Pharmacy Question

I’ve no idea if this is the correct forum. Nor do I know if the Mods will allow this question, but I’m going to take a chance because I’m not asking for advice of any kind. Repeat: I am not asking for advice of any kind; I am asking for opinions.

I have a prescription for Butalbital/APAP/Caffeine Tabs. I use these things for headaches as directed by the doctor who prescribes them: one tablet by mouth every four hours as needed; not to exceed six tablets in any 24 hour period. On the original prescription, 12 refills were authorized. These things are doled out thirty tablets at a time. If I have, which I often do, a spate of headaches that are painful enough for me to take the maximum dose in a day’s time, I could possibly take all thirty tablets within the space of a week. So far, I haven’t had to take that many but I have taken thirty tablets within a two to three week period.

The pharmacy where my prescriptions are filled takes the attitude that the thirty tablets specified by my doctor constitute a thirty day supply in spite of the directions to take one as needed every four hours. I maintain that these things are for headache pain that often doesn’t go away as a result of taking one of the tablets every four hours and that there will be times when more than thirty of them will be needed in less than a one month period. This conflict of ideas has led to some interesting conversations with the pharmacist as in what the hell makes her think she has to right to override my doctor’s instructions?

So, IYHO, (In Y’alls Humble Opinion) what the hell makes the pharmacist think she has the right to override my physicians instructions?

Please don’t advise me to change medications, pharmacies, or doctors; I already understand that I have those options, within reason.

FWIW, the doctor needs to re-write the prescription to indicate a larger amount. The pharmacy’s hands are pretty much tied by the insurance company to assume that any prescription is a 30 day supply unless specifically written to the contrary.

The insurance company has never refused to pay; they must have more common sense than the pharmacist.

Your insurance company isn’t the one having to fill out all the controlled-substance paperwork and won’t be the ones taking it in the ass if the DEA wants to know why they’re filling these scripts so often.

I’ve had prescriptions where the supply can be used up if you have a bad time. You need to have the doctor write a new prescription as when refills are written they are considered monthly refills by pharmacies. There is no reason for the doctor to not write the refills for larger quantities if they don’t worry about the quantity you are taking. Ask for a prescription for 100 with 3 refills. That will allow you to get through the bad instances and still be about the same quantity total per year. It’s often cheaper that way too.

And there ya go.

Perhaps the more pertinent question is what makes you think the pharmacist IS overriding the physician’s instructions? As suggested by others here, it seems such prescriptions are normally and properly considered to be 30 days worth unless the doctor specifically indicates otherwise, and your doctor has not so indicated.

Note that the dosage recommendation does not constitute an instruction to refill the prescription more often than every 30 days. The “as needed” could result in your using it up before that time, but could also result in your never using it. Surely you can see that the vagueness here does not authorize the pharmacy to violate the guidelines they’re obligated to follow. “Take as needed” is not the same as “refill as needed,” and that’s the key thing to understand.

I think the pharmacist is just plain wrong. Unless there is something is the directions to indicate that this is a month’s supply, it shouldn’t be viewed as one. Maybe they are taking the “12 refills” to indicate that it’s a monthly dosage, but they are making an unnecessary assumption there. Of course, it could be your insurance’s view that this is a one-month supply- in that case, there’s nothing you can do except pay out of pocket for more, or request your doctor submit a prior authorization to change the amount covered.

Pharmacists are like a safety buffer between you and your doctor. Here’s something that once happened to me:

I saw my doctor for a chronic problem that I’d been taking a medication for. After the exam he told me that he wanted me to start doubling the dosage of that medication. He filled out a prescription form and gave it to me. I put it in my pocket without looking at it. Now . . . I still had a couple of weeks worth of pills left over from my old prescription, so I started taking twice as much, meaning that instead of taking two a day I was now taking four. I continued taking four a day until I got close to running out, at which point I took the new prescription to the pharmacist. The pharmacist filled the prescription, and when I picked it up, I noticed that he had typed two a day, rather than four. I informed him that my new dosage was for four a day. He told me that the new prescription was for two a day . . . and that nobody took four a day, because four a day could be toxic.

What happened was: when the doctor told me to double the amount, he thought I had been taking only one a day, and he wanted me now to take two, which was what he wrote on the slip. But I didn’t even look at the slip before giving it to the pharmacist, or I would have caught his mistake. He is an excellent doctor, but he made the mistake of verbally telling me to “double” my dosage, and incorrectly remembering how much I was taking. If it weren’t for the pharmacist’s expertise, I could have been taking a toxic dosage.

So . . . I have an excellent doctor and an excellent pharmacist, but nobody is infallible. I’m glad I have both of them on my side.

THIS.

Trust me, if your doctor is writing the prescription for thirty, he understands quite well that the pharmacy considers that a month’s worth. It may be the doctor’s way of limiting how much you take, or forcing you or the pharmacy to contact him if you exceed taking a certain amount in a month.

If you’re going through that much medication, it may be time for a specialist. There is such a thing as ‘rebound headaches’ caused by overuse of medications like this.

Edit; re-read original posting.

It sounds to me as well like the pharmacist is doing his or her job. Doctors know (or should know) how to write scripts and what they mean. If your doctor wants you to have access to more than 30 pills in a month, he can write a script for that. He didn’t, either because he doesn’t want you take that much, or he just didn’t think it was necessary. (Or he really doesn’t know how pharmacists interpret scripts, but that’s a failing on his part, not the pharmacist’s.)

Regarding the ‘rebound headache’ thing, my doctor (she, not he) has also given me a prescription for a medication that is essentially Fiorinal #3; that is, it is to say that it contains Codeine. The directions are that I am to take one a day, day in and day out. In that case, 30 capsules are clearly a one month supply and I’ve never attempted to refill that prescription early. The medication containing caffeine is to be taken more or less as needed but within the limits imposed by the prescription when a headache strikes. The medication containing codeine is specifically for the prevention of ‘rebound headaches’, or so my doctor says: sometimes it seems to work but sometimes it doesn’t. There have been times when it happens that both prescriptions need to be refilled at the same time. On those occasions, the pharmacist very nearly gets the vapors and understandably so. On the other hand, when I’ve asked about the situation, the pharmacist has told me that the combination of the two medications for the purpose we’ve outlined is “not unusual.” Since the pharmacist knows and understands why the doctor prescribes as she does, why do I have to continue arguing and explaining my occasional need to have the damn prescription refilled? The pharmacist has called my doctor on such occasions; she has never failed to authorize the refill and the insurance company has never failed to pay. I’d just like to be spared the hassle, especially when I’m in the throes of a damned migraine.

As to a specialist, been there, done that quite a few times over the years: I have migraines and that’s the end of it. I’ve had them since I was somewhere around twelve to thirteen years old (I’m nearly 70 now). I will say that the older I get, the frequency with which I have them has diminished but the pain level seems to have increased. My hope is that once my ongoing divorce saga is ended, the headaches will finally end as well.

I missed the edit window; my shrink has now put me back on Alprazolam 1.0 mg 3x per day at least until the divorce is final. I hope that will also help to reduce the headaches; the shrink seems to think it will.

I get your frustration, Louis! The label on my alprazolam says to take as needed. Ok, who the eff figures that out?!

That’s a good question; I guess the pharmacist thinks it’s his decision. I’m seriously considering calling him two or three times a day to ask his permission to take my medications but I sort of fear the consequences----he might slip me something that would make me linger for days in unrelenting agony while paralyzed, bed-ridden, and completely dependent on the tender mercies of some sadistic nurse.

Because there are laws and regulations about filling and refilling scripts for controlled substances, both at the state and federal level, and failure to follow those laws and regulations can result in fines, criminal charges, and/or the revocation of your license and/or DEA number. You can’t just look at the name on a script and say, “Oh, him, he’s okay, go on and refill it early,” because neither “he’s okay” nor “using these meds at this amount for this reason isn’t unusual, so I didn’t think anything about it” is going to cut any ice with the DEA and the state board when they investigate you for dispensing controlled substances inappropriately. It’s not reasonable to expect people to stick their necks out like that for you.

They have to run through the rat maze to protect themselves. Trust me, they don’t enjoy having to stop what they’re doing, dig out your doctor’s number, argue with the receptionist about how important it is they get an answer quickly, sit on hold 20 minutes or wait for a call for a few hours, and then fill out the corresponding paperwork. They don’t need the extra hassle any more than you do, and they certainly don’t need snotty calls asking permission to take medicine they’ve already gone through that hassle to give you.

There’s nothing the pharmacist can do to change the situation. There is, however, something you can do to change the situation. Two things, actually. You can talk to your doctor about writing the script for 40 pills instead of 30, or however many it would take to get you through a bad month. Or, if you’re having a bad month, and you see that you’ve only got enough to do you a day or so and there’s a week left in the month, go on and start the process early, so you don’t have to wait for the wheels to grind when you need the refill RIGHT NOW.

I once delivered drugs for a living and got to know a couple of pharmacists fairly well. I am certainly aware of laws, rules, codes of ethics, etc., etc., that hamper a pharmacists ability to dispense medications.

In the case of the pharmacy that fills my prescription, they most certainly do not have to ‘dig out’ my doctor’s phone number; their system is computerized and menu driven----the computer even dials the doctor’s phone, if that is requested. Nor does the pharmacist have to speak directly with the doctor, in the usual case at least. Instead, whoever answers the phone at the doctor’s office takes the information and relays it to the doctor, who then says yes or no. I believe this is a common practice between doctors and pharmacists. I also believe that an actual conversation between the pharmacist and the doctor is seldom required. While it is true there is sometimes (usually/always) a time lapse between the request for a refill and a response from the doctor, the pharmacist doesn’t stand around waiting for that response; he is otherwise occupied with other patients and their needs. Nor is there any paperwork to fill out—remember, I said their system is computerized and menu driven. This does present some complications inasmuch as if I see that I might/will need more pills before the usual fill date, the computer will inform the pharmacist that my insurance will not authorize a refill without the doctor’s say so; the pharmacist obviously has to comply or all sorts of problems, as you point out, will result. Another problem, for me anyway, is that customers in general have to jump through hoops in the form of an automated telephone system; all requests for refills are taken automatically by the computer and not by a conversation with anyone in the actual pharmacy. The phone system is not ideal and often enough, I end up being routed to an actual person, who may or may not be located in the pharmacy; in the later case, the customer, me, specifically, must wait while my call is transferred to the pharmacy department. By the time all this is accomplished, my patience, if not exhausted is strained. Hence the sometimes irritated conversations that you choose to classify as ‘snotty.’ AND, because my pharmacy is open 24 hours per day, I usually wait until around 10:00 PM before starting the refill request process simply because I want to minimize the stress involved for both me and the pharmacy department.

For whatever reason my doctor will NOT write me a prescription for more than thirty pills at a time, probably because I have made her very aware of my history of drug abuse. In any event, I’m sure she has my best interest at heart. The only viable solution that I can see would be for me to carefully schedule my headaches to occur only at times and intervals that satisfy the refill schedule to the letter. If you have suggestions as to how I might accomplish that I would be grateful if you would pass them on.

While I’m in a bad mood there is something else the really bugs me: the medication in question can be purchased ‘under the counter’ in any pharmacy in Canada and for less money than my copay; why can’t that be accomplished here in the USA? The FDA, for no very good reason, will not allow it.

The laws must’ve been changed recently. I had a prescription for diazapam for my Meniere’s Disease. I have 30 pills. It says “take as needed.”

I refilled the prescription and I lost it somewhere since I had one refill left, I decided just to refill it since I had to go to my annual doctor check up in March.

The pharmacist says they can only fill diazapam and other similar drugs, once every thirty days. She said if I lost it I’d have to have my doctor call in new prescription.

Since I have to go in March, I just made an appointment to go earlier.

I was paying cash for the drugs, so I figured I could get them refilled whenever. In the past I lost drugs on a trip, one was an inhaler and the other was Ziac (for high blood pressure.) I had just refilled them. The pharmacist said, I could use the refill but the insurance only pays for once a month. So I had the doctor change the type of blood pressure med for one month with a new prescription and skipped the inhaler.

So it depends on the type of drugs and it also depends on the pharmacist, depending on state laws, they have the authority to fill drugs or not. Walmart is probably the worst at doing any “special favours” because they know people who use them are doing so because they are the cheapest around and they are paying cash, so they don’t have to use any customer service. I found Walgreen’s to be the most accommodating in terms of pharmacy services.

The laws have changed pretty radically over the last ten years. In what timeframe was your expertise?

I deal with these issues constantly, as a result of the pain medications my mother takes. Yes, it is a PITA. No, it is not the pharmacist’s fault. Nor is it the physician’s fault.

Bitch at Congress for changing the laws, or at the DEA for their regulations, or at the FDA for their rules, or at the people who abuse drugs who created the mess in the first place.

So you have a history of drug abuse and your physician refuses to prescribe more than thirty pills - which she knows good and well is going to be considered a monthly prescription at the pharmacy - and somehow it’s the pharmacist’s fault that you can’t get all the drugs you want whenever you want? Cry me a river.

That sort of drug-seeking behavior is exactly why it’s such a pain in the ass to get the damn things in the first place.

I do NOT engage in drug seeking behavior so get that ill-informed idea out of your (presumed) brain right up front.

Now, look, sport, I no longer have a problem with drug abuse; I do have a problem with migraine headaches. I SOMETIMES have such a problem with migraines that I NEED more than thirty pills in one month; in which case the pharmacy MUST contact the doctor and the doctor must authorize, of not, the refill. Drug abuse doesn’t enter into it although it did at one time and might again, if I fall off the wagon, which I will continue to try very hard not to do. However, I haven’t in about fifteen years, which is a pretty solid indicator that I will not but the potential is always there. I haven’t had any binge drinking in that time, either, but that was also a problem, along with the drug abuse. The doctor is well aware of my drug abuse history because I MADE her aware which is hardly drug seeking behavior.

Cry your own damned river and then take a swim in it.

I delivered drugs for a mail order pharmacy strictly to nursing homes in the greater Tampa Bay area during the last six to seven years; I’d still be doing it had I not required back surgery following an automobile accident. I haven’t demonstrated in drug seeing behavior as a result of that surgery, either.