“John” (or so we shall call him) was sitting quietly, albeit uncomfortably, in the customer waiting area of the outpatient pharmacy. His wrinkled blue jeans and un-tucked shirt seemed to announce the fact that he would prefer to be sleeping at this early hour on a snowy Saturday morning. His unsettled look did not appear to be the result of his own physical discomfort. I studied him out of the corner of my eye as I finished working on a prescription. He seemed to express, by his posture, how a piano must feel when it knows it is out of tune. Something was wrong. I noticed several concerned glances at his wrist watch. He appeared to be like man on a blind date waiting for a late companion he had never seen.
As I smiled and made eye contact, he uprooted himself from his awkward seat.
“Did a doctor possibly leave a prescription with you for my wife?” he asked in a tone that fell somewhere on the scale between frustration and doubt.
I introduced myself to the strange visitor. “What’s her name?” I asked.
After a brief conversation the details unfolded like an overturned laundry basket. John’s wife, “Denise,” recently had surgery at a hospital about 60 miles away. She was at home, and out of her prescribed pain medication. They had supposedly contacted a physician at our hospital whom they knew from a previous surgery experience. He was going to drop off an oxycodone prescription for her. He hadn’t. And he wouldn’t answer my page.
John was as out of luck as a dead leprechaun with no boots.
“John and Denise’s” situation was not unique. Dozens of times in my pharmacy career I have had to help a patient manage their way through some variation of this frustrating scenario. If we were to dissect the issue and pull it apart we discover several contributing factors that have created a significant problem for our patient:
1) She ran out of meds on a weekend. Think of the weekend like a long stretch of highway with no rest stops or fueling pumps. Trying to get help from covering physicians who may not even know you is hit or miss. Sometimes you get lucky. Sometimes you don’t.
2) She ran out of oxycodone. Post-surgical pain often has to be managed with strong medication for a little while so that the patient can move around without agonizing discomfort. But oxycodone is a Schedule II controlled substance and cannot ordinarily be phoned in or faxed except under certain narrow circumstances.
3) She wasn’t near the hospital where the surgery was done. This required getting creative, and in this case the creativity didn’t pan out.
There may be more issues that contributed to the problem that Denise encountered. It is possible that a good plan was in place, but that someone else failed to follow through. Nevertheless, the situation offers us a teaching opportunity for both patients and new pharmacists alike.
In my experience the best way to help a patient in this situation is provide them with options. They need some ideas, and those of us who work in this setting should know what to say. In this case, I offered John a few alternatives for him to consider:
1) John could wait around for this missing doctor to arrive with his prescription. At this point, I didn’t think that would ever happen. Somewhere along the way the communication broke down (if there ever was any such communication). Someone misunderstood something. So I didn’t see much hope here.
2) John could have Denise call the actual surgeon’s office and ask for the on-call physician. Once contacted, they could agree on a plan for prescribing something for pain management until Monday. Obtaining an oxycodone prescription might be unlikely, but possibly some acetaminophen with codeine would work.
3) Denise could call her primary care doctor. This on-call physician could also possibly help her manage her weekend pain.
4) Denise and John could attempt to visit an Emergency Department or walk-in clinic.
5) Denise could attempt to manage her pain with OTC products (or whatever was available to her at home) until Monday.
These are not EVERY possible option, but they were enough options that John felt empowered to do something, and after waiting around a short while longer, he went home to check on Denise and decide together on what to do. I never saw John again.
This situation illustrates the frustration that can be encountered when a need for strong pain relief arises on a weekend when your physician or surgeon’s office is closed. Preventing this involves planning. Denise could have requested an extra written prescription post-surgery due to her distance from the hospital. Maybe she needed to have a better discussion with her doctor about managing post-surgical pain. It is possible she over-used her medication, and that may have contributed to the fact she ran out. If so, that should have been addressed prior to Saturday.
Note: Pharmacy Tales are semi-true stories in which all names and specific details have been significantly altered.