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What the pharmacist won't tell you
Recently pharmacists have gotten more and more control over your narcotic pain management. Gone are the days your pharmacist would fill the prescription that your doctor wrote simply by counting the number of pills prescribed. These days, pharmacists literally have more control over your pain medication than the doctor who treats you for your autoimmune disease!
We all remember last year’s news headlines touting “pill mills in Florida” and how oxycodone “has a street value of $1-$2 per milligram“. But we don’t care. You and I appear to be among the minority of people who actually use our narcotic pain management for a legitimate reason and exactly as prescribed. We don’t sell them, we don’t snort them, we don’t steal them. But we are caught up in the fall-out of the drama. We are made to pay the price of what the sleazy underworld has done.
My friend Robert* tells me of how much trouble he has had trying to cash his monthly pain medication prescription over the last eight months. For years he has been seeing his Rheumatologist religiously every four weeks for follow-up for his autoimmune disease and chronic pain management, and yet he began getting turned away at the pharmacy when trying to cash his prescription. The reasons varied each month. Some months they would say “we don’t have it in stock” other months they would just say “I can’t fill this until tomorrow”, still other months the response would be “insurance won’t cover it today, come back tomorrow”, however, none of these excuses ever really felt like the truth to Robert.
Robert decided to start with a phone call to his insurance carrier. What was their policy for renewing monthly long-term narcotic pain management? He was told that he could fill any prescription up to 3 days in advance. But the reality, Robert learned, is that even though his insurance company states that they will process any refill within 3 days of it’s due date, those guidelines are still subject to the discretion of the pharmacist. Robert’s doctor is furious because he writes a “new” prescription every month for his patient. A new script is technically not a “refill”. And a “new” prescription should be filled on the day it was written! The pharmacist feels he has the right to not fill the script because he is treating each prescription as a “refill”. There is no clear and definite answer here. Could you imagine bringing in a prescription from a cardiologist for a blood pressure medication and having the pharmacist say “I can’t fill this until Tuesday”? Doesn’t this smack of “script-ism”? This is a slippery slope to discrimination people!
We can make the argument for the pharmacist that narcotics need to be counted daily and if you are given 120 pills, then that is 4 pills a day for 30 days. Mathematically speaking, the pharmacist is correct. However, he is treating Robert like a criminal, not the “good patient” that he is. He is not allowing for the fact that Robert and his doctor have a long-standing relationship. His doctor understands that if Robert had to do the grocery shopping for his sick wife that he needed an extra pill that day, and another extra pill the next day because he really did too much the day before. His doctor knows this. His doctor knows him. The doctor understands, and if he is willing to see Robert in his office on the 28th day and write a new prescription on the 28th day, and the insurance company is willing to pay for it on the 28th day… then, who is really in charge of Robert‘s care? On what planet can a pharmacist over-ride a doctor’s order?… wait for it… this planet!
Robert’s story brings up issues that we need to be aware of, but there’s more. My husband had surgery very recently and it unearthed a new change in the way pharmacists do their job.
With Robert’s story in the back of my mind, I went to drop off the prescriptions that the doctor wrote when discharging my husband from the hospital. I asked the pharmacist if the medication was in stock. Before he gave me my answer, he asked me a question that I was not prepared for. “What is he being given this pain medicine for?” This really caught me off guard! My first thought was about patient confidentiality and I wondered if the pharmacist had a true “need to know” in order to do his job safely and effectively... I didn’t really think he needed an answer to the question; however, I did consider him to be on my husband’s “team of health care providers”. I decided not to let my “bitch flag” fly and just answer him. I explained that my husband had just had a total knee replacement. “OK, yes we have it”, was the pharmacists’ response. My sarcastic mind quietly wondered if the medication would not have been in stock if I had given a different response… Honestly, something inside me felt defensive at this question. I felt like I was being made to defend my husband’s need for this medication, and, indirectly, his honor.
When I finally handed over the prescription to this man (another new face, mental note about the high turn-over at this chain pharmacy) he wouldn’t make eye contact, he seemed to be banging the keys of his computer in an angry fashion. Maybe his actions had nothing to do with me, or maybe ordering a narcotic makes him nervous because it could call his license into question if he were to make a mistake, but the way I was feeling was… I’m just going to say it, I felt judged! And there is even more!…
A friend of ours has also recently had some stressful interactions with local pharmacies. He encountered the same problem as Robert did, he was told his medication was “not in stock”. Now let’s just take a second here to explain to the readers who don’t have the working knowledge of narcotic pain management that we do. With long term narcotic pain management, there will be a physiological response to the abrupt stoppage of this medication. (OK, layman’s terms… withdrawal symptoms). That does not mean the person is “addicted” to the medication, however, it does mean that since the body has become used to having a certain level of this medicine in the blood stream, that certain things will happen if the medication is stopped abruptly. (many other medications require tapering down as well, such as corticosteroids). A patient will, within a few hours of their first missed dose, experience severe rebound pain (this pain can be more uncomfortable than their normal pain), anxiety, agitation, they may find it difficult to stay still, yawning and insomnia among other symptoms. As the hours become days, more symptoms will start, such as abdominal cramping, diarrhea, dilated (big) pupils, nausea and vomiting (among others). Here is a link if you want to know more about withdrawal. http://www.nlm.nih.gov/medlineplus/ency/article/000949.htm
Again, withdrawal is separate and distinct from “addiction”, which is characterized by using the drug to obtain a “high”, drug-seeking behaviors, putting the need to use above all else (relationships, jobs, mortgage payments), and finding new reasons to stay on a pain regimen when the original reason is healed, among others. (here is a link for more info on addiction www.mayoclinic.org/diseases-conditions/drug-addiction/basics/symptoms/CON-20020970 Anyway, drifted off topic there. My point was that the pharmacists are trained and have the knowledge that refusing to fill a prescription for a long-term narcotic patient can and will cause a cascade of effects that might send the patient to an emergency room to deal with the symptoms. It is not in the patient’s best interest to be told to “come back tomorrow”. The doctor who wrote the prescription did not intend for the patient to go home without any!
This friend of ours had become friendly with his pharmacist and was given the following information. He got confirmation that there really could be a shortage of oxycodone, (at least through legal channels). He said that the pharmacies order medication weekly but they are not receiving what they ordered. The pharmacist is quoted having said that “If we order say, 500 oxycodone tabs, they may only send us only 300. No matter what we order, they send what they want!” He continued on, “So if your script says that you get 120 pills, and the pharmacy you normally go to has 3 patients that are on 40 pills monthly, they may be holding you off so that they can keep 3 patients happy and in the process making you (only 1 patient) dissatisfied, rather than keeping you happy and making the 3 other patients dissatisfied.” That seems to make sense. The young pharmacist also shared that Friday was the day they got delivery. It was not clear if all local pharmacies get their narcotic delivery on the same day. I assume it would depend upon what company they order from. Feel free to ask this question of your pharmacist and see if you get an honest response.
I also found out that Pharmacists are now, in certain circumstances, asking to have a letter on file from your doctor stating why you are on this type of pain management. I made a call to my insurance company to inquire about such a letter. Here is what I was told. If a patient uses over 4 pills per day in a 90-day period (over 360 pills for the 90 days) the pharmacy will request a letter called a “prior approval letter”. It does not matter what strength (or milligram) you are on, just if the number of pills exceeds 360 in a 90 day period, it will “flag” your chart at the pharmacy causing this letter (which is something the insurance company can fax to your doctor, who fills it out and signs it) and placed on file with the pharmacy in order to have any more pills dispensed using your insurance.
What the pharmacists don’t care about is that many doctor’s offices no longer keep their phone lines “open” for incoming calls until any more. They may be in the office, but they are very busy and send the phone calls over to voice mail preferring to deal with calls on the next business day. If the need for this letter pops up on a Friday, or God forbid, a Friday of a holiday weekend, you could be caught “up a creek without a pain pill!
Paying cash overrides the insurance companies need for that letter… but guess who can afford that $700-$900?… Right! The drug dealers can afford to pay cash and avoid having this letter on file! See what I’m saying? The good people have more rules and the drug dealers keep on sneaking under the radar!
Anyway, the “prior approval letter”, I am told, is good for a certain period of time. This might be different according to what insurance carrier you use. So, if you think this applies to you, I would find out the specifics from your insurance provider and then once you get the first letter on file with the pharmacy, make a note in your calendar so that you can ask your doctor to take care of this just prior to the original letter’s expiration date. (It may be a year, it may be six months). Being this sick require a secretary? Right???
Two more interesting things that my sleuthing skills have not been able to prove (or disprove). Several different people have mentioned to me that they believe that the pharmacists are compiling information in a “patient chart” that they have. One gentleman was turned away for his prescription with the “out of stock” story, and attempted to go to three other pharmacies in the area. He reported to me that he was quite annoyed by the time he got to the third pharmacy. The following month he returned to his original pharmacy, the pharmacist asked him, “why did you go to another pharmacy?” This man (sorry, I didn’t retain his name) told me that he really felt like there were “notes” in his “file” about how he went to another pharmacy and about how he was “quite upset” when he was turned away. This poor guy explained to me that yes, he was upset! Of course he was upset because he couldn’t believe that no one had his medication in stock and that he was wasting time, gas and energy trying to get his script filled all while in pain and not feeling well. He admitted that he was upset because he knew he was going to have a long night ahead of him with no medicine at home to carry him over until he could get his script filled.
It was filled the next day, but now he feels as if he has this “big black mark” in his file. The last thing he said to me was, “If there is part of the patient chart out there that pharmacists are keeping, shouldn’t we be allowed to read what is in there?” Definitely something to consider!
Lastly, two of the guys in this physical therapy group stated that they felt as if they had their picture taken or are “being filmed” as they do their narcotic transaction. I wish I had thought to ask them if they had all pharmacy transactions filmed, or just narcotic transactions. I wish I had! But I do understand that it makes sense to do so, if someone were to inadvertently get their hands on your prescription and cash it in your name, then they would have a record of who was posing as you. I can see that it would be a valuable piece of evidence if a crime like that were to occur. I assume we are all being filmed when we do an ATM transaction so I wanted to pass that along just so you don’t go up to the pharmacy check-out with spinach in your teeth or your hair in curlers. (You’re welcome!)
I reported to you all after the Chronic Pain Conference last year that there is now a state-wide DEA drug database. It makes sense to me to reiterate here that no matter where the source, in-hospital or out-patient setting, everything you’ve been prescribed are all listed in one place. This is for your safety, it reduces errors in giving two different medications that do the same thing, as well as helping to track medications that may have drug interaction problems. Those are great and nice, but the real reason is so that you cannot go to two different doctors and have them both prescribe narcotic pain management and then have both legitimate prescriptions filled. People paying cash could skip the insurance regulations and get away with this previously. It is a safety-measure put in place to keep those of us that are trying to do the right thing from sneaking over the to dark side. If you know this exists, you won’t make the mistake of trying to do it, and then get all caught up in having to explain yourself. Please know that if you are attempting to do this, that you may actually need the help that they force you to accept, such as going to a rehab facility.
In summary, a word to the wise, apparently now the pharmacists are now legally allowed to question you as to why you are on this medication. The pharmacists are now legally able to question the doctor’s judgment. But please don’t get upset when your pharmacist starts asking ridiculous questions or if they turn you away saying that they “don’t have it in stock”. If they really do have the ability to make statements on some computerized patient chart, they may also be filming your pissed off face while they are doing it!