Ask the Pharmacist: Corresponding Responsibility vs. Irresponsible Negligence

Ask the Pharmacist: Corresponding Responsibility vs. Irresponsible Negligence

Dear Steve,

I think your response to the patient’s letter in your last column was horrible.

Pills as question on white isolated background. Medical concept.We as pharmacists are the last line of defense against prescription abuse. If you look at the data about hydrocodone consumption and abuse in the United States, you would understand why the need for monitoring early refills is necessary.  We dispense 96% of the hydrocodone in the world.  Are Americans that much worse off than the rest of the world?

You have obviously never heard of corresponding responsibility.

Sincerely,

J.S. in Indiana

Dear J.S.,

You are correct that the U.S. uses the vast majority of the world’s hydrocodone production, but what you may have missed is that most of the rest of the world uses dihydrocodiene. We have a product containing dihydrocodiene called Synalgos DC, but how much of it do you see prescribed? The DEA still has production limits on this opiate.

Yes, we are the final line of defense, but we are also supposed to be patient advocates – not cause patients to go into withdrawal and elevate their pain. Right now in the media, they are discussing the aggressive interrogation of terror suspects that happened after 9/11 and they are using “pain” and “torture” in the same sentence.

In my opinion, the DEA and our judicial system are playing a sickening game with their registrants, all to help ensure the War on Drugs (and patients) continues, providing job security for them and making criminals out of people who have mental health issues.

I receive emails weekly from all over the country, but Florida seems to be the worst, about patients going to the same pharmacy for years — same doctor, same meds, same dosage and very compliant — and all of a sudden they are refused by a pharmacist, usually a newbie or floater. Often at Walgreens they are blackballed throughout the entire chain.

Why are investigative reporters from across the country doing pieces on patients being denied prescriptions at pharmacies they have been patronizing for years? The number of emails that I get strongly suggests that these are not isolated incidents.

Do you chastise patients for not taking their medications for chronic conditions like diabetes as you do patients on opioids that may take a few extra doses? Both are non-compliant and the outcome for both is the same reduced quality of life and/or death if they don’t get their meds.

When you see a person buying nicotine products or tobacco, do you tell them that they are addicts and you are not comfortable selling it to them? If alcohol is sold in your store, why aren’t you telling these people that they are addicts and they shouldn’t buy alcohol?

Do you chastise a known diabetic buying a candy bar or other sweets that they should not be eating? But do you sell insulin syringes to someone who is unlikely to be diabetic?

Read up on where the War on Drugs started in 1914 with the Harrison Narcotic Tax Act, which is based on racism and bigotry. The court system then even determined that the mental health issue of opiate addiction was a crime, not a disease. Look up the ICD9 codes. Medical science considers it a disease.

Physicians have been taken to court and found guilty of irresponsible negligence for failing to treat pain. Irresponsible negligence is the other side of corresponding responsibility. Corresponding responsibility requires that a dose never gets in the wrong hand. Irresponsible negligence requires that you always get a dose in the right hand.

We don’t expect a diabetic’s blood sugar levels to always be between 80-120. Likewise you don’t expect a patient being treated for hypertension to have the same blood pressure every time it is taken. Why is it expected that pain levels for a chronic pain patient always be the same 24/7?

Pharmacists need to keep the prescribers’ feet to the fire about more honest dosing rather than routinely allowing early refills.

But until pharmacists, collectively, always get a dose into the right hand, I will continue to be critical of those who don’t.

Steve AriensSteve Ariens is a pharmacist and patient advocate. Steve has over 40 years’ experience as a pharmacist in Indiana and Kentucky, and has served on the board of directors of the Indiana Pharmacists Alliance and on steering committees for the National Community Pharmacists Association.

Steve’s wife is a chronic pain patient. You can learn more about Steve by visiting his blog at Pharmacist Steve.

If you have a question for Steve, send it to AskthePharmacist@nationalpainreport.com.

The information in this column is not intended to be considered as professional medical advice, diagnosis or treatment. Only your doctor can do that!  It is for informational purposes only and represents the author’s personal experiences and opinions alone. It does not inherently or expressly reflect the views, opinions and/or positions of National Pain Report or Microcast Media.

There are 14 comments for this article
  1. Christina at 7:27 pm

    dollars a tablet. If we are required by law to have health insurance why are the private pharmacies the ones who choose not to except it? Why are they helping the patients who do not have insurance? Greed and not being properly regulated..When you look at the national average for a tablet that goes for a 1.24 and private pharmacies are charging 4 to 6 times higher then that how can that be legal? How can a business take advantage of a pain suffer? Why is this continuing to be the behavior of these business? Nobody ask to be in pain and it is something you don’t have control over or a choice in. Your pretty much screwed and it’s ridiculous nothing is being done about it. I think everyone getting the picture here of why and we continue to elect these people who could care less about us. These people should be educated on auto immune diease, surgeries that go wrong, these shots that are being put in patients backs and necks that splice nerves or other damage I could go on and on. They need to pray that they never have to live their lives in this time..

  2. Christina at 10:55 am

    I am also a patient in Florida and let me tell you this controlling of amounts of meds into the state is just one of the strikes they have done against pain patients. Being there is a shortage and the DEA cAn denie all they want that there is not one. The compounding market is open again in the state.To get a pharmastist to help you and how much you have to do to get someone to help you is unreal. There is no confidentiality anymore. I’m still trying to find out what happen to the hippa law. The chain stores move the pharmacist around just so you can’t build a relationship with one. Florida has left one rock unturned after they went threw and put doctors out of business. They have left the private pharmacies open market on charging a pain patient what they see fit. I think it is sicking to charge a pain patient so much money for their pain meds. These patients are already limited on being able to work if they can work at all. So that leaves the gateway to the black market. Florida is aware if it but in my opinion they are using it to fuel the court systems and to keep DEA jobs. Tell me why a pharmacy would need to charge a 7 to 10

  3. Coonhound at 1:43 pm

    JS, u know, the US also has largest % of population incarcerated as well, & that stat is explained just as easily. >500,000+ on drug charges alone. http://www.drugwarfacts.org/cms/Prisons_and_Drugs#sthash.UXbX7Z3e.dpbs
    You said ”You have obviously never heard of corresponding responsibility”.
    Responsibility? What was DEA doing letting pill mill situation get so out of hand in the first place? Its their job, yet they are trying to deputize pharmacists, doctors, drug addicts (testify or face more time than a rapist), even delivery companies (UPS+FED EX).

    We are doing just what they want, blaming & fighting among each other rather than joining together to get law enforcement & insurance co the hell out of the examination room ! IF DEA is acting in good faith, they proclaim they would never stand in the way of patients receiving legit Rx, why not provide guidelines? (almost did but retracted them in 2004). They aren’t qualified.

    PDMPs? Supposedly created to stop diversion while ‘protecting’ legitimate patients. NOW? DEA wants unfettered access to EVERYONES medical records w/out a warrant!
    see ACLU/Oregon VS DEA.
    Americans are sick of population control, otherwise known as the War on Drugs. This is obvious w/ direction of MJ legalization, which just happens to be DEAs main cash cow (asset seizures & appropriations) so….they need a new boogyman. Anyone notice they never mention protecting legit patients access anymore by balancing our needs while fighting diversion ?

    Steve has great ideas on how to turn around this absurd situation. Problem is too many patients are content just to stand
    on the sidelines.

    As a disabled citizen i wasnt worried when the crackdown on the ‘epidemic’ started. I was a patient @ a well respected medical center & affiliated PM clinic w/ referrals from Johns Hopkins AND Baptist Medical Center. (how much more legitimate can u get?) After 5yrs i was ASSIGNED to ONE of their 7 pharmacies (all open to public mind you).IF that one was out of stock, tough s***

    I complained to patient services/advocates & was sent to the head of pharmacy services. I explained they were in direct violation of their obligations as in-network pharmacies for my Part D coverage. Like the PIC this did not phase her.

    next i filed a complaint w/ insurance co. Told them i was not receiving services paid for by my premium which clearly is stated in their evidence of coverage book. Was Assured i would hear back w/in 30 days. That was Nov 10 & despite several calls to check progress of grievance i haven’t been told anything!! They DID hold up my approval of nebulizer solutions w/ 3, yes THREE different reasons! one of which was Express Scripts call saying they couldnt verify if i had proper equipment to use the meds!!! That i went to ER w/ extreme broncospasms, severe bronchitis, exacerbating my Interstitial Lung Disease & suffered complete respiratory arrest in exact same situation in 2000 [almost died admitted for IV antibiotics & pulse steroids] did not impress upon them the urgency of the situation because when i asked them to give me emergency meds as stated in their formulary book they refused request reminding me i could pay out of pocket &file for reimbursement!!

    Is it not enough to fight for our lives against incurable diseases & unfixable injuries? We shouldn’t have to fight insurance co, pharmacists, state & Federal governments, and the entire health care system !!!

    Finallly callled CMS filing grievance against med cntr PIC, director of Pharmacy , & BC/BS. As rep listened she, like insurance company tried to dimiss,minimize ,even steer me away from making my compliant ‘official’. Finally said there was nothng she could do since she could not find pharmacies being in network !! Scream for supervisor and get one after 15 minutes of elevator music. She agrees that im being discriminated against & takes down my info. (FINALLY SOMEONE WHO WILL help)

    During down time i say ”’you guys must get alot of these complaints ” her response left me feeling defeated, astonished ,stunned , shocked,,& ultimately depressed as hell.

    She said “This is the 1st one I’ve seen filed against a pharmacist”
    Keep in mind she is a supervisor at CMS!!!

    If we don’t file complaints or grievances against those who throw up barriers to our treatment we can never win.
    One last comment. As a disabled citizen w/ 2 systemic INCURABLE autoimmune diseases [sarcoidosis & MCTD also known as ‘lupus overlap/Mixed Connective Tissue Disease)
    i have many systems involved which means many other symptoms besides pain. One fact i do know is that w/ untreated or under-treated pain all my other symptoms get much WORSE.

    WE WILL CONTINUE TO BE INVISIBLE UNLESS WE MAKE THEM PAY ATTENTION TO WHAT Is REALLY HAPPENING And WHAT THE REAL EPIDEMIC IS…….UNDERTREATED PAIN AND DISCRIMINATION AGAINST OUR MOST VULNERABLE CITIZENS …..THE DISABLED .

    *I dont believe the American people would support this endeavor if/when they know the whole story. I still cant believe we are being treated this way & i’ve experienced it firsthand. We must let everyone know it is not only addicts who are being targeted.

    Thank you Steve for all your time and efforts pointing us in the right direction so we can stand up for our rights.

    Merry Xmas/happy hanukkah
    Coonhound

  4. Brenda Alice at 12:06 pm

    Thank you for your great information and standing up for patients. I have been a chronic pain patient for over 10 years. No cure available. Never arrested, never lost medication or requested a early refill. Yet last year I went to 6 pharmacies trying to get a prescription filled. After the painful hour drive back to doctor He located the medication and drew a map. Got to pharmacy and they don’t have it. Funny that they did 15 minutes earlier. Prescription grabbed and finally filled. Now Tennessee is using the monthly medication sheets to go investigation the top providers and pharmacies. They first limit which doctors can prescribe and now investigating the ones that can help. I will never be able to walk a block but value the ability to visit the doctor every 30 days for the rest of my life and the ability to walk to the bathroom. The last medication cut took away my ability to attend the grandkids ballgames and birthdays. I pray for the end of needless suffering and for more people like you that DO not discriminate. You are my hero.

  5. Pharmacist Steve at 10:08 am

    Dakota… obviously you are trying to walk that thin line of never getting a dose in the wrong hand and always get a dose in the right hand. I wonder how much of empathy has been generated by your chronic pain.. standing all those long hours on your feet without breaks. Personal experience with any chronic disease always makes a better informed healthcare professional. Right now I am learning about my “golden years” as I approach 70.. and I am finding that not every day is “golden” some or more like “fool’s gold”…

  6. marty at 1:42 am

    Pharmacies have to protect themselves also. I have never had a problem with any doctors or pharmacies. I have been on everything under the sun and now only use vicodin. But never have I run out or ran to the ER to try to get other pain pills. I read in these chronic pain groups daily how they run out every month. They take 3 instead of 1. Well if 1 isn’t working than 3 isn’t going to do anything more than give you a high. In fact it is also known for actually making your pain worse. So instead of always blaming the doctors and pharmacists take a look around at all the people that really are abusing the drugs that are meant to help them. It reflects on us all.

  7. Dakota at 8:57 pm

    Pauly, I completely agree and empathize with you. Many pharmacists have been trained and have had it ingrained into their minds that anyone receiving regular opioid medications should be more highly scrutinized. However, this is due to many things. One, the state boards of pharmacy watch us like hawks just waiting for one of us to fill an opioid script one day too early (as determined by them), second, the DEA is also breathing down our necks to be vigilent in making sure no one is abusing the system which is why many pharmacies require that we check the controlled database to make sure patients haven’t received any of their opioids early and that it is time for their scripts to be filled. Lastly, the pharmacy chains are now very watchful of how early we fill these prescriptions. After basically all of them being fined hundreds of millions of dollars for the fiasco in Florida, they audit every pharmacist that raises any red flag.

    I do disagree with you on one point however, our sole job isn’t to mind our own business and fill your prescriptions. This is honestly degrading and hurtful to any pharmacist. We have gone through at the bare minimum 6 years of school and are Doctors of Pharmacy. Our area of expertise is medications, their effect on the body, side effects, drug interactions, and what medications are right for each disease state including the causes of chronic pain. Many, many times we have to call the doctor because the medication they wrote for a patient, they’re actually allergic too or the dose is much too high, it interacts seriously with one of their other meds, etc. THAT is our job! We are patient advocates! We look out for your health and make sure you get not only the right medicine but the best one for you!

    Just today I had a patient come in with a prescription for Norco 7.5mg from the ER. My pharmacy requires we look at the controlled substance database and ensure that the patient is eligible to have this filled. It turns out the patient had just gotten a prescription for the same medications from their PCP 2 weeks ago for a 30 day supply. I gladly offered to call the ER doctor to make sure it was ok with him because the patient ensured me he had known she gets a regular script for it. The ER doctor had no clue she did and said to but a do not fill until date on it before I could give it back to her.

    Another good example of pharmacists trying to do our best for the patient and do something that is part of our JOBS besides blindly filling your prescriptions. A patient came in with 3 prescriptions from a well known podiatrist in the area. This doctor requires that a patient get all 3 scripts which includes Norco, gabapebtin and prednisone or they get none. Obviously some people just want the Norco and I call every time one of these patients just want the Norco and he says absolutely not.
    Anyway, this patient came in and had the scripts filled and when we were ringing him up, he said “Oh I’ll just take the Norco. The others don’t work for me.” Well obviously all the techs know this doctor’s rules and tell him its all 3 or nothing. Then he says he only has enough money for one specifically the Norco. At this point I step in and explain that this is the doctors rules and I know he gives every patient a handout explaining this. He says he can’t afford all 3 and would come back when he gets paid on friday. I say ok I understand and I call this doctor to see if he will allow me to bend his rule. I call him and he answers very quickly. I explain the situation and the doctor refuses right away saying the patient knows the rules as he is a regular. I tell the patient who then becomes irate and then magically finds the money 1 minute later and gets all 3.

    So you see how some pharmacists can become a little suspicious of patients. However, I always try to give the benefit of the doubt because I suffer from moderate chronic pain with severe arthritis in my knees and hands that is now developing in my back. I take Norco for this from a very understanding doctor who I’m lucky to have. Every new patient who is asking to fill an opiate prescription I give a blank slate. I just go by what I see on the controlled database and by talking with the patient.

    Letting a pharmacist know why you need these pain medications greatly increases their trust in you. Being upfront and honest is what makes me trust patients and when some of my regulars need to fill a day or 2 early I happily call the doctor to ask. I have no problem with that because as a pharmacist my job is to look out for the wellbeing of my patients and ensure they are taking medications that are appropriate for their indications as well as make sure they have enough to cover their needs.

  8. Mark Ibsen MD at 5:07 pm

    The Linda Cheek reference is not on the DEA website.
    Hmmmm.

  9. Scott Mitchell at 4:15 pm

    STEVE,once again i applaud your level headed reply.I am in FL. and have been treated worse then a stray dog.I literally would give my left foot if it would stop the pain i have.I think if you took a poll,99% of us severe chronic pain medications would love to give them up.But who enjoys chronic pain? IN the beginning of my injuries and the usage of opiates,sure there was a pleasurable/high feeling.But they also controlled the pain.It has been years since there was anything enjoyable about them.They only control my pain,barely.I know for a fact that i would not be here if i didn’t get my prescribed medications.Death no longer fears me,and it’s sad,but there are still days when it seems like a better alternative.And i am only 56.Keep up your good work.With much respect,Scottie

  10. Phil Noir at 4:05 pm

    Steve, your very powerful statement highlights many of the problems (and hypocrisy) that we chronic pain patients face every month on our visit to the pharmacy to obtain a month’s supply of medication.

    Other chronic patients can receive refills for three, six, or even 12 months of medication. Chronic pain patients who use opioids and controlled substances cannot have refills and must visit their doctor every month. As I’ve heard you say, chronic pain patients are exhausted physically, emotionally, and financially,.

    We are not allowed partial fills when our pharmacy doesn’t have a full quantity of controlled medication. So, we are often required to do the “pharmacy crawl” to seek out the pharmacy that will fill our Rx, in spite of the fact that many of us are in violation of their controlled substance agreements when we use multiple pharmacies. Some patients are cut off from opioid analgesics and perhaps dismissed from a practice for this very reason, in spite of PMPs that provide their doctors (and the police) with information about every controlled prescription.

    Perhaps 4 times in 2014 I’ve agreed to accept less than my full 120 pills for BT pain (rather than do the pharmacy crawl) because my pharmacy of choice was short by 10 to 20 pills. I got by without incident, but I certainly felt their absence in increased pain during the final few days of those months.

    The thing is, a few years ago, I could have phoned my pharmacist who would have “fronted” me a dozen pills for a few days until I had my refill. The 72 hour emergency rule was honored by a few of the pharmacists I did business with, while today, with many apologies, I have not found a pharmacist willing to apply the rule for a few pills. DEA scrutiny and PMPs have made this kind of compassionate health care impossible.

    I also used to do business with two or three pharmacies in my area to familiarize the pharmacist with my needs, and to give myself multiple choices for acquiring my monthly dose. It was a smart thing to do from my perspective, and didn’t hurt anyone. Now these “agreements” prohibit our ability to encourage local pharmacies to keep methadone or 4mg hydromorphone in quantities of 120 tablets each month.

    I started this practice around 2003 when the DEA/FDA decided that 40mg methadone diskettes should not be dispensed to pain patients. When I was forced to use the 10mg tablet, I required #480 10mg tablets per month.

    Periods of vacation, holidays and long weekends, and international travel could all be accommodated in those days (only 5-10 years ago), with multiple Rxs and a note from my doctor. Today, that’s been outlawed, and big box pharmacy policies do not allow filling early. These policies interfere with treatment.

    One of the primary goals in the use of opioid pain medication is to improve function of people in chronic pain, but the intrusive rules for preventing diversion interfere with a patients ability to function — business meetings, vacations, and other events need to be arranged around the refill date to accommodate these highly restrictive rules regarding my medication refill schedule. (How this practice prevents diversion by an opioid dependent pain patient is a mystery to me.)

    In my experience with over 30 years of treatment with opioid analgesics, I’ve noticed that (in general) there are two kinds of pharmacist: 1) The professional member of the health care team. 2) The professional who feels like a member of the police, DEA, and other regulatory agencies — the beady-eyed “gate keeper” who sees, not pain and suffering, but high drama and malingering.

    Where the former sees suffering in the person shuffling up to their counter and reflects on the epidemic of under-treated pain in his or her community, the other, a skeptic, looks behind the veil of fraud and deception used by the criminals who are causing this “epidemic” of opioid diversion.

    So many pain patients complain of “being treated like a criminal” by the latter type of pharmacist who identifies with the gate keeper serving on the “last line of defense.” We are well aware that the regulatory sectors of our government have failed in 40 years of the “war on drugs” in spite of their billion dollar budgets, militarism, draconian asset seizures that have broken the innocent with no resources with which to defend themselves. The DEA et. al. has a vested interest in protecting their empires, and their budgets. They create an environment of fear and intimidation to indoctrinate new generations of health care providers to feel their responsibility to “gate keeping” is of greater importance than their responsibility to the public health of Americans in treating suffering.

    But it’s not all Sturm und Drang in getting treatment (although at times, it may feel this way.) We are fortunate to have skilled health care providers who read through the lies and inflated risks of using opioids, they understand the skewed mortality statistics, the fear mongering around OIH, the conflicts of interest by groups like PROPs, and understand that big money lies at the very heart of the decision to move the “war on drugs” from an external security matter to a witch hunt among American physicians who treat pain with sufficient quantities of opioid medications.

    These practitioners are a precious commodity who need nurturing and support in their constant battle to keep regulators at bay, and treat pain with empathy and compassion regardless of the risks they face.

    (To read a typical horror story about the DEA’s kangaroo court persecution of one typical pain practitioner, see the story of Dr. Linda Cheek: http://www.deadiversion.usdoj.gov/fed_regs/actions/2011/fr1028_4.html)

    We the people allow this interference, harassment, and Gestapo tactics when it comes to the “war on drugs.” A 72 year-old physician with over 40 years of experience wakes to a knock on the door at 3am, and finds a SWAT team with automatic weapons pointed at his head, and at the bodies of his family. The result — no evidence was found.

    This is our government in action.

    Pharmacists like Steve spread the truth about how agencies that act in our name “protect” we citizens from these highly trained medical professionals who understand the nature of chronic pain, and the dosages necessary to get it under control in many different kinds of disease states.

    In my work as an advocate, I hear from the heartbreaking majority of people in pain, most of them under 35, who continue to hear the old saw “you’re too young to start narcotics” or worse, “let’s reserve those high-powered medications for when you’re really in pain.”

    It is more difficult to receive effective and adequate pain treatment today than it was in 1980 (when I was 30).. Resceduling hydrocodone compounds to CII, along with the change in indication — from “mild to moderate pain”, to moderate – moderately severe pain” leaves many with no pain relief and no recourse other than drowning in alcohol or using street drugs. Heroin deaths are up this year.

    We’re going backwards into a world of ignorance, scientific bias, increased suffering, and yes, more gate keeping when it comes to treating pain. We live with this paradox — less people are being treated effectively, yet we have more knowledge about the physiology of pain, its pathways and endogenous regulation, the mechanisms behind opioid tolerance, and the benefits of treating pain early and effectively than ever.

  11. reta coon-jiminez at 2:11 pm

    I have good results with my Dr. and using Hydrocodone.
    I see her once a month for a 30 day supply which I get at Walmart. The price is right and they keep tract of my prescriptions.

  12. Pauly at 1:03 pm

    Thank you, Steve for standing up for those of us in pain but are looked at like pond scum by these snub nosed pharmacists. They need to mind their own business and do their jobs by filling our prescriptions. Last time I looked, a pharmacist and doctor were 2 different job titles and governors and senators should have NO say so at all. Donna: I am sorry for your pain and that you are no doubt treated like pond scum also.

  13. Donna M. Harker at 11:37 am

    I was wondering why I was told by my doctor that I have multiple chronic pain conditions and that I will always be in pain that I should get use to it.I got this pain because I lifted a car that fell off a bumper jack onto my husband at the time yes I have done pt,meds,exercises and anything else that could possibly help I basically ripped the nerve bunches in my neck and the ones that go through the collar bone and that isn’t able to be fixed so why should the government make my life so miserable by telling my doctor that he can’t give me anything for pain and why are the doctors and pharmacies so afraid of standing up and suing the government for these people who don’t have a medical licence deciding how to treat their patients.