Question for the medical/pharmaceutical folks

I’ve heard quite a bit about pharmacists who’ve refused to fill prescriptions for contraceptives due to personal moral stance. But I’d not heard any who refused to fill a prescription for painkillers until yesterday.

Here’s the story. A relative just had surgery to remove a lump in her breast. Her doctor sent her home with a scrip for Vicodin, which she sent her husband off to fill at the local pharmacy. They refused to give out the drug, sending him home instead with a codeine-containing drug. She’s allergic to codeine, so she sent the husband back to the pharmacy to get the Vicodin as prescribed. They sent him home, telling him the drug didn’t contain any codeine. She sent him back, with the codeine ingredient circled (I wish I could think of the brand name of the drug, but it’s not coming to me). This time, they sent him home empty-handed, saying she needed to have her doctor call the pharmacy and confirm her codeine allergy before they would fill the prescription for Vicodin. By this time, it was after 5PM and her doctor was out of the office, and she didn’t have any emergency numbers to call, so she just took aspirin last night and dealt with the pain.

So my question is–is this normal? I know Vicodin is tightly controlled because of the possibility of people selling their pills, but can’t codeine also be sold in this manner? And isn’t that why a prescription is required in the first place? Why would a doc prescribe it if she didn’t expect it to be filled by the patient?

The whole incident just ticks me off–something doesn’t seem right here.

Comments

#1 Bob
June 29, 2006

I’m wondering if part of the problem was that the husband was filling the ‘script. I think also that Vicodin has a greater “street resale” value than codeine. It’s definitely not right that your relative has had this hassle. Along these lines, have you tried to buy a pseudoephedrine-containing decongestant recently? They’re beind the pharmacy counter, and you get to provide name, address, SSN, driver’s license number, et al, before you can buy any. Thanks to the druggies, those with legimate need and use for these medications have to jump through all kinds of hoops before getting them. Doctors who prescribe pain meds are also under scrutiny from the DEA and other law enforcement agencies, again thanks to the drug abusers.
#2 Tara C. Smith
June 29, 2006

I’m wondering if part of the problem was that the husband was filling the ‘script.

I’ve never had a problem with that. Surely they don’t expect people who’ve just had surgery and are in pain and woozy to go to the pharmacy themselves?

And yeah, here in Iowa, getting over-the-counter cold medicines is a struggle, since we’re 3rd in the nation as far as meth labs go. Hadn’t thought about docs being scrutinized as far as writing scrips for meds, but I guess that’s just one more prong to it…
#3 Sunny
June 29, 2006

Here in NYC there isn’t that much of a problem in getting cold medicines with pseudoephedrine, but just across the river in Jersey they’re starting to check IDs at the counter.
#4 daksya
June 29, 2006

The Pain Relief Network is on the case.
#5 Todd Raine
June 29, 2006

I don’t even know where to begin. This is definitely suspect behavior. At best I would say the pharmacist was being overzealous, at worst behaving unethically and illegally. Pharmacists often make prescription substitutions, but always for an equivalent medication (usually the generic – and thus cheaper – form of a brand name med). Hydrocodone (the opiate in Vicodin) and codeine are NOT equivalent (codeine, IMHO isn’t worth the powder needed to blow it to H___). If I found out a pharmacist was making this substitution on one onf my prescriptions ( I am an emergency physician) I would tear them a new orifice and then think seriously about making a formal compliant to the state college of pharmacists.

Bottom line – what you describe is WRONG, WRONG, WRONG, ethically and perhaps legally.
#6 Zach
June 29, 2006

Pharmacists aren’t responsible for saying if someone should or should not take a specific drug. That is the job of the physician. A pharmacist that refuses to fill a prescription because of moral stance should be disciplined at best and fired at worse.
#7 Abel Pharmboy
June 29, 2006

I’ll go one stronger than Zach – this is bullshit. This is the slippery slope I feared once pharmacists started refusing to fill scripts for Plan B. As a pharmacy professor, I’ve been meaning to prepare a post on this and the responsibilites that a state-licensed medical professional has to fulfilling the duties of the profession above and beyond one’s personal views. I’ll come back when I have my post done.

BTW, the reason codeine works poorly for many folks is due to it having relatively low affinity for mu opioid receptors. Most of the analgesic effect of codeine is due to its hepatic metabolism by CYP2D6 to morphine. About 15% of the population have a slow-metabolizing polymorphism in 2D6 that slows this conversion to the more active analgesic. Also, SSRI antidepressants (i.e., Prozac, Zoloft, Paxil) are competitive inhibitors of CYP2D6 – if you take an SSRI antidepressant, codeine won’t work for you because it’s metabolism to morphine is slowed or inhibited completely.
#8 Cynthia
June 29, 2006

If there’s a problem doesn’t the pharmacist phone the physician’s office? It sounds like someone enjoying a little bit of power and/or not knowing what they’re doing.
#9 Stephen Uitti
June 29, 2006

I filled, but didn’t use any of my last vicodin scrip. I could sell it to her.

(this is humor – not a real attempt to sell illegal drugs… no animals were harmed in the filming of this joke.)

What is true is that i’ve not had any problems of this sort. I often pick up drugs for my wife, who has a different name that mine. They need to know what drug was requested, or her address, or some other confirming data, but i don’t have any problems. I could refer this person to my pharmacist. I live in Michigan. It is much more likely that a reasonable pharmacist lives near her. My local drug stores are all offering free stuff if i start buying drugs from them.
#10 biosparite
June 29, 2006

Try reading a book titled BOWLING ALONE. It makes the point that Religious-Right wingnuts are far more focused on and involved with their personal salvation than garden-variety, mainline Protestants, but that mainline Protestants are much more likely to become involved with public-service and charitable activities outside the church. The exception: anti-abortion,anti-sex, and anti-drug initiatives, in which the crazies, who, after all, KNOW they are correct as a matter of faith, force their insanity down everyone else’s throats. Elsewhere I have read that the continuing Puritanical strain in American society accounts for such things as withholding sufficient doses of painkillers from people recovering from major surgery becuase you are supposed to suffer in this world and not partake too much of analgesics.
#11 Abel Pharmboy
June 29, 2006

Okay, here’s the link to my rant on pharmacists and the responsibilities of the profession.

I’m still unclear as to the pharmacist’s rationale for not giving the Vicodin to the husband of your relative. Most states prohibit the substitution of DEA scheduled drugs without the approval of the prescribing physician. Not sure if these relatives are in Iowa or Ohio or Connecticut, but I’d urge them strongly to file a complaint with the appropriate state board of pharmacy regarding this incident.
#12 Tara C. Smith
June 29, 2006

Thanks Abel for the excellent post (and everyone else for the advice)–it’s much appreciated. For the record, this is back in Ohio, and I’m already working on helping her draft a complaint. She was going to call her doc today and try to get things straightened out, so we’ll see how things turned out. As far as the rationale for substitution, I’m not sure they provided one, but I’ll double-check.
#13 Dennis Benton
June 29, 2006

I’m not a pharmacist, but do work for a large health care organization. Is it possible that the drug formulary for her health insurer excludes Vicodin except in the case of a codeine allergy? Even if this is the case, the pharmacist should have called the physician – substituting one drug for another (rather than for a generic version of the same drug) is highly inappropriate without the physician’s consent (and would be a firing offense here in California).
#14 Tara C. Smith
June 29, 2006

Is it possible that the drug formulary for her health insurer excludes Vicodin except in the case of a codeine allergy?

I’ll have her ask, if so, shouldn’t the pharmacist (or someone else?) ask prior to switching the medicine? And because she *does* have a codeine allergy, swapping it out for a different drug containing codeine seems to me incredibly incompetent. She’s never experienced anything more serious than nasty hives from taking it, but you never know…
#15 ericnh
June 29, 2006

Like Stephen Uitti, I also pick up drugs for my wife, who kept her maiden name. However, even though its Vicodin which she takes for her back, I’ve never had a problem at the pharmacy (usually Brooks). Just pay and go. Where my wife does have a problem is getting a refill from the doctor. While I certainly understand doctors’ reluctance to refill her Vicodin prescription, I’m also puzzled at this because she so rarely takes it, sometimes going most of the year on one 20-pill bottle. Mostly that’s because it makes her quite drowsy, and she prefers other methods of mitigating the pain, taking the Vicodin only when the pain makes it hard to move. I realize the doctors are trying to prevent abuse, but with her long documented history of back pain and infrequent use of the drug I’m surprised it’s so difficult for her to get a refill.
#16 David Harmon
June 29, 2006

Abel P: Would this affect OxyCodin? If so, that would explain my particularly unpleasant experience after dental surgery, when the pills simply failed to work….
#17 Dawn
June 29, 2006

Wow, Tara. That poor relative and her husband! I am married to a pharmacist, and, like Abel Pharmboy, he was appalled by the story. However, we both wonder if it was the pharmacist or a technician he was dealing with. Techs are supposed to have a pharmacist check any of their work before giving it out. If this was a pharmacist who made the error..right drug/wrong label or wrong drug/right label…then a complaint is certainly the next step. If it was a technician and they were trying to hide their error from the pharmacist then my first step would be to complain to the pharmacist and/or the store manager (as well as file a complaint anyway)
#18 CC
June 29, 2006

What the pharmacist did is nothing short of criminal. And no, I’m not talking about not issuing Vicodin (even though refusal to issue a drug – especially at a time when the pharmacist could have called the doctor to verify the script – could, on its own, be a basis for a lawsuit for pain and suffering).

I’m talking about sending back the codein-containing drug, saying there is no codeine in it. This is terminally incompetent, and the pharmacist who did this is a danger to his/her patients. It’s only a matter of time before the drug is issued to someone who believes the pharmacist rather then reading the label.

While I absolutely hate the existing litigative culture, which is to blame for many woes of modern healthcare, this is one case where I think even most pharmacists would agree that your friend should sue. Not just because of what she has been put through, but to get this pharmacist somewhere where he/she won’t be a direct danger to the patient’s lives.
#19 Dave S.
June 29, 2006

You know Jerry Seinfeld used to have a joke that pharmacists were “stock-boys with pills”. We know that’s not true, that (most) pharmacists are dedicated professionals. But this one…I’m not so sure.

Ohio State Board of Pharmacy
#20 Abel Pharmboy
June 29, 2006

Mr Harmon: I assume you are speaking of OxyContin, a sustained-release form of oxycodone that has been increasingly abused for recreational purposes, but is an excellent analgesic in most cases. However, the story is the same for oxycodone in that it is extensively metabolized to more active metabolites – the CYP2D6 reaction (called O-demethylation) produces a metabolite called oxymorphone, a compound 3-5X more potent than morphine.

So, if you’re a 2D6 slow-metabolizer or are taking SSRIs, OxyContin won’t work very well for pain. This paper gives a little more background but is pretty technical outside of the introduction. However, it gives a nice diagram of how oxycodone is metabolized.
#21 David
June 29, 2006

I would suggest getting a local TV station that does investigative reporting to do a story on it. Looking bad on TV seems to make management types take notice.
#22 Kathryn from Sunnyvale
June 29, 2006

The whole story has a form of incompetence in it- a form of willful stupidity that must be tied into the mindset that ‘pain isn’t really a medical condition’ (or something like that).

Take the event and substitute ‘penicillin’ for ‘codeine’ and ‘cephalosporins’ for ‘Vicodin.’ I’d bet that even the pharmacist in the story would be horrified at the thought of trying to give penicillin to a person who insists they are allergic to penicillin.

And, similarly, I doubt that pharmacist would allow himself to say “if you can’t prove you’re allergic to penicillin, I’m willing to wait until tomorrow morning to fill your antibiotic prescription.”

But (perhaps) because this is pain medication, the pharmacist allowed himself to dismiss both the concerns about allergies and the 15-16 hour delay in filling the prescription.
#23 anon medical bystander
June 30, 2006

Seems the pharmacist’s role has been pretty well covered from several angles here.

I’m glad Dawn brought up the possibility that an assistant may have played an appropriate role. The description of the situation reminds of cases when unqualified people try to make decisions about policies they don’t really grasp.

Also, a separate issue: It seems odd to me that your relatives could not reach the surgeon or prescribing physician. It’s common for post-surgery patients to have questions or minor issues after discharge, so it’s common to provide after-hours telephone access. Either the surgeon, family doc, or someone should have been on-call and reachable for just such an issue. Docs I know are accustomed to after-hours calls from pharmacies and patients to resolve such questions.

–
#24 anon medical bystander
June 30, 2006

Doh! That should say:

“…an assistant played an inappropriate role…”

–
#25 Lenn Sisson
June 30, 2006

I just have to add my two cents worth here.

I was a pharmacy tech for three years, before leaving that profession to become a journalist and (later) a technical writer. Personally, in the absence of any additional information, I believe that this pharmacist acted wholly and entirely inappropriately, and perhaps criminally (if you believe as I do that denying someone pain medication when they are in pain is a form of assault).

When I was in pharmacy, we never refused to fill any prescription. If we thought someone was faking a script, we would call the doctor. The same if we thought someone was doctor hopping (going from doctor to doctor until they found one who would prescribe the drug they wanted).

This pharmacist may be reacting to a “moral” concern (more like an immoral concern if you ask me), but part of it may be a reaction to what went on in the early 1980s.

I remember many doctors in my area (Atlanta) back then seemed to prescribe controlled substances like they were candy. I can’t tell you how many times we filled scripts for valium, Librium, and the like. And many of these were for large doses with multiple refills.

At the time, my boss predicted that in 20 or 30 years there would be a reaction and that controlled drugs would be very hard to get. This is something I’ve seen more and more of in the last few years (at least from the standpoint of a casual observer).

Certainly there has to be a happy medium here. It seems that government can’t foster a middle road, but must always go to extremes… either throw drugs at people, or don’t give them any at all.

I would be interested in hearing if other people have similar thoughts, or am I just “seeing things”.

As for your relative, if it were me I would start by complaining to the doctor, then the district manager for the pharmacy, then the state pharmacy board.

I also like the idea of contacting a local TV station that does investigative reporting. They can often get a situation corrected that formal channels won’t touch or are slow to react to.

Good luck to your relative, and please keep us posted about this!

— Lenn
#26 Tara C. Smith
June 30, 2006

Re: pharmacist vs. technician, I’m not sure but I’ll find out.

I’m talking about sending back the codein-containing drug, saying there is no codeine in it. This is terminally incompetent, and the pharmacist who did this is a danger to his/her patients. It’s only a matter of time before the drug is issued to someone who believes the pharmacist rather then reading the label.

I completely agree, and this is why I’m pushing her to document all this and report it to the state board. I know she won’t sue, but this should at least be brought to the attention of higher-ups.

Also, a separate issue: It seems odd to me that your relatives could not reach the surgeon or prescribing physician. It’s common for post-surgery patients to have questions or minor issues after discharge, so it’s common to provide after-hours telephone access. Either the surgeon, family doc, or someone should have been on-call and reachable for just such an issue. Docs I know are accustomed to after-hours calls from pharmacies and patients to resolve such questions.

I’m not sure what happened. This was just the second time she met the surgeon–I went with her for a consultation while I was back in Ohio a few weeks ago, and the surgeon was recommended by her OB/GYN (whom my relative had originally gone to about the lump). So I don’t know if an after-hours number just got lost in the shuffle and confusion, or what. I know that she said the surgeon didn’t meet with her following the surgery, and that she had a nurse (or perhaps a PA, but definitely not the surgeon) deal with the her discharge. I’ve never had major surgery and don’t know if this is normal procedure or not.

As far as an update, she was too tired sore yesterday to try and deal with any of this. She also has a 5-month-old to care for, so this has all been very stressful for her.
#27 Dave S.
June 30, 2006

From the Ohio State Board of Pharmacy website:

PHARMACY TECHNICIANS IN OHIO

(02/10/2005)

The Ohio State Board of Pharmacy does not license or certify Pharmacy Technicians. There is no legal requirement to be licensed or certified as a Pharmacy Technician in the state of Ohio.

Rule 4729-5-25 of the Ohio Administrative Code addresses the dispensing of drugs and compounding of prescriptions. It states that a person, not a pharmacist or intern under the personal supervision of a pharmacist, may assist a pharmacist in the compounding of prescriptions and dispensing of drugs. It further states that this person, who is not a pharmacist or pharmacy intern under the personal supervision of a pharmacist, may not engage in any procedure requiring professional judgment and that the system of drug distribution must provide exact control and assign immediate responsibility only to a pharmacist accountable at every point in the system between the receipt of the order for a drug and final delivery for administration or use by the patient.
#28 Justin
June 30, 2006

Hopefully impossible, but the lengths the pharmacist went to not go back on the substitution made me wonder if s/he is skimming vicodin from the store, with the scam hidden by legitimate prescriptions accounting for every vicodin pill taken.
Is something like that possible, or is there sufficient oversight/paperwork associated with the codine substitution that it’s not a concern?
#29 Gerry L
June 30, 2006

Related to the comments above about the new obstacles for getting cold meds containing pseudoephedrine: As of tomorrow (July 1) here in Oregon you have to obtain a prescription. That’s right. For the past year these OTC products have been behind the counter (BTC?) but now they will be prescription only.
#30 Julie Stahlhut
July 1, 2006

Gaaaaahhhhh … I’m appalled. I’ve had several surgeries and injuries that required me to take pain meds for two to ten days afterwards, and my husband has never had problems picking up my prescriptions for me. Even New York has permitted it, and New York doesn’t permit much of anything.

The hypothesis that the pharmacist is pulling a drug scam is an interesting and plausible one. If I were your relative, I’d certainly phone my surgeon and my family physician to tell them what had happened, and I’d certainly never, ever go to that pharmacy again. Someone who is very close to me has to use prescription meds for a chronic pain problem, and found out that a formerly trusted person was using a complicated ruse in order to steal them. The theft wasn’t merely a rip-off; it left my friend in severe physical pain. There’s no professional or moral excuse for a pharmacist refusing to fill a legal prescription and leaving a patient in pain.
#31 Dan R.
July 1, 2006

This seems so outrageous, I find it hard to believe. If it really happened that way, then someone should lose a job.

My guess is that somewhere along the way, in someone’s head, hydrocodone (generic Vicodin) became codiene. I can think of no situation where insurance would have been involved, since hydrocodone is also available as a generic.

I will tell you that MD’s/pharmacists will be suspicious of a patient complaining of a codiene allergy. Although anything is possible, complaining an allergy to codiene is much like complaining of an allergy to tauine. More than likely, your aunt had a reaction to the inert ingredients in the pill, or the pill was ineffective (as detailed above). Many/most drug seekers also claim the codiene allergy as a way to try to get stronger medicines.
#32 bint alshamsa
July 1, 2006

I used to work as a pharmacy technician and I must admit that the pharmacist at the chain store where I worked regularly engaged in behavior like this. On the one hand, there were people who would come in with prescriptions for pain meds and it was obvious that they had attempted to change the count on it to a much higher number. Others who came in had multiple doctors prescribing the same narcotics. The pharmacist would regularly tell “suspicious-looking” customers that we were out of the medication and that they’d need to try somewhere else. Because there were three other pharmacies on that street, most people were able to just get it filled somewhere else.

I quickly grew pretty disgusted with it all and found a new job. Between battling the insurance companies and watching how this pharmacy was run, I wanted no part of the profession. I also switched out of the pre-pharmacy program and went into biology instead. That experience has stayed with me for all these years. Even though some of these turned-away customers may have had drug problems, I’m sure that there were a lot of legitimate scripts that just weren’t filled because of how the customer looked.

Now, I’m the one on the other end and it scares me to death. I have an incurable chondrosarcoma and I often have to send my husband to get my prescriptions for narcotics, muscle relaxers, etc. The pharmacy that we used to go to was absolutely horrible. Whenever I sent him, they’d always have some excuse for not giving him all of my meds. He’s over six feet tall and he’s African-American and I suppose he might look “suspicious” to the pharmacy staff (especially after getting no sleep for days on end from taking care of a post-operative wife and a rambunctious daughter all by himself) but it wasn’t until I had my doctor write a note to the pharmacy explaining my situation that they started filling my medicine appropriately. It was absolutely infuriating to have some pharmacist making judgement calls about which medications I really needed.

We’ve found a new pharmacy with a wonderful and ethical pharmacist and an absolutely bubbly pharmacy technician. My husband and I can afford to go the extra distance to get to the good pharmacy but I can’t help thinking about all the people in my area who don’t have their own transportation and have to rely on whatever business is along the buslines. God help us all if things don’t start to change in this country really soon! Otherwise, I fear that many good pharmacists will just give up the profession and do something much less stressful for a living.
#33 kathryn from sunnyvale
July 1, 2006

Dan R.,

Although anything is possible, complaining an allergy to codiene is much like complaining of an allergy to tauine.

And people could be reporting penicillin allergies because they want a shorter-acting course of antibiotics. Or because they want a Cipro prescription because of fear. But I’m betting even the bad pharmacist would hesitate to actively substitute penicillin for cipro.

Your hypothetical doctor’s willful ignorance can only exist in an environment where ‘pain medication’ isn’t really considered medication. For what other types of medication could a doctor refuse to believe in self-reported allergies and not be called on it?

Taurine? A minute on Pubmed looking at taurine allergy finds nothing.

A minute on Pubmed looking at codeine allergy finds on the first page of results:
“Generalized dermatitis due to codeine. Cross-sensitization among opium alkaloids,” “Drug-induced urticarias,” “Pancreatitis due to codeine,” and “Documented allergies of patients with cancer.”

In the latter they report:
‘Results of the study indicate that the percentages of stated allergies for persons with cancer might be higher than those for overall populations. The top four medication allergies were penicillin, sulpha, codeine and contrast media. The top four food allergies were milk, eggs, chocolate and strawberries and the top four environmental allergies were bee stings, chemical sprays, dust and mould [sic]‘
#34 Bill W
July 1, 2006

I take three psych meds three times a day (and probably will have to do so for the rest of my life). The combination has allowed me to get out of bed in the morning and go to work to earn a living for twenty (20) years now.

In California there is a shortage of pharmacists and they have just re-written their organization’s code of ethics to allow not filling a script based on their own religious beliefs. That, however, has not been my problem.

One of the meds I take is traded by criminals as a street drug.

I have had pharmacists refuse to honor a script for this med twice this year. One even told me that he would rather I change the amount I take each day.

This last time my psychiatrist sent me to a friend who is a pharmacist and he filled the script.

I am now doing ALL of my business at that pharmacy.

This crap has to STOP!

For a pharmacist to intervene in a physician’s treatment plan should be CRIMINAL!
#35 David Harmon
July 2, 2006

Abel: Thanks! And (of course) you’re right about the name.

Kathryn: Any sufficiently advanced stupidity is indistinguishable from malice. I would consider the “drug scam” scenario to be a type of malice.

The So-Called War On Drugs has led to a basic moral failure in America. Several of them, actually, but this one, is that our medical systems and practitioners are effectively required to consider the mere possibility of allowing abuse as more “threatening” than the likelihood of letting genuine patients suffer in pain.
#36 jim
July 3, 2006

Another unfortunate aspect of this kind of situation, and especially those involving Plan B/contraception and religious nut-jobs, is that pharmacists generally may have undeserved credibility issues when they intervene to correct a physician’s mistake (which happens quite a bit, Bill W).
#37 Cirya
July 4, 2006

Isn’t there a small cross-sensitivity between codeine allergies and hydrocodone? My foggy recollection is 15-20%. If yes the pharmacist should have warned the patient might also have reaction to the Vicodin, and maybe even inquired further about the nature of the codeine reaction to learn if was true allergy or something like a GI intolerance.

To disregard a declared allergy and dispense the suspected med is either gross error or malice.

Please keep us posted of the complaint.
#38 Concerned & Disappointed Pharmacist
July 4, 2006
Tara,

As a pharmacist, I am truly sorry to read what you have described as your family members’ unprofessional treatment in a retail pharmacy setting. It is quite understandable that your relative is upset and I agree that she should have had access to her pain medication. In response to you and fellow commentators, I have a few comments. (This may take a little bit of reading.)

First, let me give a disclaimer. I do not know which state this incident occurred and I do not claim to be licensed in either your state or that in which it happened. Everything that I am responding with are my personal opinions and thoughts that are influenced by my own personal morality and professional ethics.

Response to the unfortunate encounter:

I am curious about other factors that may have played in this unfortunate encounter for your family. (Please do not answer these questions specifically since this is open to the public and I would not want to risk any HIPAA violations. However, consider posing these items to your family member.)
- * Was she dispensed generic hydrocodone/apap in lieu of the brand name Vicodin? (Hydrocodone/apap is a permissible substitution and anything else dispensed without the permission of the prescribing physician would be considered a dispensing error. Any such error should be brought to the attention of the manager of the pharmacy for discipline/correction and possibly be reported to the board of pharmacy.)
- * Did the pharmacy have the information that your family was allergic to codeine? (Does her stomach get upset when she takes it or does she have difficulty breathing or break out in hives? If the codeine allergy was in the computer, the dispensing program would have sent a red flag out and the pharmacist should have counseled the husband on the possibility of a cross-allergy.)
- * What was she taking in the hospital?
Reasonable actions that the pharmacist should have taken (Remember these are my personal professional questions and not from a standard protocol.):
- * Try calling the physician’s office number (even after hours) because most have some type of answering service. Whether the physician answers the page is another issue.)
- * Asked the husband “what was she taking in the hospital?” (Sometimes family members may or may not know, but could ask the patient. The pharmacist could then determine or reasonably assume (and of course document) if the patient was on the same medication in the hospital, even if the allergy was in the pharmacy computer. For example, if she was taking the Vicodin in the hospital and tolerating it, then we could assume that the possibility of a cross reaction from being allergic to codeine was negligible.
Response to comments on my profession:

It saddens me to know that from reading comments posted here that there are so many negative encounters with pharmacists. I know that there are a lot of good pharmacists who have put a lot of time into being a professional that also receive a lot of flack from patients, other healthcare providers, and unfortunately media. It is also unfortunate that a few “bad eggs” get highlighted and that becomes the perception of the public.

(Pardon my personal soapbox for a moment, but please indulge me.) Pharmacists are now required to complete pre-pharmacy requirements (many even hold bachelor degrees, such as myself), complete the four-year doctor of pharmacy program, many complete post graduate residencies (such as myself) or even fellowships, must pass a national competency exam (1/2 of the boards) and a law exam (that includes state and federal law). As someone who has gone through all of this, it disappointments me to know that there are apathetic and/or morally up-righteous pharmacists (and I do know a few, regrettably) that do a disservice to this profession by showing the public a bad image.

A good pharmacist can be a valuable healthcare resource and an important member of your healthcare team. I sincerely hope that your family (and the other commentators) finds a new pharmacy where there is a responsible and caring professional.

Sincerely,

A Concerned and Disappointed Pharmacist
#39 Chris Claypoole
July 4, 2006

Concerning the post by Bob: It is not “thanks to the drug abusers” that we have problems such as have been noted here. It is because of the so-called drug warriors. Your rights should not depend on the actions of others. Should you lose your right to the freedoms listed (not granted – these rights existed before and independently of this document) in the First Amendment because of how others have behaved? Oh, that’s right! Our government already has restricted those rights, too.

Actions by the regulators such as these are the famous “slippery slope” much bandied about. Once we let the government restrict us once because a small minority of individuals have acted irresponsibly, we have no way of preventing that government from continuing down that path until we reach the point which brought forth the Declaration of Independence. Please re-read it, especially the part about a “long Train of Abuses and Usurpations.”

I can understand the motivation of the pharmacist, because of the increasing scrutiny of the drug warriors is becoming more intrusive and less sane. Following the regulations to the letter and always erring on the side of the regulators and never on the side of the people the pharmacist is supposed to serve is the safest course. Just not a moral one.
#40 tgibbs
July 4, 2006

My initial suspicion upon hearing the story is that maybe the pharmacist gave her hydrocodone/acetaminophen, the generic equivalent to Vicodin (which he is required to do unless the doctor specifically required the more expensive brand name version), and they misunderstood the generic name and thought that they were getting codeine.

If the pharmacist actually gave her codeine in place of hydrocodone/acetaminophen, then he is actually committing a crime, dispensing a controlled substance (codeine) without a valid prescription.

By the way, if she is actually seriously allergic to codeine, and her doctor gave her a prescription for Vicodin, I’d wonder about the doctor. Hydrocodone and codeine are pretty similar molecules, and if you are allergic to one, you may well also have an allergic reaction to the other. However, I’ve noticed that a lot of people say that they are “allergic” to a drug when actually they have had a side effect rather than an allergic reaction. In this case, prescribing another drug of the same class would make sense.

My own complaint about pharmacists is that they won’t make trivial substitutions. I once was prescribed codeine 20 mg for a severe cough. The pharmacists said, “I can’t fill this prescription, all I have is 10 mg codeine tablets.” I said, “That’s fine, I’ll just take two.” The pharmacist refused, insisting that I would have to get my doctor to issue a new prescription for 10 mg tablest (this being 8 pm on a Saturday night).
#41 Tara C. Smith
July 5, 2006

Thanks again, everyone. A few more comments:

Isn’t there a small cross-sensitivity between codeine allergies and hydrocodone? My foggy recollection is 15-20%. If yes the pharmacist should have warned the patient might also have reaction to the Vicodin, and maybe even inquired further about the nature of the codeine reaction to learn if was true allergy or something like a GI intolerance.

I can’t comment on cross-sensitivity, but in the past she’s developed hives after taking codeine, so I don’t think it’s just GI intolerance. (I’ve never had any allergies myself, so a lot of this is somewhat foreign to me). She’s had Vicodin before without problems.

Concerned pharmacist,

Was she dispensed generic hydrocodone/apap in lieu of the brand name Vicodin?

I still can’t recall the name she gave me, but that wasn’t it. I’ve not talked to her since last week (she was also busy over the weekend).

Did the pharmacy have the information that your family was allergic to codeine?

***

What was she taking in the hospital?

Not sure about those questions. I know she’s had prescriptions for other meds filled at the pharmacy before, but I don’t know if they have allergy information for her (though don’t they generally have people fill out a questionnaire for that type of thing?) or if she’s received painkillers there previously. I’m also not sure if she took anything at the hospital. It was an outpatient procedure, so I’ll find out if they gave her meds before she left or not.
#42 Dr. Steve
July 7, 2006

Tara – not to dismiss your gripe but it sounds to me like communication breakdown. I have had more than one patient who is “allergic to codeine” call me back about a vicodin prescription becuase it has “hydrocodone” in it. The “codone” part looks similar to codeine. But they are not the same and if the reaction is “GI upset” then there is no reason to avoid hydrocodone. Since you are getting second-hand information and I am therefore working with third-hand information it is difficult to be accurate.

However, refusal to prescribe vicodin and substituting codeine (which is actually quite commonly abuse) doesn’t pass the sniff test. I can’t see any reason why even the most hardened moralist would take such a hard stance against one opiate and freely dispense another one so similar and so prone to abuse.
#43 Tara C. Smith
July 7, 2006

I agree about the second- and third-hand information, and I hadn’t realized that Vicodin had a generic that sounded similar to codeine. But I’m almost 100% sure that wasn’t the switch, because they (my relative and her husband) googled the drug they gave her to find out more information about it. That’s what the husband took back into the pharmacy when I said “She sent him back, with the codeine ingredient circled”–he took the printout of the web page detailing the drug as a codeine-containing product. And I certainly am not sure whether the switch had anything to do with moral values of the pharmacist/tech/whomever. I mention that in the post because that’s played a role in prior stories like this, but in this case, I have no idea whether it was any moral issue or (more likely, it seems) simple incompetence.
#44 Matt
February 4, 2007

Allergy one of the most unfortunate categories of people. And the spectrum of allergens is so wide, that is simply surprising to see sometimes absolutely healthy and happy person to whom are not terrible neither violent spring flowering, nor any especials WBR LeoP
#45 Jennifer
March 13, 2009

I have a question is it legal for a pharmacist to give your prescription history to a doctor or anyone without asking for your consent?
#46 Rich
May 28, 2009

I currently work at a pharmacy right now and understand your frustrations. Like a previous poster mentioned, it sounds more like a communication error, and yes, if you google hydrocodone, you will find that it is related to codeine. (Maybe that is what you pulled up on the internet)

As for the miss-fill, substituting codeine for hydrocodone (or vise versa)is a big no no. At the pharmacy I work at, we have 2 strikes and you’re out. You can also be disciplined for those miss-fills by the state board or the company you work for.

Now on the flipside, the pharmacist reserves the right to refuse to fill a prescription. If they deem it unsafe for you to use there is NO reason they HAVE to fill it (this is otherwise known as neglect which is also punishable by law). For example, if a patient comes in with a schedule 2 prescription for 600 tablets of oxycodone with directions to take 20 tablets a day, I will not fill it. It is THEIR license on the line, not only will they can potentially be disciplined by the DEA for filling a narcotic, but the state board can also strip your license away for not following the proper procedures to verify a prescription (not that this pharmacy did that). Currently, it takes 6 years to get a doctorate in pharmacy in order to be competent enough to be allowed to work in the field. All that work and for it to be potentially stripped away in seconds is asinine.

From what it sounds like if we refuse to fill a potentially dangerous prescription, you get angry at us, if we fill the potentially dangerous prescription and you die, we get sued and possibly lose the license we worked so hard to get and therefore must start from scratch again. Honestly, I’d rather you be angry than dead.

In response to Jennifer’s post, no, it is not illegal to give your prescription history to a doctor you are seeing or even the insurance company you are using (we have to bill the insurance company for said drug and they need to price your copay accordingly). HIPPA allows us to do this without your permission, its to a third party like your husband (we won’t know if you’re divorced or not), a family member, a business, or selling your information to marketers, is where it becomes a problem. The reason for this is so we can avoid problems like this one, if we don’t know you are deathly allergic to said medication, there are no red flags to stop us from dispensing it. This also avoids mistakes caused by ignorance on both sides, if a patient has a representative pick up a prescription without proper knowledge of their allergies or history (not everyone goes to the same pharmacy time and time again) then we cannot make the proper adjustments in order to make things safe for you (such as drug-drug interactions filled at pharmacy A but you are now using pharmacy B).

I understand everyone’s frustrations, but please take the time to understand ours as well.