CII narcotic volume at chain pharmacies

[Sine Cura]

I was just curious what kind of ordering & dispensing volume is typical at "narc" stores.

I heard Walmart and Wags have CSOS ordering that is based on "forecast" demand where no pharmacists have power of attorney (AFAIK), whereas ordering at CVS requires power of attorney assigned to PICs and sometimes other staff pharmacists (another reason to throw someone under the bus if the DEA comes knocking).

In my case, I have hit monthly limits on hydromorphone (5k tabs) and oxycodone presentations (25k tabs) in the past (I get the "maximum regulatory purchases exceeded), but not hydrocodone (in the past before the CII change some stores in this area were getting 80-120 bottles just of Norco 10/325 Mallinckrodt generic per week), but I'm not sure if this is something set by the DEA explicitly, corporate, or some combination of the two (there are certainly manufacturing quotas at the least so perhaps ordering quotas are based off those). My main interest is whether this kind of ordering still invites scrutiny by DEA in light of what happened in Sanford, FL several years back regardless of the quotas set.

sold scripts 2,500 currently from a peak of 2,800 in the beginning of February, March, and April

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[SClENCE]

Wow that's a lot, what's you total script volume?

 

[NateRobinson]

How in the holy hell do you dispense 50 bottles of 100 count hydrophones EVERY MONTH?

Unless your store is right across the street from a cancer facility or right next door to hospice care, there is no need for you to be dispensing that much hydromorphone. You need to be more diligent in identifying red flags and turning down patients. There is simply no need for that much, and you're asking for the DEA to come after you.

 

[doublehh03]

I was just curious what kind of ordering & dispensing volume is typical at "narc" stores.

I heard Walmart and Wags have CSOS ordering that is based on "forecast" demand where no pharmacists have power of attorney (AFAIK), whereas ordering at CVS requires power of attorney assigned to PICs and sometimes other staff pharmacists (another reason to throw someone under the bus if the DEA comes knocking).

In my case, I have hit monthly limits on hydromorphone (5k tabs) and oxycodone presentations (25k tabs) in the past (I get the "maximum regulatory purchases exceeded), but not hydrocodone (in the past before the CII change some stores in this area were getting 80-120 bottles just of Norco 10/325 Mallinckrodt generic per week), but I'm not sure if this is something set by the DEA explicitly, corporate, or some combination of the two (there are certainly manufacturing quotas at the least so perhaps ordering quotas are based off those). My main interest is whether this kind of ordering still invites scrutiny by DEA in light of what happened in Sanford, FL several years back regardless of the quotas set.

sold scripts 2,500 currently from a peak of 2,800 in the beginning of February, March, and April

I think those numbers may apply to "hospice" pharmacies (I said "may").

If you work for CVS, I don't think your safe can even fit 1/3 of what you are ordering so yes, you are ordering way too much.

 

[Sine Cura]

This is good to know. There are actually two "pain management" clinics that have existed for at least 4 years , and a cancer clinic, and many hospice patients (this place is truly miserable). I think I will ask the other notorious "narc" store about their volume sometime

There is a point (according to the DEA action against the Sanford, FL CVS pharmacies) where some red flags are irresolvable, so I guess in this case the fact that this area is a ****hole makes 95% of CII scripts irredeemable

No one seems to bat an eye at the Norco though?

 

[wagrxm2000]

I don't "punish" cancer patients ever but these pain clinics end up giving the same script every month. At some point if I were you I would start calling and making sure they are doing their job right and not becoming complacent.

 

[doublehh03]

This is good to know. There are actually two "pain management" clinics that have existed for at least 4 years , and a cancer clinic, and many hospice patients (this place is truly miserable). I think I will ask the other notorious "narc" store about their volume sometime

There is a point (according to the DEA action against the Sanford, FL CVS pharmacies) where some red flags are irresolvable, so I guess in this case the fact that this area is a ****hole makes 95% of CII scripts irredeemable

No one seems to bat an eye at the Norco though?

My store is 24 hours. I order 15 bottles of 10/325, 10 5/325, 5 7.5/325 and sporadically the /300mg APAP here and there weekly. Monthly, max for me would be 130-140 bottles combined.

So again, excessive. That's just asking for people to track you, including your LP.

 

[M0df]

Your hydromorphone dispensing is very high. Percocet volume is not unusual but it is not good to hit limits month after month.

 

[BenJammin]

I don't "punish" cancer patients ever but these pain clinics end up giving the same script every month. At some point if I were you I would start calling and making sure they are doing their job right and not becoming complacent.

Damned if you do, damned if you don't.

 

[PharmacistReb]

5,000 tablets of Dilaudid per month?!?!

 

[PharmdA07]

At my LTC position, we process orders for 5 hospice services and their associated LTCF / SNF palliative patients, and we don't even come close to the amount of dilaudid that you order each month. We do dispense quite a large number of Norco (and its liquid counterpart since a lot of these patients have dysphagia and several SNF's do not crush pills--thus requiring a large volume of liquid to be equivalent to the ordered dose). Of course we have protocol and paperwork in agreement with these hospice companies that we serve; therefore, if the DEA comes knocking, the hospice services' directors are the one answering to them first.
If you're a retail stand-alone store with such a high volume of C2 like that, definitely watch out cause DEA will red-flag you. Our whole-drug seller told us once that they're obligated to report to the DEA if any of their contracted pharmacies order "large" quantity of controlled substances. When I personally asked the account manager about the definition of "large", she said it was to be a secret number she couldn't disclose and laughed it off...

 

[owlegrad]

Do what my PIC does and only order a small amount of each C2 so that you are perpetually out.

 

[Dr Wario]

I remember we used to order oxy 30's by the case (2400) my partner would dispense them and I refused due to where they were all coming from (doctor's all lost their licenses and had criminal charges filed against them). Narcs are becoming a real problem in this country and it isn't just limited to the ghetto, I've worked in rich areas where xanax and adderall went out the door like water. I'm not personally a big fan of drug control, but this garbage being touted by trusted healthcare professionals really needs to stop.

 

[wagrxm2000]

There are plenty of other pharmacies they can go to, just stop filling them. We fill 500+ at times and I have 2 bottles of oxy and will never order more.

 

[type b pharmD]

For norcos and Percocets combined, around 100,000 ct per month. Not worried. I work with fed agents on at least a quarterly basis on doc investigations, corporate has been working with DEA too to make sure our orders are ok.

 

[tryingtomakeit]

For norcos and Percocets combined, around 100,000 ct per month. Not worried. I work with fed agents on at least a quarterly basis on doc investigations, corporate has been working with DEA too to make sure our orders are ok.

damn..

 

[SClENCE]

I think your first step is to stop accepting new patients on narcs weather the patient is legit or not. You are justified to do so with those numbers.

 

[type b pharmD]

I think your first step is to stop accepting new patients on narcs weather the patient is legit or not. You are justified to do so with those numbers.

Try mentioning the words "stop accepting new patients" in a chain retail setting sometime.

I agree that is a prudent course of action for a pharmacist who is worried about the DEA .. but you do it by ordering less .. I write up pharmacists who turn patients away, unless there is a 100% clinically real reason , there is illegal conduct, or the patient is being threatening or combative. We are running a business here folks.

 

[Lnsean]

that store is a legal hazard. I would ask to transfer out or try to find another job if you can't.

 

[type b pharmD]

that store is a legal hazard. I would ask to transfer out or try to find another job if you can't.

OPs or mine ?

I don't feel we do a disproportionate amount of c2s even though our order is always maxed , if you rule out the Norco / perc, most of it (95+%) are patients where there is no valid reason to deny the script.

Thankfully at walgreens I have no real responsibility over c2 ordering , I have been told it is normal for our geographic and demographic factors.

When I took this store , I did quite a bit of research into DEA pharmacy busts ... The flat out majority of it (that resulted in Rph discipline or charges) involves pharmacist gross negligence or even criminal behavior.

 

[Lnsean]

OPs or mine ?

I don't feel we do a disproportionate amount of c2s even though our order is always maxed , if you rule out the Norco / perc, most of it (95+%) are patients where there is no valid reason to deny the script.

Thankfully at walgreens I have no real responsibility over c2 ordering , I have been told it is normal for our geographic and demographic factors.

When I took this store , I did quite a bit of research into DEA pharmacy busts ... The flat out majority of it (that resulted in Rph discipline or charges) involves pharmacist gross negligence or even criminal behavior.

I was referring to OPs. It's not really a contest that one should be proud of winning. If you're doing that kind of volume on C2s, there's a good chance if something goes wrong (like the pain doctors get busted), the prescriptions that you've filled will be thoroughly looked at. This is all about risk vs rewards. Are you highly compensated for taking on this risk? If that store is dishing out 50-60k bonuses...then yes. If you're just getting paid like any other pharmacist at any other store...then no.

 

[type b pharmD]

I was referring to OPs. It's not really a contest that one should be proud of winning. If you're doing that kind of volume on C2s, there's a good chance if something goes wrong (like the pain doctors get busted), the prescriptions that you've filled will be thoroughly looked at. This is all about risk vs rewards. Are you highly compensated for taking on this risk? If that store is dishing out 50-60k bonuses...then yes. If you're just getting paid like any other pharmacist at any other store...then no.

I agree. I hope I can make a career here at my dream store location and survive the inevitable DEA busts on local Dr's .. I hope by cooperating and only filling in good faith that I can insulate myself .

What frustrates me most is Rphs who seem to see a contest in how many c2s they can refuse .. this takes literal Rph hours out of my weekly budget for the customer complaint , the disciplinary process, coordinating with corporate , fixing the Rphs mess , etc. Refusals are for inane reasons .. if you refuse a script for real reasons it doesn't bother me .. when an Rph refuses because it's a "high count" , "suspicious looking " , "too many c2s that day" .. it challenges my patience.

I think a lower volume store would be safer for long term stability.. but hoping to make >200k next year so maybe it is worth it in the short term.

 

[doublehh03]

I think your PIC need to understand the customer base. Order enough for the regulars who truly need them.

I agree. I hope I can make a career here at my dream store location and survive the inevitable DEA busts on local Dr's .. I hope by cooperating and only filling in good faith that I can insulate myself .

What frustrates me most is Rphs who seem to see a contest in how many c2s they can refuse .. this takes literal Rph hours out of my weekly budget for the customer complaint , the disciplinary process, coordinating with corporate , fixing the Rphs mess , etc. Refusals are for inane reasons .. if you refuse a script for real reasons it doesn't bother me .. when an Rph refuses because it's a "high count" , "suspicious looking " , "too many c2s that day" .. it challenges my patience.

I think a lower volume store would be safer for long term stability.. but hoping to make >200k next year so maybe it is worth it in the short term.

I think "most" pharmacists do their due diligence before accepting or deny a script.

When someone says "high count," that is valid esp. if it's a multiple time filling a "high count" prescription. You should question a doctor if a patient keeps getting #240 norco 10 and why that doctor isn't titrating him onto an ER to better control his pain and limit his IR intake.

"I think your LP will call you if you do "too many C2s." Trust me, CVS LPs are crazy. So in your case, maybe Walgreens isn't as strict in terms of how many you dispense.

High or low volume stores are irrelevant in this case. I've seen stores that do 1700 scripts and order 30-40 methadones 10s WEEKLY and 50-60 norco 10s weekly.

The point that people are telling OP is fill legit scripts, keep in stock what is necessary to fill those scripts, and if you have other customers you have to cater to, then order. But a manager knows his customer base and knows the population. Again, order what's necessary to meet the customers' demands. And for most places, that doesn't involve 5000 dilaudid or 25000 oxy monthly.

 

[Lnsean]

I think your PIC need to understand the customer base. Order enough for the regulars who truly need them.


I think "most" pharmacists do their due diligence before accepting or deny a script.

When someone says "high count," that is valid esp. if it's a multiple time filling a "high count" prescription. You should question a doctor if a patient keeps getting #240 norco 10 and why that doctor isn't titrating him onto an ER to better control his pain and limit his IR intake.

"I think your LP will call you if you do "too many C2s." Trust me, CVS LPs are crazy. So in your case, maybe Walgreens isn't as strict in terms of how many you dispense.

High or low volume stores are irrelevant in this case. I've seen stores that do 1700 scripts and order 30-40 methadones 10s WEEKLY and 50-60 norco 10s weekly.

The point that people are telling OP is fill legit scripts, keep in stock what is necessary to fill those scripts, and if you have other customers you have to cater to, then order. But a manager knows his customer base and knows the population. Again, order what's necessary to meet the customers' demands. And for most places, that doesn't involve 5000 dilaudid or 25000 oxy monthly.

walgreens is definitely stricter than CVS since that debacle down in Florida.

 

[Sparda29]

I've noticed that some of these oxy mill doctors are sending patients with more scripts for regular stuff like inhalers, htn, dm meds to make the profile seem more legit. One red flag I pick up all the time is when the patient tells me they have a preference for a generic manufacturer.

 

[npage148]

I find that we don't have many/any new patients from pain docs and their high qty scripts. All of these pts have been with us for years

85% of the CS I turn down are bs ER scripts from ER hoppers. Like 14 Lortab or 20 tramadol every 2 days from one of 4 local ERs. Luckily the Prescribers are very willing to cancel these scripts and note the pts profile

 

[BidingMyTime]

In my case, I have hit monthly limits on hydromorphone (5k tabs) and oxycodone presentations (25k tabs) in the past (I get the "maximum regulatory purchases exceeded), but not hydrocodone (in the past before the CII change some stores in this area were getting 80-120 bottles just of Norco 10/325 Mallinckrodt generic per week), but I'm not sure if this is something set by the DEA explicitly, corporate, or some combination of the two (there are certainly manufacturing quotas at the least so perhaps ordering quotas are based off those). My main interest is whether this kind of ordering still invites scrutiny by DEA in light of what happened in Sanford, FL several years back regardless of the quotas set.

These numbers seem very high. 120 bottles, are you talking 100 count or 500 count? 500 count would mean you are dispensing 60,000 tablets/week or (assuming a 14hr day at the store), over 600 tablets every hour.

With the monthly Dilaudid, you are talking over 150 tablets/day. It could be a difference in physician prescribing habits, but that strikes me as a lot of dilaudid.

I have worked some pretty crazy, busy retail pharmacies, I've never numbers that high. Which doesn't mean that all your scripts aren't actually legitimate, but it does seem very unusual.

When someone says "high count," that is valid esp. if it's a multiple time filling a "high count" prescription. You should question a doctor if a patient keeps getting #240 norco 10 and why that doctor isn't titrating him onto an ER to better control his pain and limit his IR intake.

It depends on the persons history, IL public aid frowns on any long acting pain medication other than morphine or methadone. Many regular physicians don't want to touch methadone, and many public aid patients have a hard time getting into a pain specialist. So for the patient who genuinely has a morphine allergy, round the clock Norco's or Percocet's end up being used. Now, I'll agree that there probably many cases where the above doesn't apply, and there is no good reason why the person isn't on a long-acting pain medication, just saying that there are some legitimate cases where people do end up on round the clock short-acting medications.

 

[npage148]

If someone truely had a morphine allergy then there is almost no chance they can tolerate hydrocodone but opiate allergies really don't excist so we are good. Opiate induced purtitis is not an allergy

Morphine allergy= give me dilaudid.

 

[BidingMyTime]

If someone truely had a morphine allergy then there is almost no chance they can tolerate hydrocodone but opiate allergies really don't excist so we are good. Opiate induced purtitis is not an allergy

Morphine allergy= give me dilaudid.

Yeah, I agree that most of what is called allergies is actually an intolerance to side effects. IL public aid also does not pay for extended release dilaudid without a PA, so it doesn't solve the problem of doctors using short acting analgesics because the patient can't afford long-acting ones.

 

[Baalzeebub]

Try mentioning the words "stop accepting new patients" in a chain retail setting sometime.

I agree that is a prudent course of action for a pharmacist who is worried about the DEA .. but you do it by ordering less .. I write up pharmacists who turn patients away, unless there is a 100% clinically real reason , there is illegal conduct, or the patient is being threatening or combative. We are running a business here folks.

This is one the worst posts I have ever come across. It's almost troll-level horrible, but unfortunately seems real.

First, lets

 

[Baalzeebub]

n

 

[CetiAlphaFive]

Try mentioning the words "stop accepting new patients" in a chain retail setting sometime.

I agree that is a prudent course of action for a pharmacist who is worried about the DEA .. but you do it by ordering less .. I write up pharmacists who turn patients away, unless there is a 100% clinically real reason , there is illegal conduct, or the patient is being threatening or combative. We are running a business here folks.

Hahaha. Oh wow.
For any pharmacist seeing this guy's post:

Make sure you document on paper in the compliance box why you're turning someone away. It doesn't have to be extremely detailed.
You don't need "evidence."

If you get written up for bullcrap like the post I've quoted, refuse to sign the disciplinary form.

If they fire you, consult with an attorney.