This article was originally written by Christine Meyer, MD and I found this story too good not to share. I’m appreciative to her for letting me share it. Deprescribing and dose reductions require all hands on deck. Kudos to all of you pharmacists out there doing your best to ensure patients are taking necessary medication and if so, getting our patients to the lowest effective dose!
“Yesterday, something happened that has never happened to me in 23+ years of practice.
I sent a narcotic prescription for a long-time patient (10 years.) This patient has been on this same medication for 7 of the ten years at the same dose. She never asks for more. She comes in dutifully every three months, does urine screens, signs pain contracts, and does all I ask of her. I have never doubted her.
Anyway, about an hour after sending the script to a local chain pharmacy, I got a message from the pharmacist. He was NOT going to fill this script until he spoke to me. He felt her dose was too high.
Ok. Full disclosure. My immediate reaction was fury and indignation. I. AM. THE. DOCTOR. I know this patient, and I know what she needs. Before I called him back, I looked over the chart and discovered everything was in place. He picked up my call immediately and was so professional that it took me off guard. I had been ready for a fight. He asked me ONE question: “Has she needed any medication for breakthrough pain?”
Wait. What? I was confused. I thought he was calling me out for overprescribing. Why was he asking about breakthrough meds? “No. She is fine on THIS dose of THIS med. Never asks for more. For years..this same dose has controlled her pain.”
“Well, have you ever considered maybe LOWERING the dose to see if she still needs this one? Maybe she could take a little less if she doesn’t have breakthrough pain?”
I was stunned. My neck prickled, and I got sweaty. No. It had never occurred to me. I never once asked her if she thought we could lower the dose.
The path of least resistance was to refill the same dose every time. In the end, my fury and defensiveness turned into sheepishness. To be honest, I don’t think this patient will be able to lower her dose, but I SHOULD have at least considered trying.
I don’t know why I was so surprised by this. I got a call two weeks ago after prescribing amoxicillin for a patient with a penicillin allergy. The other day, a pharmacist called to remind me of a vital drug interaction with Paxlovid that I had just prescribed. A few years ago, a pharmacist called to let me know my patient had altered one of my paper scripts and changed the number of Valium dispensed from 10 to 100–it is really easy to add a zero.
The bottom line is that pharmacists have saved my butt and patients from harm countless times. So it makes total sense that they step in when it comes to opioids.
The opioid crisis is one that we ALL created: prescribers, drug companies, pharmacists, and patients. We must work together to fix it.
It was tough, but today, I called and left a message for this pharmacist. I apologized for my tone. I thanked him for his diligence. I acknowledged that we are all on the same team here.
This was a giant mouthful of humble pie to swallow, but when it comes to the care of people, there is no room for egos.”
This article was written by Christine Meyer, MD
- 30 medication mistakes PDF
- 18+ Page Drug Interaction PDF
- 10 Commandments of Polypharmacy Webinar based on my experiences in clinical practice
That reminds me something. There was a 20+ experience oncologist e-scripted a rx of Fentanyl patch, lowest dose. I called the doctor and raised my concern that pt was opioid naive upon checking CURES but the doctor said she has prescribed this for naive patient before without any problem and plus that was a cancer pt. I asked for an alternative, such as morphine but she refused. I didn’t fill the prescription but the PIC ended up filling it… I didn’t know what else I could have done…