Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Wednesday, March 12, 2014

Confused about Control

I'm confused about Ambien. I don't love it as a sleep aid, but it works for some of my patients, so I do prescribe it.

What's confusing to me is not the confusion it causes some of the people who take it, even the ones who mistake it for synthroid. What's confusing to me is its status as a controlled substance.

It seems to me that some pharmacies allow refills, others don't. Some will allow you to order refills on the phone, others won't. Some will require a cover for a phone order.

The most recent time I had to mail in the cover, I asked the pharmacist what exactly the deal is with Ambien, and he told me that it's a Schedule IV substance and as such, is controlled.

The weird thing was that before I called it in, I checked the PMP registry, even though I wasn't sure I needed to, and none of my previous ambien prescriptions showed up. I told the pharmacist this, and he said some doctors have complained that no information ever shows up for them. But this is the first time it's happened to me. Mostly, when I check for benzos and ritalin and whatnot, I see all the prescriptions I've written.

Well, this puzzle sent me into research mode. And this is what I found (on the DEA site):

(a) No prescription for a controlled substance listed in Schedule III or IV shall be filled or refilled more than six months after the date on which such prescription was issued. No prescription for a controlled substance listed in Schedule III or IV authorized to be refilled may be refilled more than five times.

Okay, so I can write for 5 refills of Ambien, and the prescription is good for six months.

What about calling in a prescription?

(e) The prescribing practitioner may authorize additional refills of Schedule III or IV controlled substances on the original prescription through an oral refill authorization transmitted to the pharmacist provided the following conditions are met:
(1) The total quantity authorized, including the amount of the original prescription, does not exceed five refills nor extend beyond six months from the date of issue of the original prescription.
(2) The pharmacist obtaining the oral authorization records on the reverse of the original paper prescription or annotates the electronic prescription record with the date, quantity of refill, number of additional refills authorized, and initials the paper prescription or annotates the electronic prescription record showing who received the authorization from the prescribing practitioner who issued the original prescription.
(3) The quantity of each additional refill authorized is equal to or less than the quantity authorized for the initial filling of the original prescription.
(4) The prescribing practitioner must execute a new and separate prescription for any additional quantities beyond the five-refill, six-month limitation.

No problem, even with up to 5 refills.

So what's the problem? It seems to me that it's a lot of work for the pharmacist. I left out a bunch of stuff on the link, which you can check out yourself, but there's a lot of initialing that needs to be done, and recording of names, etc. Is the real problem that pharmacies don't want to be bothered with the paperwork (HAH! Tell me about paperwork!), or that they're not clear on the details?

Even more puzzling, here's a link to Schedule IV meds, also from the DEA site. Zolpidem is down at the bottom, with the other "Z"s, (ZZZZ for sleep). But what else is on the list? Let's see, alprazolam, clonazepam, diazepam, lorazepam, a veritable cornucopia of benzodiazepines.

Now, I'm not advocating for a benzo prescribing free-for-all. There are good reasons to keep it contained. But if I am writing for benzos, do I and my patients really need to be inconvenienced?

Can I write refills for benzos? Can I phone in benzos with refills, and without a cover? Is this one of those lies that's perpetuated so benzo prescribing doesn't go haywire? And if so, why not just change the law to what everybody thinks it is anyway?

Am I missing something here? What gives?