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Thursday, December 6, 2012

Did you ever Wonder?

I am pretty good at math. Always have been. I can do most pharmacy calculations in my head rather quickly. If you need a calculator to double-check, please grab one. I mention this because I always wondered why people would prefer to argue with me, when I am obviously right, rather than acquiesce. I present two cases today:
1. Birth Control: There are 365 days in a year. In order to give someone a year's supply, most doctor's offices will give patients 12 packs (usually 1 pack with 11 refills). This is not enough. How many months have 28 days in them? (All of them actually, but most have 30 or 31...) This is where the problem lies. If they are scheduling patients to return in 1 year, 12 packs will last 336 days, 13 packs will last 364 days. She will still need a 14th pack. I called a nurse out on this when she called in 1 pack with 11 refills.
Combative Nurse: That's 1 pack with 11 refills. Her appointment is next year.
Me: Ok. But she'll need 14 packs to get her through until then.
CN: No. There are only 12 months in a year. She will be back in 12 months. Therefore she needs 12 packs.
Me: But there are only 28 tablets in each pack. You are only giving her enough for 336 days. There are 365 days in a year.
CN: That's how we always do it.
Me: Ok. Then you always do it wrong. Grab a doctor and a calculator and call me back.
(Yes, most gynecology offices know better. Yes, they sometimes give patients free starter packs. The point is, outside of that being true, this conversation happens. It is not legal, here, to put "refill x1yr" so that is not an option.)

2. Pain Meds (and others as well): Everyone has a rule about how early we fill controlled substances. Usually it is 1 or 2 days early. Ever wonder what happens to those cumulative refill quantities? If someone fills his prescription 2 days early every single month, assuming a 30-day supply, at the end of the year, he will have an extra 29 days of medication somewhere! Where do they go? If we are so concerned about early refills and abuse potential (obviously legitimate patients are not being discussed here), then how do we deal with this issue? Some insurance companies will stop refills on heart or cholesterol medication if the cumulative refills amount to too much over a certain period of time. Has anyone ever really looked at these "repetitive creep" amounts? I know we can research these fills through some states' Prescription Monitoring Programs and alert doctors but what else can we do? I've had the "cumulative refills are too soon" conversation with a number of patients and doctors. Most of them have been quite receptive but some are argumentative. I am not talking about shirking our duties of having the conversation with the patient and doctor about how much they are actually taking, dosing increases, strength changes, status changes (pre-op vs. post-op vs. accident, etc). This is simply about the woman who presents a prescription early for Vicodin 5/500 written for 4 times a day for 120 tablets and always shows up saying she is out or needs them right now, every single month.
Where did they go?

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