Are you kidding me?

Our pharmacy technician requested, “Spell chronic,” quite loudly as he typed away at his workstation at the other end of the prescription counter.

Nov 1st, 2011

Pharmacist wonders about those Friday evening prescriptions

by Thomas A. Viola, RPh, CCP

Our pharmacy technician requested, “Spell chronic,” quite loudly as he typed away at his workstation at the other end of the prescription counter.

I turned and glanced at him. He was a good guy from a good family. Near the end of many dizzying, relentless days of filling prescriptions, he was exactly what I needed: a smart kid with a good work ethic, as well as a fresh pair of eyes.

However, the fact that he was a high school student asking me to spell “chronic” (as I was checking what felt like one thousand prescriptions on this very long day) was enough to cause me to shoot him a look that surely betrayed the list of possible responses to his question that I had lined up in my head. These included: “What is this, a spelling bee?” and “I just felt your SAT score drop 100 points.” In the end, I settled on a less-caustic, “Why, what’s up?” But before I had the chance to speak, he turned away, annoyed, and said, “You’re so different on Fridays!”

He was right. I am different on Fridays, especially Friday nights. The mild-mannered “Tom the pharmacist” is gone. Dr. Jekyll caught the last train for the coast, and Mr. Hyde is in the house. While this abrupt change in personality might be problematic to a business, which relies so heavily on great customer service, it is no worry to me. Experience has shown me that, by this time on a Friday, the majority of my regular patients are “down the shore” or “up the Poconos.”

What is troublesome to me is what replaces them — a steady stream of new “patients” looking to fill prescriptions for opioid analgesics. To be fair, not every prescription we receive on a Friday night is for opioid analgesics. Also, not every prescription we receive for opioid analgesics is questionable. I am just astounded by how many are. The sheer volume often leaves me feeling more like a goalie than a guardian of my patients’ health care.

However, nothing disturbs me more than receiving a fraudulent prescription for an opioid analgesic from a dental office. I guess I’m sensitive. You see, in addition to my full-time career as a pharmacist, I have the privilege of teaching pharmacology to some of the best dental hygiene students in the country at five different colleges in two states. Also, as a professional speaker, I regularly present continuing education seminars and local anesthesia certification courses to practicing dental hygienists and other dental professionals. This is when I feel truly blessed to witness my students’ transformation into the professionals I knew they could become. I have great respect for the profession of dental hygiene and consider it an honor to serve it as an educator, author, and colleague.

Substance abuse is certainly not a new topic to any health professional. In pharmacy school, I received countless hours of instruction on the effects of illicit substances. What is disturbing is the explosion of the illicit use of licit substances (especially opioid analgesics, over-the-counter cough and cold preparations, psychotherapeutic medications, and even medications used to treat HIV) to get high.

Opioid analgesics definitely top this list. After cigarettes and alcohol, they are the most abused licit substances by teenagers. The medications are inexpensive and readily available (read as “taken from prescription vials in medicine cabinets”). They are considered a “safe” method of getting high (based on how many patients take them legitimately without serious adverse effects). They also have a high street value (which makes them lucrative in trade for other things).

What is even more disturbing, though, is how such illicit use of licit substances has been so widely integrated into the mainstream of our lives. While it may not be considered acceptable to use illicit substances on a daily basis (unless you have prebooked your rehab), it seems perfectly acceptable to take a few Vicodin or Percocet as a respite (to help get you through your day) or as recreation (to make your night that much more special).

Dental offices have always been the target in the cross-hairs of opioid analgesic-seeking abusers or distributors and are often seen as an easy target. In one of the opening scenes in “The Hangover Part 2,” Stu (the dentist) says to Phil (the school teacher) as he’s leaving: “Phil, put the prescription pad back. You know that’s a felony, right?” With this superlative film reference, I suppose I need nothing more to prove my point. Well, as with all humor, this scene, unfortunately, has just the right amount of truth to make it funny.

Consider this if you have been asking yourself while reading this, “Why Fridays?” Most dental offices are closed or open only limited hours on a Friday. At the pharmacy, prescriptions for opioid analgesics from dental offices are easily collated with prescriptions for these same substances from other prescribers treating chronic pain. Most dental prescribers would be reluctant to refuse to provide opioid analgesics to a patient in (supposed) obvious severe pain, so the prescription is viewed as undoubtedly legitimate. Most pharmacists would be reluctant to refuse to fill a prescription for opioid analgesics for a patient in (supposed) obvious severe pain, especially over a weekend.

On this Friday night, I glanced at the prescription. In a few seconds, I immediately understood the technician’s request for a spell-check. The prescription was from a dental clinic of a local university hospital. I noticed the misspelling he mentioned (“cronick”). I also noticed that the name of the city was spelled incorrectly. I also noticed that the quantity of Percocet to be dispensed was 120 and that the directions for use indicated that one tablet was to be taken four times a day. Did the prescriber really expect this patient to be in chronic dental pain for 30 days?

I called the patient by name and asked him to see me at the prescription counter. I looked him straight in the eyes and saw lots of eye, but not so much pupil. With the wads of clean cotton in his mouth, he could not speak to answer my pointed questions. I stood there motionless, watching the first bead of sweat drip from his brow.

And the four words of the title just rolled off my tongue…

Thomas A. Viola, RPh, CCP, is a practicing pharmacist and pharmacy consultant, as well as a professional speaker and writer. He is a member of the dental hygiene faculty at Harcum College, Manor College, Middlesex County College, Burlington County College, and Bergen Community College. Tom offers seminars on dental pharmacology and local anesthesia to dental professionals nationally. To contact Tom for speaking engagements, call (609) 504-9252 or email him at thomas.viola@comcast.net. Visit his website at http://www.thomasviola.com">www.thomasviola.com.

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