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Here is a dumb question-

   Has anyone had difficulty with patients filling Benzo's early?? Of course you have.

Do you ever wonder why? I have been scratching my head about this for months now. Here comes the bullet-

 

This is part of a draft of letter I want to send to the state board of Medicine about a particular pharmacy's business practices.

This is a HUGE retail chain pharmacy.  All 3 fills were at the SAME location. This is the text from the top of the letter:

 

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

 

February 11, 2015

 

 

 

 

RE: RX# 0XXXX

 

 

To Whom It May Concern:

 

Original prescription was written on 12/22/2014 for Xanax 1.0 mg. Take 1 tab three times daily #90, DS 30

According to the PMP database, the above referenced prescription was filled on 12/22/2014 for #90, refilled on 12/30/2014 for #90 and again on 1/3/2015 for #90. This spans a 12 day period where the patient was issued #270 Xanax 1.0 mg. tablets. The prescription was filled and subsequently refilled at name of Pharmacy at Address and store # of said pharmacy. How was the pharmacy able to Re-fill a 30 day prescription after 8 days then re-fill again in 4 days? 

 

I am concerned that this puts my license at risk. The pharmacy clearly did not follow the 30 day period on this prescription putting the patient in danger of overdose.

 

Thank you for your attention to this matter.

If you have any questions, please do not hesitate to contact me. 

 

Sincerely,

 

 

 

 Me, PA-C

 

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

Before anyone chimes in WRT the ridiculously high amount of Xanax this prescription was written for - Don't  bother.

This particular patient is a regular at our practice. Almost exclusively seen by 1 particular staff MD.

I assure you, when I wrote this prescription I felt the pucker factor but, I was not going to reverse the treatment course that the MD was following.

     When I learned about the dispensed amount and dates of dispensing this medication I immediately bought it to the MD's attention. I also let the staff know I was not comfortable seeing this patient again and it was my belief that this constituted abuse. Thus violating the practice agreement. I suggested the patient be discharged from the practice. The MD was not willing to discharge this patient and agreed to exclusively see this patient.

 

Thoughts??

 

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Maybe the MD, the pharmacist and the patient have an agreement in place so they each can get their benzos.  Was the script filled by the same pharmacist?  You might not have that information. 

 

I would send the letter, definitely, but be prepared to strengthen your back bone if there is something fuzzy going on with the MD and the patient.

 

The MD is not very smart. 

 

The pharmacy (or pharmacists(s)) are not following the instructions on the script so it is fraud or illegal or something like that and it should be reported to the pharmacy board, too.

 

The patient came in and told the pharmacist the bottle fell into the toilet on 12/29 (right before New Years), so he got the second script.  Then after the New Years celebration was all over and the patient woke up from the haze he realized his script was stolen and the pharmacist filled it again.

 

I suspect diversion.

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I think writing this letter may not only expose the pharmacies practice but the PCP.

Are you ready for that sh7t storm?

My personal policy is a steadfast no in those instances. I think you are doing the right thing saying you dont want further involvement in the care of this patient. 20/20 hindsight is always clearer. Next time will be different.

The likelihood of diversion here is very high. You could also make a report to the DEA. They would be very interested in the patient, the doc and the pharmacy and their behaviors.

Good luck.

G Brothers PA-C

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I just started a new job and went through a week of training.......you know.....all that stuff you learn to be part of the machine.  Part of the training was about ethics, honesty, morality  and patient safety.  These values were emphasized frequently and that it is key to having a good organization.  (I joined a catholic organization, apparently the largest in the nation).

 

So, as providers we have the charge to remain ethical, moral, honest and think of patient safety in all things.  As GB said and I alluded to (back bone) you need to be prepared for consequences.  Do you have a committee or supervisor other than your SP to go to? If you do, and they want to sweep it under the rug, then you know it's time to report, and probably look for another job.  

 

I'm not trying to scare you.  I support your actions.  Keep a record of everything you do.  Let us know what happens. 

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the PMP data base allows one to flag and report suspicious activity. although it is a useful tool it is not without flaws. i have myself noted inaccuracies and errors. the more important question is consistency. is this an isolated incident or recurrent? I would not write the letter, i would notify dea if you felt that there was truly diversion going on

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Maybe the MD, the pharmacist and the patient have an agreement in place so they each can get their benzos.  Was the script filled by the same pharmacist?  You might not have that information. 

 

I would send the letter, definitely, but be prepared to strengthen your back bone if there is something fuzzy going on with the MD and the patient.

 

The MD is not very smart. 

 

The pharmacy (or pharmacists(s)) are not following the instructions on the script so it is fraud or illegal or something like that and it should be reported to the pharmacy board, too.

 

The patient came in and told the pharmacist the bottle fell into the toilet on 12/29 (right before New Years), so he got the second script.  Then after the New Years celebration was all over and the patient woke up from the haze he realized his script was stolen and the pharmacist filled it again.

 

I suspect diversion.

--Unfortunately there are 3 MDs at the practice that see patients taking large amounts of Benzos.

I am 100% certain the MD is not involved in anything un ethical.

  I did a ton of digging on the Virgina Gov site. Never found anything specifically stating that the pharmacist is required to follow the -30 day supply rule.Did find out they CAN NOT fill early when the prescription ha a *DO NOT FILL UNTIL-* DATE :)

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I think writing this letter may not only expose the pharmacies practice but the PCP.

Are you ready for that sh7t storm?

My personal policy is a steadfast no in those instances. I think you are doing the right thing saying you dont want further involvement in the care of this patient. 20/20 hindsight is always clearer. Next time will be different.

The likelihood of diversion here is very high. You could also make a report to the DEA. They would be very interested in the patient, the doc and the pharmacy and their behaviors.

Good luck.

G Brothers PA-C

I was trying to find specific info WRT reporting to the DEA. I could not find specifics on Virginia privacy act info.

I can not violate privacy... I was just going to report it with the RX# and pharmacy name/address and date it was filled.

    I am pretty certain they can take it from there.

Some of the advice on the responses has made me second guess reporting due to possible repercussions.... I do like the hindsight point. I am now more cautious from this experience..

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I just started a new job and went through a week of training.......you know.....all that stuff you learn to be part of the machine.  Part of the training was about ethics, honesty, morality  and patient safety.  These values were emphasized frequently and that it is key to having a good organization.  (I joined a catholic organization, apparently the largest in the nation).

 

So, as providers we have the charge to remain ethical, moral, honest and think of patient safety in all things.  As GB said and I alluded to (back bone) you need to be prepared for consequences.  Do you have a committee or supervisor other than your SP to go to? If you do, and they want to sweep it under the rug, then you know it's time to report, and probably look for another job.  

 

I'm not trying to scare you.  I support your actions.  Keep a record of everything you do.  Let us know what happens. 

I am keeping a record. I am worried about the consequences though.....

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I don't think Virginia's PMP has that feature.

   What is the time frame for other states out there?

Virginia is supposed to be 'timely'. I have had patients tell me they filled  a script 7 days ago and no info in the PMP for that...

7 day lag... Seems like a long time to me...

Prescription monitoring is not as robust as we would like.

For example, in my state we have one. When I check it, it hardly ever makes sense to me. Plus I check it infrequently enough that I either forget my password or the password outdates and I spend more time resetting than I do actually performing some other worthwhile task.

But PMP are after the fact, used to expose when patients are shopping or refilling early. It does nothing to reduce the access they have to the controlled substance to begin with.

So I have a handful of rules that I live by most of the time to do my small part.

I dont refill scripts for controlled substances given by other providers.

I give small amounts of controlled subtances for obvious injuries only.

I maximize recommendations for other interventions.

I dont give controlled substances for nonspecific HA, abd pain or chest pain.

I will spend the time and money to evaluate a complaint to its fullest prior to pulling the controlled substance trigger.

Since I am in the ED, I always make a referral to a pcp or specialist whom will take over care and send the note.

I always have a treatment plan, it just may not be the treatment plan the patient wants.

I dont prescribe to avoid complaints. 

I review old records and if there is a pattern, I discuss with the patient that this pattern will not be repeated today. There is a department and facility substance policy in place that I refer to and give a copy of.

I still reserve the right to make a decision based upon other variables. 

But this covers about 99% of my practice.

GB PA-C

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Prescription monitoring is not as robust as we would like.

For example, in my state we have one. When I check it, it hardly ever makes sense to me. Plus I check it infrequently enough that I either forget my password or the password outdates and I spend more time resetting than I do actually performing some other worthwhile task.

But PMP are after the fact, used to expose when patients are shopping or refilling early. It does nothing to reduce the access they have to the controlled substance to begin with.

So I have a handful of rules that I live by most of the time to do my small part.

I dont refill scripts for controlled substances given by other providers.

I give small amounts of controlled subtances for obvious injuries only.

I maximize recommendations for other interventions.

I dont give controlled substances for nonspecific HA, abd pain or chest pain.

I will spend the time and money to evaluate a complaint to its fullest prior to pulling the controlled substance trigger.

Since I am in the ED, I always make a referral to a pcp or specialist whom will take over care and send the note.

I always have a treatment plan, it just may not be the treatment plan the patient wants.

I dont prescribe to avoid complaints. 

I review old records and if there is a pattern, I discuss with the patient that this pattern will not be repeated today. There is a department and facility substance policy in place that I refer to and give a copy of.

I still reserve the right to make a decision based upon other variables. 

But this covers about 99% of my practice.

GB PA-C

I agree with what you philosophy. The one thing I don't agree with is your utilization of the PMP.

I have my  browser set to open on the PMP page for my profile it saves and auto fills the login/password.

   I check with EVERY patient for whom I am writing stimulant/benzo prescription.

I make it part of my routine, as I am greeting the patient. The info is not easy to read but, as I use it every day I can get a quick 'tone' of the patient's history WRT controlled meds.

   I'm not trying to argue.

     I don't agree with "It does nothing to reduce the access they have to the controlled substance to begin with."

Although a true fact I can not change the past. I use the info to break the chain of abuse for the future.

Thank you for sharing your philosophy on controlled meds.

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I was trying to find specific info WRT reporting to the DEA. I could not find specifics on Virginia privacy act info.

I can not violate privacy... I was just going to report it with the RX# and pharmacy name/address and date it was filled.

    I am pretty certain they can take it from there.

Some of the advice on the responses has made me second guess reporting due to possible repercussions.... I do like the hindsight point. I am now more cautious from this experience..

There has been discussion of this in the past on the forum.

You can call your local DEA office and speak with any agent.

They will ask you for specifics concerning the pharmacy and patient along with circumstances.

The DEA agent will tell you that the patient's privacy is out the window if they are committing a felony.

The pharmacy has no privacy. They have a responsibility to properly dispense, in this case they didnt.

On the other hand, they do not have to release to anyone whom contacted them and informed about the situation.

 

Here is the response I have prepared if anyone inquired for the times I have contacted law enforcement about circumstances surrounding suspected wrongdoing.

 

My concern about patient safety and the impact on the community led me to take the moral action of notifying law enforcement. I only related identifying information about the patient and the specific circumstances that caused my concern. I did not divulge any other information about the patient or their past medical history other than what was necessary for law enforcement to investigate.

 

But I would point out that prescribing and dispensing that amount of xanax described is not proper practice and is dangerous. You may think this physician knows what they are doing, but they dont. What they are is at the endpoint with a patient whom symptoms have escalated over time and the answer was more drugs. This patient is a bad outcome waiting to happen. Either some adverse issue will occur to affect their health if they are using that significant amount or they will be arrested for diversion if that is in fact what is happening. Least worst case scenario is that this one MD continues this pattern till they stop practicing and the patient is the left to the rest of the practice to deal with. I always dislike seeing a local MD retire we all knew as a candy man. Their patients come out of the woodwork cause no one will take them on due to their overwhelming controlled substance need that developed over time and that the MD or other provider enabled

.

Good luck with this.

GB PA-C

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Every time I get a patient from another FM/IM provider who placed them on high dose, scheduled Xanax I want to throw stuff across the room.  Many of these patients have no idea how serious their medication regimen is and how dangerous and difficult it will be to get them weaned off due to their length of use.   Some have not even had SSRI trials and little or no counciling/cbt/ect.......   Personally I feel it is akin to malpractice to do this to patients.  If you need daily, scheduled BZDs beyond a short stint to get an ssri on board, you need to be in intensive therapy. 

 

I personally love our state pmp.  I know the bullshitters before I walk in the room.   It lets me prepopulate my EMR for tessalon perles or ibprofen 800mg, as indicated...

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I have made it my policy to run any and all patients through the PMP database if their chief complaint is pain, of any kind, before I even go in to see them. That way, I'm not picking on anyone just because they came in 15 minutes before closing, I'm not picking on anyone just because there are no previous records on them, I'm not picking on them because of any demographic info. I just do it for everyone seeing me for a pain-related complaint, end of story.

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IMO anyone with this level of anxiety (3 mg of xanax every single day) needs a psych referral.  They need counseling to learn to better deal with stress, or at least an evaluation that covers my ass.   Also, I wouldn't have given them any refills.  If the MD wants to OD someone on benzos, let him do it.  I might give one refill if he is out of town, but after that, he can refill this himself.

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A pharmacy once made a mistake and listed a suboxone rx under my name when PA's cannot rx it here. I contacted the PDMP administrator for the state as soon as I noticed, who sent several threatening letters to the pharmacy (which closed shortly after the incident came about). I've kept a folder filled with all of my correspondance with the state to cover myself. My SP actually makes a note in the pt's chart stating when he identified to problem and what steps he had done to resolve it.

 

All our controlled substances are written for 28 days (so rx don't run out on weekends), rx's don't include refills, and we write a "do not fill before xx/xx/xx" on the rx. The patient has to call every 28 days and we run a PMP on every single refill request.

 

The county I am had at one point, the highest drug diversion per capita in the country, and these contracts have eliminated most of the true drug seekers in the practice

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