More Phun with Pharmacies

It seems to come in waves. Weeks will go by without any pharmacy troubles, and then all at once several crazy or annoying things happen at once.

 

First, I got a message from a patient asking why he received fewer films than I usually prescribe. This patient is a star. He’s been in recovery over ten years and prefers to stay on buprenorphine/naloxone films to treat pain from a chronic medical issue, rather than taper off the medication. I’ve had the pleasure of treating him for over ten years, and he’s never had unexpected drug screen results. He always keeps his appointments and is flourishing in his life.

I thought the issue was likely due to his insurance, but knew I’d have to talk to his pharmacy to figure it out. So, I called, and a pleasant pharmacist tried her best to be helpful. I’d written for one and a quarter films per day and wanted #40 dispensed.

Technically, the pharmacist explained, I should have prescribed 37.5 films, but of course that’s not possible, so insurance would only pay for 38 films per month.

“OK,” I said, “But why did you only give him 35 films, instead of 38, then?”

There was a moment of silence until she said, “Huh. Well, that’s a good question. I don’t know.”

“Who would know?” I asked, foolishly.

“I don’t know.” Maybe the head pharmacist?”

“Can you ask, if you don’t mind? I’m kind of curious.”

She said she would, and that she would call me back with an answer. It’s been a week and I’m not expecting a call back. It’s really a minor thing, and maybe not worth anyone’s time, except…WHY?????

Today, I was enraged at the experience of another patient. He’s been in recovery for around twelve years and has been doing very well for the past six years with no illicit drug use. He has a family and just started his own business employing several other people. He’s doing well and made much progress in recovery.

He got a tooth pulled recently, a procedure that was more complicated than usual. His dentist gave him a prescription for ten hydrocodone pills for pain, and he tried to fill it at his usual Walgreen’s, where he fills his buprenorphine/naloxone tablets, prescribed by me.

He said the pharmacist said no. She told him that people being prescribed buprenorphine/naloxone can’t fill prescriptions for opioids. She didn’t offer to call the dentist, or to call me, to see if it was medically appropriate to fill the prescription, which it was. She just said no.

I saw red.

“What did you do? Did you call the dentist? Did you talk to her boss?”

“Nah, I didn’t want to make her angry and I wasn’t in that much pain. I just took a whole lot of ibuprofen along with Tylenol and got by.”

“If that happens again, please call me. I’d be glad to set this pharmacist straight. In fact, what’s her name? I’ll call her now.” I was fired up and ready for a fight.

He couldn’t remember her name and seemed a little reluctant.

I get it. He must deal with that pharmacist to fill his medication and didn’t want to make waves. I didn’t call, but told him if he ever had a similar experience, let me know, and I’d call and explain that being on buprenorphine products doesn’t mean a patient can never be treated for pain.

Then tonight was one of the funniest and most bizarre things I’ve heard from a pharmacy.

It started when my fiancé (and therapist to my patients) told me he had a message from a patient, saying that my E-prescription couldn’t be processed because it needed to be in a different format.

Well that’s odd, I thought. The format is determined by the electronic prescribing platform, and is fairly standard. Alas, I’ve had to learn two different e-prescribing software programs.

Again, I was going to have to speak to the pharmacist directly.

Initially I spoke with a nice gentleman who tried hard to help me. I asked him what the problem was, and he told me my DEA number had to be in a “Nadine” format.

“Wait, what? What are you talking about?”

“You need to put in your N-A-D-E-A-N number.”

“Do you mean my DEA X number?”

“No, it’s the NADEAN number.”

“You’re going to have to explain that to me. I don’t understand.”

“Ms. Burson, I’ll get the pharmacist to help you.”

“OK,” I said.

I had my phone on speaker, and I thought he had put me on hold. I sighed and asked my fiancé, “Did he just call me Ms. Burson?”

I wasn’t on hold.

“I’m sorry, I should have said Dr Burson. It’s just habit,” he said.

I felt a little ashamed about complaining. It’s not a big thing. I went to med school in the 1980’s, so I’ve had many colleagues, nurses, patients, AND pharmacists call me “Ms.” instead of “Doctor” over the years. But then again, it is 2020, so maybe it’s time to realize that females are doctors, too.

Anyway, another nice pharmacist came on the phone and explained that the DEA must be formatted in a specific way. All CVS pharmacies had been given instructions not to fill buprenorphine products unless they were formatted thus:

NADEAN:X and the rest of the DEA number.

I had not used this format – instead, I typed “Use DEA X1234567.” (not my actual DEA number, of course),

I said I did put the DEA X number on the prescription. I asked her if she saw it. She said yes, she did, but the NADEAN stands for Narcotic Addiction DEA Number and if it wasn’t submitted in that format, it couldn’t be filled.

I thanked her for her time, and told her I knew she was only the messenger, and said I would cancel the prescription I had just electronically submitted and re-issue another with their preferred format of “NADEAN:X1234567”

I’ve seen plenty of inefficient and even counterproductive things in my career in Addiction Medicine, but this is probably the funniest and most ridiculous bit of red tape I’ve seen in a long time. It was so silly I didn’t even get angry. I was giggling to myself, thinking was a great blog post it would make.

Obviously, someone was over-interpreting a corporate message that was trying to say that the X DEA number needs to be on every electronic prescription. But it is being literally interpreted, at least at this CVS, that NADEAN:Xnumber has to be in that format. Prescribers beware: if you are sending a prescription to a CVS, use this format or your patient will be unable to fill their prescription, even if you have your DEA X number on it.

18 responses to this post.

  1. Posted by Lisa Wheeler on March 1, 2020 at 4:25 pm

    So 35 is different than 38. It’s less than 1.25 and more than 1.125 (34 strips).
    I think I’ld want that explanation! That’s a pharmacist practicing medicine without a license.

    Last week I lost a nut on a pharmacist who wouldn’t fill Bup/Nal until the start date. I wrote for patient to be able to fill day before. (We always write fill and start dates.) Walgreens wouldn’t. They don’t open until 9. People have to be at work typically before 9 and this patient takes meds in AM.
    Physiologically am I am not worried about withdrawal. Psychological stress (regardless of my explanation of half-life) is very real in an already stigmatized population.
    Pharmacist explanation “policy”. Meanwhile, I’m furiously googling Walgreens prescribing policies—for which THERE IS a policy and regulation page!
    I asked where I could find this policy on the site.
    “Nowhere, it’s an internal store policy we have.”
    I will acknowledge being less than professional at that point (not sure what color is beyond red, but I was there) and accused the pharmacist and pharmacy of discrimination and called the pharmacist a bigot (had to look up definition to make sure I was meaning what I wanted to mean). Pharmacist shared she was not a bigot in fact had worked at a Methadone clinic. At which point I then explained that she, of all people, should know the difference between the meds and clearly comfortable managing them as a pharmacist.
    The pharmacist noted if had I written the fill date as day before (as I had) AND a reason FOR FILLING BEFORE THE START DATE she would fill it.
    I get early refills for travel and yes I write that out, but denying bup/nal refill the day before the start date because I didn’t give an excuse is ridiculous.
    The fact that big box stores can individualize their policies thus not matching corporate policy is ridiculous.
    In our area we do not have a shortage of X-license prescribers. We have a shortage of pharmacies to a) have the medications in stock b) be willing to fill.

    Reply

    • If I know you, Lisa, you created a whole new color of red!
      I appreciate your advocacy for our patients.
      Dealing with such ridiculousness with a few pharmacists puts me in a bad mood for all pharmacists, obviously not a great attitude to have when collaboration is in the best interest of the patients.
      But if you have pharmacies who refuse to fill prescriptions…that’s really worrisome. And the reasons they give…a pharmacist in Statesville refused to fill a prescription written by me in my Cornelius office because it was written by an “out of town” doctor. I’m twenty miles away…

      Reply

  2. Posted by What’s the point on March 1, 2020 at 4:49 pm

    blows my mind how these pharmacists let the oxys that caused a epidemic flow out of their stores for 20 years and now give people shit that are picking up the treatment medication that they helped cause the addiction. It’s 100% discrimination . Amazing how America can be the worst place to be addicted to something, if your able to move to Canada or England do it . They are years ahead of us in treatment and acceptance. If addicts had money to offer or treatment with meds made big money things would be different. But that’s no the case and I always say that Americans love to shit on people, addicts are the new minority without rights . Even though every doctor and scientist says it’s a disease and no o e gets high off the medication they still treat people like they are in active addiction and will never trust or treat people with dignity and respect that everyone else with a chronic disease gets . It’s why people hide their addiction for as long as possible and overdose needlessly all because of out dated laws and discrimination.

    Reply

    • I believe their obvious UNDER-reaction in the past, with OxyContin, etc., is fueling the OVER-reaction to buprenorphine for treatment of the problem they helped to create.

      Reply

  3. Posted by Paul Simpson on March 1, 2020 at 4:51 pm

    I started running into this problem with CVS over a year ago. It’s a corporate policy, not overzealous interpretation at a local pharmacy. Corporate has the CVS e-prescription software programmed so that no electronic buprenorphine prescription can be received at any CVS pharmacy unless the proper NADEAN format is used. If I don’t use it, the prescription will not be accepted, so the pharmacist never even sees it. In my state, all controlled substance prescriptions must be sent electronically. I don’t prescribe other controlled substances, so I don’t know first hand if this only applies to x-waiver prescriptions. I have been told by colleagues that they do not have to use the NADEAN format to get there Percocet and Norco prescriptions accepted electronically by CVS. I have suspected this is corporate discrimination against buprenorphine prescribers and patients, but don’t have proof of that.

    Reply

    • That’s for writing in! I don’t know what state you are in, but NC implemented the e-prescribing requirement on Jan 1 of 2020. I certainly have never before used a “NADEAN” format and plenty of patients go to CVSs, which was why I assumed it was one pharmacy. But what you’re describing demonstrates otherwise. It DOES feel like discrimination. The only difference is in the first letter of the DEA number, so why NADEAN for one and not the other?

      Reply

  4. Posted by Steve on March 1, 2020 at 6:28 pm

    OMG, you are so right about CVS eprescribe! Florida just switched to mandatory eprescribe and CVS has major problems with the format. I sent one rx 5X using every combination of NADEAN that I could think of. Lower case, upper case, combinations of the above; finally I just gave up and called the pharmacy myself.

    Reply

  5. Posted by Paul Simpson on March 1, 2020 at 7:10 pm

    Mandatory e-prescribing for controlled substances started in Pennsylvania in October 2019. Here’s another tidbit I think is interesting and supports the corporate discrimination theory. My clinic has two separate programs. One program treats chronic pain in patients who have no history of substance abuse and do not carry a diagnosis of substance use disorder. Most of those patients are treated with Butrans. The other program treats opiate dependence with Suboxone. I have always prescribed Butrans using my regular DEA number since those prescriptions are not subject to the DATA 2000 law regulating buprenorphine use for addiction treatment. Before CVS changed it’s e-prescribing program, I could send the Butrans prescriptions with the regular number. When they made the change, I started getting calls from patients complaining that the prescription was not at the pharmacy. After inquiring of CVS, I learned that their programming was changed to reject any buprenorphine prescription unless the Note to pharmacist starts with NADEAN:X
    I now have to put this notation or the pharmacist never receives it:
    “NADEAN: X…….. Please use A…….. for chronic pain.”
    where X…….. is my X waiver number and A……. is my regular DEA number.

    Reply

  6. Posted by Chuck the Sham on March 1, 2020 at 7:33 pm

    I was completely clean for 18+ years. I had a motorcycle accident and I took oxycodone for it. I had taken it before for a dental procedure (don’t remember what), but it was for a relatively short time, but I thought that I would be okay. Wrong. This injury (3rd degree burn on ankle) had me laid up for over 2 months. Needless to say, my addiction took over and I relapsed completely, back on heroin. I am in medication-assisted sobriety now, using Sublocade. It is only once a month, and they require that I talk to them on the phone before every refill. Still, I feel much better than having to deal with CVS, Walgreen, WalMart, et al. for my medication. The rules and regulations are really something, and I think there is an element of Puritanism in the whole thing, making us immoral drug users go through the paces like they do. Do they do that with other people with chronic illnesses? I guess the answer would be yes, if the illness requires opioid prescriptions.

    I swear, somewhere the ghost of Harry J. Anslinger must be grinning like a devil.

    Reply

  7. Posted by william taylor on March 1, 2020 at 8:42 pm

    It took us a month to sort out the glitches to e-prescribe buprenorphine in NC, and I’ve given up hope of ever using my regular DEA number, even 100% pain patients. For people with multiple prescriptions, apparently “early fill ok” has to be on EVERY prescription.

    Reply

  8. Posted by Sparky on March 1, 2020 at 9:59 pm

    More total nonsense from even stupider people,no wonder people go postal over minor things

    Reply

  9. Dr. Janaburson I am surprised you had not been Had this problem already with CVS. Colleen Labelle Massachusetts state OBAT director has been dealing with this problem for at least 6 months and go all the way to the top of CVS and they state they are working to fix this and promised to notify all pharmacies a temp work around after many of us have had are scripts delayed and put in harms way. They promised by April their software will be fixed but they can override if script is not written in the NADEAN:X
    Format also just a semi-colon or space will get system to reject this script.

    Reply

    • WOW. I had no idea this was going on until last week. It’s just crazy. I thought it was the misguided over-interpretation of one zealous pharmacist, not the idea of the major corporation that is CVS. I get so frustrated that pharmacies don’t understand that delays with medications put our patients at risk.

      Reply

  10. Unreal but the same thing happened to me at CVS and I had to put my XN number in the comment section because even though it was on the script they could not see it. We won’t even get into missing strips. I tell my patients to not leave the pharmacy desk without counting their strips as it is not uncommon for 2 or 4 to be missing per month leaving the patient short and not understanding how this could happen. Pharmacists have addiction issues as well so 2 here or 2 there adds up. Sad but true!!!!

    Reply

  11. Posted by Paul Simpson on March 4, 2020 at 12:28 am

    When I open my first primary care practice in 1982, I had two or three patients per year catch recurrent pharmacy pill shorting by counting their pills each time before leaving the counter. The frequency of this occurrence has gradually increased since then. After it seemed to take a big jump in the 1990s, I started advising patients to count pills every time. The problem has always been worse with controlled substances, so I think the drug dependent pharmacist idea is valid. However, I have also seen this problem rise with medications not prone to abuse. Health insurers notoriously strive to avoid paying for care to improve their profit margin. It’s part of their business model. CVS filled or managed 1.4 billion prescriptions in 2014. Imagine the potential for boosting the bottom line if most of those prescriptions were short a pill or two, especially if the medication sells for $12 a pill as I’ve seen charged for Suboxone at some pharmacies in my area. I’m certainly not suggesting this is corporate policy, but I’m sure it is corporate policy to push each pharmacist and each pharmacy to maximize profits.

    Reply

  12. Posted by Stu Gitlow on March 22, 2020 at 6:48 am

    We went through the same thing with the NADEAN. No one in the entire medical community refers to the DATA 2000 waiver as a “NADEAN.” So I had a long phone call with the pharmacist who kept telling me I needed to include that, and he pronounced it as Na-Deen. I had absolutely no idea what he was talking about. DATA 2000 waiver, X-number, DEA certification — I’d have understood any of those. Minutes of discussion passed. The pharmacist, by this time convinced that I wasn’t a physician, since obviously a physician would know what a NADEAN was, had hung up on me.

    Then I went to look it up online, and indeed the DEA refers to it as a NADEAN! I sent off a memo to officers and other members of ASAM asking if any of them had ever heard it referred to in that manner. Nope, not one.

    OK…something new. So now we have to change every single entry in the e-prescribing database to accommodate this absurdity. Thanks, CVS.

    Reply

    • Thank you for writing in, Dr. Gitlow.
      If Stuart Gitlow, past president of the American Society of Addiction Medicine didn’t known what NADEAN meant, then I don’t feel bad for not knowing!!!

      Reply

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