I know it is just easier for the DEA to blame all of the opioid crisis on the doctors so they can go home early. Now, somehow, they think that sending three ADHD scripts at one time with limiting when the second and third can be filled just leads to marijuana and then opioids.
I don’t know how it affects others, but this makes it extremely more difficult for me. Now, my CMA has nothing to do with these scripts. She can't talk to the patient, then load up three scripts for Vyvanse, and I just go in and approve it. I now have to do each one at a time.
OK, I just send six ADHD scripts one at a time. I am venting here after each one. How in the world is it safer to send one at a time than three. Seriously? NewCrop is furious.
Well, my post count is going to skyrocket until a few others complain about this. This is three times as long and we do about four of these per day. Used to be a 7 to 8 minute appointment, now it is always 15 minutes. What in god's name makes this safer. Three times loading the med. Three times editing. Three times entering your PIN. Three times entering the 3rd factor authentication. Three times waiting for it to go through. Three more chances times the number of meds of making a mistake. Can't go back and look how many went. It is total frigin' bullshit. I am going to fight this. Write a letter to the DEA. At least ask them how this makes it faster or safer. Have to be careful not to draw their attention.
I feel your pain. We rx lots of controlled meds, and the wait is burdensome.
But I think the prohibition from sending in advance is to require checking PDMP registry monthly. If someone is on Adderall and they have to call monthly for a refill, I check PDMP monthly. If I gave 4 rxs at once, PDMP would only be checked every 4 months.
Not defending it, but I think that is the rationale.
Gene
Gene Nallin MD solo family practice with one PA Cumberland, Md
Maybe what they want is more like Gene says. That we can only send one MONTH at a time. But if that is true, why not say it. But, NC wouldn't be able to monitor if a script was sent once that day followed by a second script exactly the same. It would make more sense even though it wouldn't make more sense. Let's concentrate on one type of drug at a time DEA. Like the opioids. And, while you are at it, just have refills for all of them.
Where is this rule? Does it apply to paper rxs? My state has not gone mandatory electronic rx yet.
Hi Larry,
This all gets very confusing, and there may be state to state differences.
Of course, per DEA, schedule II prescriptions cannot have refills. The last DEA directive I was able to find says that it is legal to give up to 3 months of prescriptions, with the second and third month indicating a fill date. How this is different from giving a prescription with 2 refills, I really do not see that that…
I was unable to find any modification of this, when prescribing is electronic. I think that Bert is saying he likes to see the patient, then give 3 months worth of schedule II at the time of that visit, which involves 3 separate prescriptions. And, of course, with the recent delay in prescribing, the fact that they have to be separately sent is quite time consuming.
I have patients call in monthly, the day before they are due for a new prescription, and check Maryland prescription drug monitoring program website before each refill. This is overkill, Maryland law just requires that it be checked every 3 months.
Did you have other specific questions or concerns?
Gene
Gene Nallin MD solo family practice with one PA Cumberland, Md
OK, in order to KIND OF understand this, let me give some background on the three major controlled substances. They are basically based on three times per month with medication checks after. Not doing those is at your own peril and loses EASY MONEY.
Opioids Class II -- can only send one month at a time (best to do 28 so their next script is not due on a weekend. We try to make it Monday through Thursday to give that extra Friday for those with a million excuses. These CANNOT have refills or have multiple scripts sent. They require a new PMP review (simple now that it is in NewCrop and probably much simpler if it is now within AC in v11). We do two, document the hell out of them especially if they need an exemption code for over 100 MME, then require a med check either by telemed or in person. Here we document like crazy.
ADHD meds Class II -- generally these can be sent so they are good for three months. You can actually send more, but the last script has to be filled within 90 days of the time it was written, so three is the best. Many doctors' offices send one month at a time with a lot of extra phone calls for us and the pharmacy, plus it makes the med checks hard to keep up with. By sending three scripts at a time, it builds in the three-month med check. It is absolutely STUPID you cannot write for 2 refills. Same outcome, just it is safer and easier for all concerned. Now, to make matters even crazier but better for those who don't accept Medicaid, private insurance allows 90 days supply of ADHD meds as long as documented on the script. Confused? If not, you aced the Kreb's cycle. In the days before EPCS, we printed three scripts with a do not fill before such as such a date. This, of course, led to some of the funniest excuses. We took no excuse except documented house fires. Seriously. It is difficult to keep track of who is what insurance and who changes so we just do the three months' worth.
Benzodiazepines Class III-IV -- OK, this is fun, because you can write for Ativan and put 2 refills. Three month med check. Good for patient monitoring and MONEY. You can write for up to five refills. THESE CAN BE FAXED OR CALLED IN LEGALLY, but a pharmacist can disallow that if they don't feel comfortable.
So, based on that, opioids and benzos are relatively simple.
It is the ADHDs that are STUPID. Refills should be allowed, period. But, at the very least, they have to stick with the three at a time, which changes the fact that my MA could set up 9 ADHD scripts, and I just did a telemed, documented and did 50-factor authentication (because we all know patients on Adderall have access to an EMR and authy. But, we need the code -- mine is 2437.
Now, first understand DEA came up with this new rule only they didn't bother to let prescribers or pharmacists know and, worse, why. The only way we knew was when we went to send three, we got a messages stating we could only send one at a time and to delete the other two. This not NewCrop or Allscripts or any individual company. In fact, my contact at NC argued this and was furious about it. She emailed me just after I found out, saying oh my god, Bert is going to flip out. I am on their pseud-advisory board.
Now, as physicians, let us try to figure out DEA's here. OK, they could have have a beef with doctors and want to pissed them off. Doubtful. They could just not like the idea of sending three of the same CII scripts at the same time, By the way, you can send Concerta 36 mg and Concerta 54 mg at the same time. The computers can only differentiate EXACT CIIs for now. So, I thought about it and I put two and two together and got five. Why five. Because that is how stupid the DEA is. The ONLY thing that would make sense in their reasoning, although it will make documentation and our work MUCH harder if we do three-month med checks (remember good for documentation, PMP and MONEY). It sounds like what they meant by you can't SEND three controlled at a time, they meant you can only send ONE month at a time like the opioids. That would make sense to some degree.
All in all, it will make things much more difficult, less safe, more work on both the prescribers, patients and pharmacies (it is hard enough to get along with pharmacies as it is).
What is needed and I would be the first one to volunteer would be quarterly meeting with prescribers, pharmacists and the DEA. I am not saying we can stop the DEA. But, at least the pharmacists and PCPs could talk and the pharmacists and PCPs could get to see who they don't get along with.
We could also mention to the DEA that rather than worry about prescriptions that are being sent to people who supposedly need them and are being monitored by a electronic system which is damned near fool proof. That just maybe they could use their time to look at Heroin, laced-fentanyl, drugs coming over the border and the Al Pacino's of the world. "Say hello to my little friend."
I myself am contacting the DEA's top people as well as reaching out to our governor. This is bullshit. And for those who talk about well opioids are done the exact same way, well maybe it is reversed in offices with old patients, but we have six patients over 100 MME (easy to keep track of) and over 50 patients on ADHD drugs. Oh and quite a few on Klonopin. Covid made a lot of patients anxious beyond Atarax, Intuniv, Buspar and Prozac.
Well, the DEA didn't strike. Spoke with them for over 30 minutes today. The last mandate/rule/regulation they came out with was 2011. It is somehow NewCrop. In fact, the DEA told me they just make the laws. They have nothing to do with how the EMRs or EPCS vendors program their product. For instance, it is the DEA that doesn't allow us to write more than five (5) refills on a benzodiazepine. If we do and the pharmacy accepts it, we are both in violation of the DEA regulation.
But, the DEA doesn't tell NewCrop or Allscripts how to make their EMR. Now, I just have to research Dr. First, Allscripts and all the rest to see if they have this bizarre thing in their program. I know I will have to use Dr. First on the side just for ADHD. Can't keep doing ADHD meds the way NewCrop is forcing me. 15 minutes instead of 2 minutes. Very frustrating. And many more errors.
Wow nice job getting to the bottom of it, Bert. I admire your perseverance. This problem doesn't effect us but I hope you find a good solution for you!
Serene Office Manager General Pediatrics Houston, Texas
I wonder if your irritating program was written to accommodate some long-forgotten pharmacy that insisted that one-at-time prescriptions would protect them from the DEA?
That is, it sounds as if you can write multiple ordinary prescriptions, but your screenshot shows that someone went to the trouble of writing a one-at-a-time routine for the more restricted drugs.
That irritating company is NewCrop, the intermediary company which 99% of AC uses. It is the only one that is configured to work with AC. Like the DEA said today, "If you can do the same thing with paper scripts (which you can) and you have done it this way for years, then they see no reason why the company would all of a sudden stop." Sounds like Allscripts doesn't do it, and I am in the process of talking to Dr. First and any other company to see if a) they do it and b) if they know any reason someone would. The fact that the assistant marketing manager of NewCrop telling me I would hate her, must mean that it is something NC decided. When I first thought it was the DEA, I didn't understand why should would say that. Now it sounds like an internal decision. Now, we and I must find out what NC sees as a problem with it that none of the other companies see, especially when every pharmacy I use: Walmart, Walgreens, CVS, Target, Miller Drug, Community Pharmacy, Hannaford, Shaw's all accept three scripts. It is actually much safer and more efficient and less time-consuming for the patient, physician and pharmacy, a good enough reason I suppose for someone outsider to try to screw it up. But, they will lose business. Already looking for another company for scripts due to this and since I am looking elsewhere anyway, it will not be a problem long. I guess one of my Must Have will be an EMR that doesn't use NewCrop. I am not sure about the other EPCS intermediaries, but NC has AI. I mean they can tell when you write the word "written" in the pharmacy message line that you may be trying to write Dispense as Written, and it will be rejected.
Greetings from the original home state of AC. It has been so long since I’ve logged in that I had no idea what my password was.
My practice is almost entirely devoted to treating adults with ADHD - about a thousand in the practice. The day we learned that we could not transmit 3 schedule II prescriptions in a single batch was not a good one!
I read the relevant DEA prescribing regulations and did not see anything that on its face makes sending 3 rxs in a single batch a violation. However, I made some inquiries and might have learned why this was done. Since starting to send these rxs electronically we have had many instances of prescriptions being deleted at the pharmacies. Apparently, writing July rx, August rx , September rx on the instruction lines AND different do not fill dates on the “pharmacy” line is not enough to avoid this. The problem, supposedly, is that the 3 rxs have the same written on or prescribed on date. I was told that the possible fix is to allow us to send the prescriptions with different effective dates. Supposedly, NewCrop is working on this.
I have a pretty fast way of cloning and editing these rxs, with some modifications to deal with this new glitch. I’ll share if anyone is interested once I’m in front of AC so I can identify each step correctly.
Last edited by braindoc; 07/31/20211:46 PM.
Jeff W Behavioral neurologist & attorney Providence, RI
Intesting. First, I am so envious of you it is crazy. I LOVE treating ADHD. And, having patients switch to me because their doctor can't write it correctly or won't even write it. It's funny though about the reasons. I have talked directly with the DEA, and they claim they didn't change the rule nor do they even know much about the rule. They just know that you can't write for refills WHICH WOULD SOLVE THE WHOLE FRIGGIN' PROBLEM AND IS FRANKLY STUPID. Sending three scripts at a time (you can send 20 if they fill them within 90 days -- well maybe not 20) and having the pharmacy keep them on file is the same thing. I am on the pseudo-advisory board for NewCrop and still need to send in my comments to them. A few of their higher-ups fought their policy of not allowing it. They think it is a DEA rule,and they are basing it on a 2008 statute. The DEA told me that they haven't set a regulation since 2011. I believe that Allscripts and Dr. First allows it.
The other interesting thing is when we used the Star Printer and printed three on tamper-proof paper, we just had a stamp that send Don't fill prior to August 1, then September 1, etc. We could change one stamp at the end of the month. Typing do not fill before August 29th and then doing it for a different date on the third one is just way too much work. A pharmacy at Shaw's where I go taught me to just write 1 of 3, 2 of 3 and 3 of 3 and let them handle it just like they do with any script. ALL PHARMACIES ACCEPT THAT EXCEPT HANNAFORD. We had ALL of our patients switch away from Hannaford. Literally told them we don't send ADHD scripts to Hannaford and blamed Hannaford. I would love to see your way. Previously my MA set it up this way:
Concerta 54 mg tablets ER, 1 tablet po daily 1 of 3 Concerta 54 mg tablets ER, 1 tablet po daily 2 of 3 Concerta 54 mg tablets ER, 1 tablet po daily 3 of 3 Methylphenidate tablets 10 mg, 1 tablet po noon, 1 of 3 Methylphenidate tablets 10 mg, 1 tablet po noon, 2 of 3 Methylphenidate tablets 10 mg, 1 tablet po noon, 3 of 3 Methylphenidate tablets 10 mg, 1 tablet po q Afternoon, 1 of 3 Methylphenidate tablets 10 mg, 1 tablet po q Afternoon, 2 of 3 Methylphenidate tablets 10 mg, 1 tablet po q Afternoon, 3 of 3 Clonidine 0.1 mg tablet po qHS prn insomnia, dispense 30 with 2 refills.
I would see the patient. How are things. Are you eating OK. How is your sleep. Can you focus on this dose. What grades are you getting? BP, Wt, Ht
Click on transcribe, then the stupid authetication code, then the actual send code. The whole visit was a) much quicker and b) safer.
Now, I have to step up 6 of them. Errors. Frustration. Stupidity.
The main three controlled that we sent and I think would be considered that are Benzodiazepines, ADHD meds and opiates. (btw, the whole MME thing and coming down on doctors) has led to more deaths.
Most of these are three. Opioids once monthly. Period. Med check every three months. ADHD meds. Can see every three months but send three at a time. Benzos CIV can call in, fax in or EPCS with 5 refills, although we do 2 to keep everything at three per month.
IF THE STUPID DEA AND OTHERS WOULD JUST TALK TO DOCTORS AND MAKE THE RULE THE SAME FOR THE BIG THREE. One script, two refills. With EPCS, it is still being controlled by the pharmacies. And, once they received the script, they will record two refills. Pharmacies don't f.... that up.
The other thing about all this is you have to train your patients to NEVER call the pharmacy and ask for a refill of Adderall. Always say do I have one "on file." Otherwise the new tech will just tell them no. Because they hear refill.
Everything don't in medicine like this just makes it harder for patients and doctors. Maybe even the brilliant pharmacists who don't have telephones in their stores.
Just for the record -- paper scripts are still allowed in Oregon.
We try very hard (with considerable success) to get long-term opiate patients off their opiates -- but there is a core group with serious injuries/illnesses that really can't be treated any other way. On the other hand, it is very rare in our office to initiate new long-term opiate use or to accept new patients who use chronic opiates -- the stigma is too great and the Oregon Medical Board routinely sanctions doctors for "improperly prescribing" medications. Can't tell from the notices in the OMB quarterly report what the real problem was, but anecdotally, many of the sanctioned doctors seem to be trying to follow the "old" rules about "pain is the 5th vital sign" that caused all the trouble (and made the Sackler's so much money)-- and now they are saddled with a bunch of patients they can't taper off the drugs. The losers in this scheme are doctors who are trying to be conscientious and patients who truly benefit from long term opiate use (admittedly, a relatively small number, but almost impossible to gauge accurately).
EPCS seems clumsy and time consuming -- and I am offended that it is another thing I have to pay for. Just another unfunded mandate for doctors in states where it is mandatory.
We print the prescriptions on a regular office printer (don't fool around with the Star printer) on tamper resistant paper that comes in 8.5 x 11 sheets scored into 4 Rx- sized pieces. Printer software will reduce the image to 1/4 size so we aren't sending out ungainly prescriptions and wasting a lot of paper. Three prescriptions printed for long-term users -- all prescribed the same day, but indicated for different fill dates. No pharmacy has complained
We do the same for ADHD meds -- though that isn't a major problem in a mostly geriatric practice.
Patients are responsible for the paper prescriptions. "Lost" or "stolen" Rx's are not replace.
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