Posts Tagged ‘pharmacies and buprenorphine’

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.