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Sometimes the simple things in life make a difference. It may not seem like a lot, but to a patient, it can mean everything.

I need something for a cough

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4 Comments

Recently, a family member called me at my pharmacy and asked me for help in obtaining a cough syrup. She was developing an infection along with a terrible cough. It had been going on for days and it was not getting any better. She had an appointment with her doctor and asked if I could bring her something to help with the cough.

It was the night before her appointment and the cough was one of those that would have anyone coughing all night long with very little sleep. Many of us have been in this same position or have seen a patient with a similar problem. You would like to help and you have a good idea on what would benefit the patient with symptomatic relief.

In Michigan, the Controlled Substances Administrative Rules from the Board of Pharmacy can be found at:

http://www.state.mi.us/orr/emi/admincode.asp?AdminCode=Single&Admin_Num=...

One very useful component of the above rules deals with schedule 5 cough syrups. Rule 67 states:

R 338.3167 Dispensing schedule 5 substances without prescriptions.
Rule 67. (1) A pharmacist may, without a prescription, dispense a controlled substance listed in schedule 5 which is not a prescription medication as determined under the federal food, drug, and cosmetic act, 21 U.S.C. §§301 to 392, if all of the following provisions are met:
(a) The dispensing pharmacist has determined it is to be used for a medical purpose.
(b) Not more than 240 cc (8 ounces)or 48 solid doses of a substance containing opium or more than 120 cc (4 ounces)or 24 solid doses of any other substance listed in schedule 5 are distributed at retail to the same purchaser in any single 48-hour period.
(c) The purchaser is at least 18 years of age.
(d) The pharmacist requires a purchaser not known to the pharmacist
to furnish suitable identification, including proof of age where appropriate.
(2) If a pharmacist dispenses a controlled substance listed in schedule
5, then he or she shall affix to the container in which the substance
is dispensed a label that shows the date, his or her own name, and the name
and address of the place of practice in which the substance is dispensed.
(3) The pharmacist shall maintain a record of the dispensing of
controlled substances listed in schedule 5. The record shall be immediately
retrievable and may be maintained in the same manner as required for
schedule 5 prescription medication. The record shall contain all of
the following information:
(a) The name and address of the patient.
(b) The name and address of the purchaser if different from the patient.
(c) The name and quantity of substance purchased.
(d) The date purchased.
(e) The name or initials of the pharmacist or pharmacy intern who
dispensed the substance.
(f) The medical purpose for which the medication is being used as
determined by the pharmacist.

This is a great rule in that it allows you to provide within your professional judgment, a beneficial solution for a patient in need. I don't know if all states have a similar rule, but I am sure that there are some pharmacists in states that don't have an exempt cough syrup rule wish that they had one to provide professional guidance. It is part of what we do. A patient comes to you with a problem and they are looking to you for a solution.

At my pharmacy, we did not have any of the appropriately packaged cough syrups on hand for a schedule 5 sale. A friend of mine worked at a nearby pharmacy and once told me that they dispensed them at his location. Therefore, I went to another chain pharmacy with my business card in one hand and my wallet size license in the other. I went to the back of the pharmacy and picked up some dextromethorphan and benzocaine lozenges. I was pleased when the pharmacy technician asked me if I could use any help. I told her that I was the pharmacist manager from the nearby Costco location and I needed to ask the pharmacist on duty a question.

The pharmacist from back behind the tall counter looked up and came out front when I showed him my business card. I identified myself to him and explained the situation and what I would like to purchase. He then told me that he was from a temp agency and not the normal pharmacist on duty at this location. He seemed to be proud of the fact that he was an older pharmacist, but he informed me that they did not have any on hand and that I would have to come back the next day to speak with the regular pharmacist. Unfortunately, the next day response was of no use to me. In other words, he refused to make a sale to me and turned me down. When the technician tried to quietly tell him that there were some bottles on a back shelf in the pharmacy, he once again said that I would have to come back the next day. I have been a pharmacist for over 25 years and have sold many of these cough syrup bottles in legitimate sales, but here I was, a pharmacist, being refused service.

I thanked him for his time and he returned back behind the counter. I proceeded to make my purchase of the lozenges and the technician told me she was sorry that I could not be helped. She thanked me for my purchase and said that there were some bottles back in the pharmacy. I told her not to worry, it was fine and I appreciated her help.

Unfortunately, I went to another location in the same chain and got turned down again. I identified myself, had my license and business card in hand once again, but simply received that "look" and I knew this was not going to work. Then I went to an independent pharmacy where they knew me and received four ounces of generic Robitussin AC. Simple request. Quick sale. No problem.

Now, there are a number of problems with this situation. I am in the group of pharmacists that are frustrated with other pharmacists that speculate first on diversion and put patient advocacy on a secondary level. It is unnecessary and damaging to our profession. We should all be professional and remember that we are in pharmacy to offer solutions to patients.

Secondly, all of us have so many tasks to complete on a daily basis, trust those technicians around us in our work performance. They are there to help and have often received extensive professional training. Some may argue that the above technician was inappropriate in her actions, but I disagree because she was discreet and professional in her actions. A job well done.

Finally, I have never refused any sale to anyone on the basis of what they were trying to purchase or on the basis of their appearance. There have been appropriate times whereby I have told a patient that I could not help them, but it also included an explanation which was all within applicable federal or state laws. The law is there to help us and we all need to remember our professional standing. In this way, you will make a difference in the life of a patient.

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Comments

rmwhit's picturePharmacistrmwhitJoined: Sep, 2009
Location: San Antonio, TX
Posts: 15

A Redi-Med physician (i'm assuming a doc in the box, sorry I'm from TX, not that many of them here) should NOT be treating chronic pain or giving prescriptions out in the quantity mentioned above. It is out of the bounds of therapeutically appropriate dosing, based on prescribing information.

We had a patient bring in a prescription for a full 16 oz bottle of Tussionex. The prescription was written by a doctor in Colorado. We contacted the doctor (otherwise we wouldn't fill it) and documented the discussion in the computer and on the face of the prescription, giving the patient the benefit of doubt, as well as the doc.

This guy came back a week later (that's a lot of hydrocodone) with a prescription for TWO bottles of Tussionex. We declined that prescription. By the way, we are right next to a cancer treatment center and do a large volume of narcotics. That gets us MORE scrutiny from the various agencies that check on pharmacies.

RPhXP's picturePharmacistRPhXPJoined: Aug, 2009
Location: Royal Oak, MI
Posts: 11

there seems to be two sides to this situation. 1. Pharmacies that make oodles of dough selling high margin exempt cough syrups to any Joe that walks through the door. and 2. pharmacists that suspect abuse at the mere mention of a cv cough syrup and absolutely refuse any sale. The needy people in the middle suffer unnecesarily. Pharmacy has changed dramatically over the last few decades and caring for the people has degraded to caring about ourselves. I miss the old days sometimes, typewriters weren't so bad....

jevisger's picturePharmacy TechnicianjevisgerJoined: Jul, 2009
Location: Muskegon, MI
Posts: 35

Thanks for the nice report. In times like these, it is very hard when it comes to the dispensing of Controlled Substances(CII-CV). We have a physycian at the nearby Redi-Med center. He used to be in a Family Practice. Some of the physicians got tired of the frequency he was writing for Controlled Substances to numerous patients. He chose to leave the Family Practice, but then he wanted to start the Redi-Med Center. One of the Conditions of him practicing at the Redi-Med Center was that he would "Responsibly" control the Frequency of the RX's he would write for Controlled Substances. He did agree to this. He was fine for a while, then things started getting out of hand. Everyone in town knows if they want a CII for Pain, or a Controlled Substance RX for cough that they can go see him... We actually had a gentleman come in our pharmacy with an RX for Tussionex. He got an 8oz bottle of it. Then he went to another Pharmacy in our chain (2 miles up the road) 3 days later with another RX for the same thing from the same Dr. They filled it. He returned to them 4 days later with another Rx from the same physician for the same medication, this time it was for an Entire 16oz. bottle of it. He said he knew he would have to pay cash for it cuz he knew it wasn't covered by his insurance. The Gentleman told our Pharamcist that he wanted to use our Savings card on it. Our Pharamcist told him "No, it will be for the amount that I say it is and it will be for cash." The gentleman argued with our Pharmacist and would not leave. Then man was requesting a DISCOUNT on his cough medication. He wasn't even coughing. He had absolutely no signs of discomfort or cough. The gentleman demanded to speak with the Pharmacy Manager. While they were talking, I had to go in the Manager's office and call 911. The police came quiety and reprimanded the gentleman. He had been making a terrible seen in our pharmacy. There were other needy patients waiting for the Prescriptions. The officers aked the man what was going on. He started getting defensive and making an even bigger scene. They handcuffed him. One of the officers went into the managers office and called the Redi-Med Physician on the phone. The Physician told the officer that the RX was legitimate. He told the officer that the man needed the "Tussionex for Pain. That he was dying. That he had been to the emergency room several times for Cardiac Arrests and that his liver was failing...." --- Didn't the Redi-Med Physican even consider that it was probably the EXCESS DOSES and frequency of the Tussionex that was causing the gentleman's Cardiac Arrests and liver failure?! Duh! --- The officers ended up letting the gentleman pay the $300 or so for the man's RX, and the man paid cash for it. The officer then took the bottle and the man and took him to the county JAIL! ----- The man has not been in our Pharmacy since. But he has gone back up the road to the other Pharmacy in our chain with more Rx's for Tussionex from the same Redi-Med Physician. The Pharmacist from the other store actually called our store and had me go to their store. She had me meet her up by the Photo Dept--- meanwhile the man 'thought he was just waiting' for his script. The Pharmacist asked me what had happened with the man at our store 2 weeks earlier and I told her. She told me "I cannot fill this man's prescription for this medication. It is a legitimate script. I called the doctor at the Redi-Med." She told me that when she became a Pharmacist many years earlier that it was "to assist the patients with their physicians by helping them to get well and receive proper medications for their illnesses." She said to me, "I cannot help to kill this man anymore. Not in my good conscious." She then went back to the pharmacy in the back of the store, and told the gentleman that she could "not fill his prescription- because it is too early." The man said, "alright..." and then he left calmly without his medication. That was about 4 months ago. We have not seen the man or had him bring another RX for Tussionex to our Pharmacy again. I am sure he probably still goes to our other store though, but the Pharmacists there are very careful with his receiving of Tussionex when he gets it...

I say that if the man was in that much "PAIN' he should be in an institution with a morphine pump. Don't prescribe him liquid cough syrup with liquid Hydrocodone in it! Any thoughts on this?

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jevisger's picturePharmacy TechnicianjevisgerJoined: Jul, 2009
Location: Muskegon, MI
Posts: 35

I believe that treatment for Terminal Pain , if it is IN FACT terminal pain, should be left up to those who specialize in these types of things. Situations like these should not be left up to a Redi-Med physican. Any thoughts?

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