Kevin, M.D. - Medical Weblog

Pharmacists, Oy!
 

Unfortunately, there is no easy solution, and there won't be so long as doctors are not allowed to dispense medication. Barring that happening -- and it won't -- there will always be this controversy.

And a pharmacist refusing to dispense because a dose is very high is a perfectly legitimate reason to not dispense a medication. It's the pharmacist's license, and it's their ass if there's an adverse event. The Pontius Pilate "hand washing" of any negative consequences doesn't apply.

And we've denied patients based on outlandish doses of stuff like OxyContin. I don't care if the doctor comes to talk to me in person, 4 80mg tablets QID ain't gonna fly on my license.
 

"And we've denied patients based on outlandish doses of stuff like OxyContin. I don't care if the doctor comes to talk to me in person, 4 80mg tablets QID ain't gonna fly on my license."

Do you also unlawfully practice medicine when a patient comes in with prescriptions for monstrous doses of three different antihypertensives? "Nobody could have *that* refratory a case of hypertension. You must be one of those dirty recreational hypotensionists!"

Do you bump up the dose when somebody comes in with a prescription you judge too small? "Nobody could possibly metabolize warfarin that slowly. I'll just fix this for her."
 

who gives a f*** what these wannabe-docs do? Let the pharmacist refuse to fill birth control or refuse bp meds or coumadin...the patient will get pissed at the pharmacist...when the patient complains you just say...I just write the script, blame the pharmacist, and then the pharmacist is f*****! Who gives a rats ass about the patients and the run around they're going to get...f them too!just bill you 99213...
 

"Do you also unlawfully practice medicine when a patient comes in with prescriptions for monstrous doses of three different antihypertensives? "Nobody could have *that* refratory a case of hypertension. You must be one of those dirty recreational hypotensionists!"

When the patient shits out her liver, I'll send her to see you. How's that?

In any event, we didn't withold the prescription from her. We gave it back and said "sorry, not without seeing the results of your liver function test(s)"

"Do you bump up the dose when somebody comes in with a prescription you judge too small? "Nobody could possibly metabolize warfarin that slowly. I'll just fix this for her.""

What does that have to do with anything?

--

I should have mentioned that the doctor who wrote these scripts is notorious for writing for OxyContin when 1) he shouldn't be and 2) for MASSIVE doses ALL the time. In fact, it's gotten so absurd that state medicaid won't cover *any* prescriptions written by him. It's a wonder he still has his license, really.

There's so much backstory to this doc that it really would take 10-20 paragraphs to tell it all. Suffice to say that he's not a pain management doc, he opens every visit with "what do you want?" and only writes for Xanax, Ativan, OxyContin, and Percocet. In five years, I've never seen anything but those 4 drugs from him.

Beyond even all this, this was the first opiate script she had brought to our pharmacy. And she was paying out-of-pocket.

If those aren't alarm bells to you, maybe you shouldn't be practicing medicine. (If, in fact, you are a doc rather than one who simply plays one on the Internet.)
 

Should a pharmacist question things that don't seem quite the norm? certainly. They can be a valuable check and ballance to misprescribing or miscommunicated intent of the physician. But once a valid explanation is provided can they still over rule the physician and patient? Probably not. At the very minimum they need to take an active role in finding a pharmacist and pharmacy that can meet the patient's needs in a timely manner. This is no different than the physician's duty to treat patients they would rather not until proper transfer of care is effected.

The pharmacists cannot have it all their way. With a right of conscience for themselves must be ballanced a professional obligation to the patient. The pharmacist must provide for the patient; either by exercising proper counsel and dispensing of drugs, or finding another pharmacist who can meet the patient's needs. If they want to be treated as professionals, then they need to act like professionals.
 

"Do you also unlawfully practice medicine when a patient comes in with prescriptions for monstrous doses of three different antihypertensives? "Nobody could have *that* refratory a case of hypertension. You must be one of those dirty recreational hypotensionists!"

You may infact see this if a patient has a parathyroid adenoma. If your finding hard to control hypertension. Do a thyroid ultrasound as part of a work up. It happens..can a pharmacist determine this? While invaluable to the patient for drug interactions and proper dosages,etc. Keep in mind physicians need to follow the patient and determine what's the underlying cause. Treating them before they stroke, or somesuch as we investigate, is something you may not see as they present with the script.
 

My God, what’s with all the Pharmacist bashing?
Every respectable peer reviewed medical journal has published articles as well as editorials regarding the positive impact that Pharmacists have on the care of “our” patients.
If you actually believe that they are just pains in the butt then you should search the literature and look at the statistics on how often they prevent major screw ups.
Have you ever been called by a pharmacist regarding some mistake you might have made? If you say no then you are either lying or you are Jesus Christ.
 

Pharmacists should serve as a safety valve and reject scripts that are obviously wrong (i.e. 5 times the maximum dose)

However, in borderline situations that arent totally obvious (i.e. high oxycodone dosage but not "off the charts" high) then the pharmacist should defer to the doc.

Pharmacists exist in our system to be used as consultants and as a safeguard against obviously wrong scripts. HOwever, they they should NOT be going behind the doctor's back to change treatments just because they think its a better option.
 

"if you say no then you are either lying or you are Jesus Christ."

There are alot of doc's on this site who believe they are "Jesus Christ"

Just ask them and they will tell you.
 

Heh. That is until there is a med-mal suit or a "bad outcome." Then there was nothing that they did or could have done. All of the privilege and none of the accountability.

Go to the VC Star and look up the story about the MDiety and the Pharmacist that were in cahoots to dole out massive amounts of oxycontin, most of it ending up on the blackmarket. Both have lost their licenses and are about to undertake a crash course in rectal sphincter incompetence.
 

I don't see some of these comments as Pharmacist bashing. As in my post- I stated Pharmacists are invaluabe. Your contribution to good patient care is priceless. There are however, circumstances you may be unaware of behind the scenes. It isn't likely a patient comes in carrying their health history, or their presenting complaints along with the prescription. By all means call if there is a question, but please don't take it upon yourself to deny the patient without consulting the physician. Being part of a team means working together.
 

Any pharmacists here willing to fill my 8 oxycontin prescriptions and overlook they're all by different docs?
 

Real funny Rush. You're a laugh a minute.
 

If the prescription seems unreasonable to the pharmicist, can't the pharmacist just call the doctor and double-check?

Refusing to fill the prescription just means the patient gets it filled somewhere else. If the concern was legitimate, shouldn't we be more concerned with the patient than with how it will look on your license?
 

The situation that stimulated the original article was based on a long-standing script, filled repetitively at the same pharmacy, suddenly questioned after having been filled w/o question for over a year. The point of the article was more about the inconsistency experienced by patients when the pharmacist injects their own opinion into a standing dr-patient-script relationship.
---the originaly pissed of patient
 

UPDATED: Here we are one month later and going thru the same BS. The Dr has adjusted the dosage and now we're getting the run-around from all around. This month we've started calling a week in advance to get individual "opinions" from pharmacists all over town. It's such a freakin' pain. Something that should take 15 minutes is turning into a week-long drama. It's getting to be like we have to schedule an appointment with a specific pharmacist to get this filled. BAH! I'm so freakin' mad at everyone trying to cover their butts and showing no concern for the patient.
 

Here's an interesting twist. Someone (not me) started a petition to address some of these concerns. To date, there are over 11,000 signatures.

http://www.thepetitionsite.com/takeaction/230936578?z00m=102232&z00m=102232<l=1156973819
 

There is a certain level of checks and balances necessary in any profession. Particularly, the "art" of medicine. I have been a pharmacist for 30 years, in a variety of settings. I have "saved" more than 100 patients from mis-prescribing of physicians. On at least 25 of these occasions, the patient would have died. Without each other, patients will suffer. I thought that we are both here for the patient. Or....am I mistaken? BTW, I am a PharmD, RPh, Board Certified in 3 states, BS Medicinal Chemistry, former FDA Drug information Analyst, Stanford, OSHU Assoc Professor
 

typical haughty MD attitude that our graduate education could no-where compare to theirs. Similar to how as experts in medicinal chemistry and drug interactions we could not possible be competent to prescribe medication because God only knows no pharmacy college in America requires its students to take pathophysiology.