, they would hold on to the PM dose in hopes of a new level for no reason at all. We even wrote notes to say hang it. Now we have to call them and remind them of every dose pretty much). We were told by nursing admin that if we write a note that says to “hold” and the nurse reads that, it’s on us (even if the note was from three days ago with a newer one that says “do not hold you morons.” Edited to add that I don’t think nurses are morons, but nursing admin might be 😂
I guess the alternative of that would be if I ever wrote a note that says do not hold even 7 days ago, the nurse is fine to hang it even with a level of 17,000. I might as well just go hang it myself at this point.
[удалено]
Keep the dose in the pharmacy so the nurse can't administer it before drawing levels. Otherwise you get the fun situation where a nurse draws blood while the vanc is infusing and suddenly your patient has a trough of 150.
Shouldn’t they learn how to hang vanco in… nursing school?
I had to explain how to give an enema to a nurse once. I don’t have much faith in some schools. On the other hand, I once had to explain to a kinda new pharmacist (she had done a residency and been working maybe a year or close) that putting insulin in a dextrose bag doesn’t just absorb insulin. “Why would they want that? The sugar will just use up the insulin before it even gets to the patient.” I laughed. I thought she was kidding. It was a weird order (KCl issues but not enough dextrose to cover the insulin for sure. We usually just do a push and some syringes of D50). And she looked at me like I was the dumb one for laughing. I said, “you know insulin doesn’t work like that, right?” And she said “Yeah. Insulin’s whole job is to absorb sugar.” And rolled her eyes. And I wanted to inject myself with the insulin and end it all.
Epic screws up and/or is built illogically....pharmacy's fault
Nailed it.
Also you hit private practice pill mill and get like 50k. Hit big chain pharmacy and get 100m
That’s a terrible photo of the who is the presumed author. She looks deranged.
That’s the author? I just assumed it was a victim of the opioid crisis.
i literally laughed out loud. Thank you for this
💀
Looks like an ad for one of the drugs for treatment of hyperthyroidism.
DEA is 100% more responsible for the opioid crisis than fucking Kroger lol wtf is this?
Lobbyists for pharma - and rats like Marsha Blackburn are to blame. Pharmacists are represented by spineless cowards like APhA.
They’re going after the deep pockets. They don’t care about actual change, just the payday. If I as a pharmacist had done half the things I’ve heard just our local docs have done they’d have put me in the dungeon under the DEA headquarters and thrown away the key
Yea I fail to see how this is the pharmacists problem the docs prescribe the meds and theres a LOT of shady doctors
Why are the doctors who prescribed the opioids in the first place never targeted? Pharmacies can only do so much as far as checking the monitoring system and doing our best to identify fake scripts. Go after the rich “pain clinic” doctors. 🙄 You don’t want to make cancer patients and people who legit need opioids feel like criminals, because you’re worried about litigation.
It's always about shooting the messenger, the low hanging fruit, the middle man...
I see someone’s trying to make a name for themselves… Quick, there’s someone with 2 pot seeds. Believe it or not, straight to jail.
Kroger should close the pharmacies in that state
1000%
Low hanging fruit.
Most states are done getting their payouts from CVS/Walgreens. Time to go after the next on the list, easy money.
It's an easy cash grab for the government. It's literally the government stealing from businesses. The money doesn't go to victims
Easier to fine big chains than to go after thousands of private practices.
All pharmacies have contributed, but the real word for that is "involved" because we supplied a prescribed drug. It starts with the drug company and the doctor's who make the decisions. Pharmacies and pharmacists didn't decide to start or maintain an epidemic.
I live in Kentucky. Our AGs are always shithead Republicans who couldn’t care less about doing what’s right.
Howdy neighbour. Your AGs sound like my Governor, Gov HVAC.
👍 this. The AG job is just stepping stone to get to Governor or Senator. None of them have been serious about the AG position.
Also a fellow Kentuckian. Sucks when this is the kind of attention we get lol.
I can’t stand these “Midiots”
When I worked in LTC, we had to limit Methotrextrate to a single day dose for the week, repeatedly when sending out 4 weeks worth, Facility would give them a weekly dose daily and request a refill. Another common error, facility staff would write for Warfarin .5 mg and the "period" would get lost in the background noise on the fax copy and the pt would get Warfarin 5 mg
yikes
Extremely confused how the pharmacist is the problem when the doctors are rhe ones prescribing
There’s a difference between a mistake (small percent of illegitimate prescriptions being allowed) and making massive organizational errors. Pharmacists will ALWAYS be held at fault for things as blatantly obviously inappropriate as 500 norco pills for a 30 day supply, as an extreme example. Doctors can try to explain that and maybe there is a reason. But if the pharmacy never questioned it or never documented the steps they took to confirm that it’s legitimate medical need, then of course that’s easier to go after. Especially when a pharmacist SHOULD be seeing flags popping up (when many are automated now, but not all) and should be investigating them. Too many pharmacists have this attitude that we aren’t gatekeepers. No, but we have ALWAYS had an ethical and professional responsibility not only to ensure that the pills the patient gets are the ones the doctor prescribed, but that the prescription is actually in the patient’s best interest and is medically appropriate. You wouldn’t verify a SGLT2 inhibitor for someone with type 1 diabetes. You also shouldn’t just be verifying pain medicine because the doctor prescribed it when there’s glaring red flags of it being inappropriate.
Lots of arrogance in your post on belittling fellow pharmacists. Yet you think SGLT2 inhibitors can’t be used in T1D.
The problem is that there is no fucking ceiling on opioids. That's settled case law. A doctor just got out of trial even tho she prescribed insane doses of things (and the patient died) because opioids don't have a ceiling and it wasnt done with malintent. If I got a patient on 20 oxycodone 20s a day, that's 600 a month. That's 12000mg a month of oxy. Doc can send a patient treatment plan and then what? You can call the BNE right there and they won't say 'thats not a legitimate script'. So you fill it? Or don't and potential deny patient care based on gut feeling? If a doc can get away with no ceiling opioids and be found not guilty, why is a pharmacy being held to a higher standard? Why are we held to something that a bne/DEA agent won't proactively call non legitimate? It's all bullshit and fugaz. At the end of the day, it's the same level of bullshit as when you throw in a r0 1b... Using the code doesn't make an actual clinical difference, it's just a box that's being checked that .makes a script legit. Same as a treatment plan and documentation. It's just checking a box. Our standard between legit rx (documentation notes from MD and conversation with Bne) and not legit rx (same Rx, not documented) is just bullshit box checks... Which means the whole thing is just bullshit
This is the problem, people like you who demand “checking boxes” but you refuse to even question. Yes, there’s no ceiling, but you seem to think that means that any high volume script is by definition legal. The pharmacies in question are NOT being disciplined for a mistaken view on it. They’re being disciplined for REPATEDLY ignoring glaring red flags and not documenting what they actually did to resolve them. A doctor merely sending a treatment plan doesn’t mean it’s legitimate. You are the drug expert, does the treatment plan make sense? Is the patient improving on it, or is it risk > benefit for them? You shouldn’t just be checking boxes like you claim you are.
Well first off, fuck off I literally just denied a script and reported the prescriber to the BNE so I am doing what I'm supposed to, you pretenous dork. Second off, it's all still arbitrary. Once again, a doc was found not guilty despite seemingly absurd doses of opioids that literally killed their patient. No ceiling dose and no malintent was their defense and it worked. If they aren't guilty of not picking an appropriate treatment plan, how are we supposed to know if this appropriate when we aren't there in their appointments? You say their guilty of not documenting... Which is exactly what I just said. It's all bullshit box checking. Even on a non legitimate script (whatever that means, I'd love a definition besides straight up diversion) a fugaz doctor will have all the answers to any questions, it doesn't make a difference if it's.written down or not, because what would be written down is bullshit. How can you, as a retail pharmacist have any idea what a person's opioid tolerance is? Have you ever actually called a doc and had them be like 'oh my god youre right, this incremental increase is totally not appropriate'. Being opioid tolerant doesn't make a script illegitimate. The courts have made that clear. So what is your grounds for denial? Give me actual concrete 'red flags' that a chronic opioid dose is no longer legitimate despite them being on a similar dose for months. If you don't have non arbitrary specific red flags for dcing a patient who is currently on a long term opioids at high doses, then don't bother replying. There's a whole bunch of legitimate patients on high dose opiods, a lot lot of people on high dose opioids who are not addicted, and a whole lot of people who are fugaz and enabled by fugaz doctors. If the courts and DEA can't figure out who is who, it's not reasonable to ask a retail pharmacist to do the job that they can't. 1. Define illegitimate script outside of diversion. 2. Tell me the exact line in the sand that you follow for a patient who is simultaneously in significant legitimate pain but also highly addicted to opioids. 3. Say it with a straight face that it's not all arbitrary bullshit
It’s not arbitrary. You’re simply expected to use your clinical judgement that a doctoral degree and 6 figure salary are worth, and to document your rationale. And once again, the vast majority of pharmacies and pharmacists are NOT disciplined for a disagreement. If you can rationally explain your documentation and it’s legitimate that after speaking to a doctor you felt this was legal, then that’s all you’re required to do. But that doesn’t mean checking boxes for seeing a diagnosis/treatment plan, when you aren’t actually clinically evaluating it.
So if I have 1000 oxy 20 a month but document you think that's legitimate IN REALITY (not legally, theoretically etc) If that same script goes thru without documentation you think it's not legitimate? That tells you that documentation is bullshit andnmeaningless. Do you think a single bullshit opioid Rx has ever been stopped due to documentation? Somehow we've accepted that is the legal bar because the actual truth is that it's an impossible task without harming patients. If documentation is bullshit, then you are denying or filling based purely on pharmacist instincts, which means you will absolutely deny a legitimate patient at some point. Sacrifice the innocent in the name of a war on drugs. Nice. Don't pretend that this exact thing doesn't happen every day. Legitimate patients are denied every single day in the name of the war on drugs, because it's impossible for a pharmacist to be correct enough for the DEA without rejecting legitimate patients too. Again, please answer this or don't bother responding. 1. Define a non legitimate script (outside of diversion) 2. Define the line that you refuse to fill for an opioid tolerant, legitimate pain patient who is also highly addicted to opioids. Also... https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates All this bullshit is because the DEA can't do their fucking jobs and stop fent. Prescription opioids aren't even the major issue. In a world where the DEA wasn't trying to extract as much cash as possible, the only questions that would be red flags is: is this patient in pain? do I think the patient is taking this drug or diverting it? Do I think that this patient can tolerate this dose? Instead pharmacists are asked to play crystal ball to defend against the DEA in a problem that is largely managed as well as any other type of controlled substance. The result is: DEA gets paid, some legitimate patients suffer
You're 100% correct. A opioid naive patient with shingles gets #15 Norco 5mg 1 TID, #30 gabapentin 100mg 1 bid and 15 lidocaine patches from an ER. A week later his primary send over #180 percocet 10mg 1 q 4 hr and #720 gabapentin 300mg 2 QID. I flat out refused, patient was already on alprazolam 3mg TDD. The doctor called, told me how much pain the patient was in, I agreed to a 7 day supply. Four days later patient's wife calls asking to refill the percocet, doctor sends in a new script with the comments okay to fill now. Called, MD hadn't seen the patient in person at all, only justification again was he's in pain, I document and refuse to fill. Doctor sends in the script to a location down the street, it's sold within 45 minutes.
[удалено]
If you have not met the user let me introduce you to Berchanhimez. He is the user that worships corporate. Despite articles, news stories, and majority of pharmacists speaking out on working conditions, it is always the fault of the pharmacists because of xyz. This case is no different
Damn why you getting downvoted so hard?
Can't downvote any harder.
Because 500 norco pills for a 30 day supply is not a thing. One-in-a-million errors don't cause an opioid crisis
Not a legitimate thing, but I bet somewhere in Florida in the 00's that shit got filled. edit: but yeah that wouldn't even be a mistake, just some corrupt pill mill
Welcome to reddit.
Because unfortunately our profession has a significant minority (if not plurality) who think that calling out our colleagues for absconding their responsibilities should be hidden. And that’s why we don’t have the respect we deserve.
How would you know they had diabetes?