Pharmacy and opiates

[Dr Wario]

Hello ladies and gentlemen,

As you can see from my bio, I am a pharmacist, and I would like your assistance with a major problem I am facing in my retail location. I was recently informed that my store is in the top 0.5% of my company in the dispensing of controlled substances/high-risk medications. As I am sure you are all aware, there has recently been a fairly major turf war between pharmacists and prescribers concerning high-risk medications due to the recent actions of the DEA against pharmacies. I am not here to perpetuate this battle, but to simply request assistance in handling the reality of the situation I find myself in.

As previously stated, my location is very highly ranked in the dispensing of controlled substances, the majority being opiate pain medications. I consistently max out my allowed order quantities of many of these medications each month including: oxycodone, hydrocodone, fentanyl, morphine and hydromophone. For the past 1.5 years, we have denied all IR formulations of oxycodone >10mg/dose, hydromorphone > 4mg/dose, morphine >30mg/dose and hydrocodone >10mg/dose. Additionally, we deny all quantities in excess of 90/month of any IR product and people on what are labeled as high-risk combinations. We do not conduct these denials out of personal bias, they are simply a necessity due to ordering restrictions.

I must be honest, I simply do not have the time or the training to categorize legitimate vs abusive patients, thus I need basic protocols to greatly reduce the dispensing of opiates at my pharmacy. I fear for my employment and my license if the pharmacy continues on its current path, so I am asking for your help in developing this protocol. My current thought is that I will limit all quantities of IR opiates to 60 or fewer doses unless accompanied by a long acting product. This may not be fair to some legitimate users, but it will help weed out many abusers, reduce dispensed doses, and be more in line with what I understand to be standard practice for the prescribing of opiate medications to CP patients.

I fear I may have to make other reductions, but would you say that this protocol is fair given the necessity of my situation? Do you have any suggestions on how I could do things differently? Again, I am making no personal judgements in this thread concerning the legitimacy of opiate prescribing in America, I simply want to help as many patients as I can, the best the I can, while not getting into additional trouble with the DEA or my company. I thank you all for any assistance you can provide in this matter.

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[101N]

Hello ladies and gentlemen,

As you can see from my bio, I am a pharmacist, and I would like your assistance with a major problem I am facing in my retail location. I was recently informed that my store is in the top 0.5% of my company in the dispensing of controlled substances/high-risk medications. As I am sure you are all aware, there has recently been a fairly major turf war between pharmacists and prescribers concerning high-risk medications due to the recent actions of the DEA against pharmacies. I am not here to perpetuate this battle, but to simply request assistance in handling the reality of the situation I find myself in.

As previously stated, my location is very highly ranked in the dispensing of controlled substances, the majority being opiate pain medications. I consistently max out my allowed order quantities of many of these medications each month including: oxycodone, hydrocodone, fentanyl, morphine and hydromophone. For the past 1.5 years, we have denied all IR formulations of oxycodone >10mg/dose, hydromorphone > 4mg/dose, morphine >30mg/dose and hydrocodone >10mg/dose. Additionally, we deny all quantities in excess of 90/month of any IR product and people on what are labeled as high-risk combinations. We do not conduct these denials out of personal bias, they are simply a necessity due to ordering restrictions.

I must be honest, I simply do not have the time or the training to categorize legitimate vs abusive patients, thus I need basic protocols to greatly reduce the dispensing of opiates at my pharmacy. I fear for my employment and my license if the pharmacy continues on its current path, so I am asking for your help in developing this protocol. My current thought is that I will limit all quantities of IR opiates to 60 or fewer doses unless accompanied by a long acting product. This may not be fair to some legitimate users, but it will help weed out many abusers, reduce dispensed doses, and be more in line with what I understand to be standard practice for the prescribing of opiate medications to CP patients.

I fear I may have to make other reductions, but would you say that this protocol is fair given the necessity of my situation? Do you have any suggestions on how I could do things differently? Again, I am making no personal judgements in this thread concerning the legitimacy of opiate prescribing in America, I simply want to help as many patients as I can, the best the I can, while not getting into additional trouble with the DEA or my company. I thank you all for any assistance you can provide in this matter.

I would turn to your nearest academic med ctr's Addiction Medicine & Pain Med depts
for help.

 

[deleted185747]

Find out how much the 50% percentile pharmacies in your area dispense and only allow your pharmacy to carry that much each month.

You should use the prescription drug monitoring program for your state to check if the patients are doctor shopping and consider not dispensing if they are.

good luck

 

[Dr Wario]

Find out how much the 50% percentile pharmacies in your area dispense and only allow your pharmacy to carry that much each month.

You should use the prescription drug monitoring program for your state to check if the patients are doctor shopping and consider not dispensing if they are.

good luck

Unfortunately, my state does not have a PDMP as of yet. Carrying less of the drug does not really help me determine what and what not to dispense. I wanted to add that we also do not fill for any doctor or any patient that is out of the area. Also, we are not located in Florida and if I were to tell you where I am, you will have never heard of it but we are starting to really grab the attention of the DEA. I have been interviewed by independent lawyers hired by my company to disclose my current dispensing protocol to help determine the legitimacy of the location.

 

[lobelsteve]

Unfortunately, my state does not have a PDMP as of yet. Carrying less of the drug does not really help me determine what and what not to dispense. I wanted to add that we also do not fill for any doctor or any patient that is out of the area. Also, we are not located in Florida and if I were to tell you where I am, you will have never heard of it but we are starting to really grab the attention of the DEA. I have been interviewed by independent lawyers hired by my company to disclose my current dispensing protocol to help determine the legitimacy of the location.

Sounds like Macon GA.

 

[Aether2000]

It appears you already have some steep restrictions in play, so you may want to ascertain why you continue to be a high dispenser of opioids:
1. Are you permitting unlimited amounts of long acting or ER opioids including fentanyl transdermal, oxycontin, opana ER, kadian, MS contin, methadone, exalgo, etc. If you are, then you may want to consider limiting your ER dosing to 360mg morphine equivalent per day which is that highest maximum dosage used by many pain physicians (80mg oxycontin TID).
2. Perhaps your prices are too low. Have a third party survey local pharmacies for prices on specific medications. Perhaps your parking lot is full of drug dealers trading and selling drugs (install an external cam and microphone with video tape). You need to determine why you are attracting such a large number of patients for opioids or are prescribing so many opioids

Good luck with this!!

 

[Taus]

While not a very sophisticated method... .you could always do what patients have reported that pharmacies do.... just say "we don't carry that" or "we ran out"... once you've prescribed the threshold you decide on.

 

[Dr Wario]

Thank you algosdoc, sadly I wish the solution would be to simply limit to 360 MEs/day, however I have no scripts even close to that. I would say that my highest would be about 180 and average closer to 120 for CP. Our largest problem is the sheer number of scripts, not really their strength/quantity. You are very correct in that my prices are too low, 90% of my patients are on medicaid and thus have copays ranging from $0 to about $3, though I don't see anything I can do about this.

In terms of security (and price), those are decisions I do not have the power to make as I am employed by a large corporation, though we do have the measures you have already mentioned.

Taus, I must admit that we do that, however it is not the issue of being able to turn away scripts, it is which ones to turn away.

On another note, do any of you see legitimate medical reason to dose fentanyl TD q48 instead of q72? We have a local, well established, practice that insists on dosing at this frequency due to "loss of efficacy on the third day". I must admit that I have been a bit more lax on fentanyl TD due to a perceived notion that is less abusable, however, perhaps I should rethink my position.

 

[Ducttape]

i think the best thing you could do is reach out to your neighborhood DOH and DEA agent, and ask them to come to your facility to discuss the issues and concerns, review your records and documentation. get them to assist you and on your side to correct what you feel is wrong.

also, i assume you have already contacted your corporation's district manager, to inform them of your concerns. i would do so via some train of communication that can be readily reproduced in a legal arena.

in the meantime, i assume you are monitoring the number of prescriptions per patient. obviously, if a patient is getting more than expected monthly prescriptions, or filling them early, then a phone call to the doctor's office requesting approval will surely curtail some of that activity. ("Mr. Jones is bringing his prescription for hydrocodone, 30 day supply, its been 21 days since his last script. please call to authorize me to release it to him" etc.)


fentanyl is frequently abused, and i read online on several different forums that one of the common illegal uses is as a quick fix. when out of drug of choice, chew it...

 

[RegulateRo]

Would it be worthwhile to see which physicians are prescribing the most to your patients and then filter out scripts from PCPs who are prescribing higher doses or with abnormal frequency?

 

[Ligament]

99% of medicaid people should never be on controlled substances, so there is your problem right there. You can be certain over half of the opioids you are prescribing are being abused and diverted

 

[Dr Wario]

Ducttape, indeed my district manager is very aware of the situation as he is the one receiving most of the pressure from higher up in the company, I just recently learned how much pressure that was. My concerns have been made on legal channels, and luckily for me, I have the fewest number of control dispenses under my name at the pharmacy.

Indeed a lot of my job consists of making sure patients are not refilling controlled substances early, but your point about this gives me an idea. I see many prescriptions that are days/weeks early, the people in my town don't even need to doctor shop because their primary prescriber will give them scripts early consistently. Perhaps I can use this as a criteria to start weeding out prescribers, if I consistently see patients from a practice getting meds refilled early, I will deny those scripts. Thinking about it further, shouldn't the prescribers be the ones that could most easily curtail early fills, especially on schedule IIs but also on schedule IIIs?

On CIIs, the process should be very easy for the office, simply do not give the patient the script until it is time to be refilled or write a DNF until date on them. CIIIs may seem more difficult since they can have included refills, though if a person has a 4 month script and the patient is requesting additional fills after 3 months, shouldn't the office realize the patient is not following the directions and decline the fill until the appropriate time?

I must admit, that my efforts are currently focused on denying the early fill of individual scripts from individual patients. Since my location fills an average of 700 scripts per day with generally only one pharmacist, this oversight becomes difficult and very time consuming, perhaps I should focus my efforts on targeting prescribers. This protocol would help curtail other controlled substances as we also have large problems with sedatives and stimulants in addition to opiates.

 

[joshmir]

I respect your desire to keep your exact location discreet, but can you share the state? I think Missouri is the only state without a database, correct?

 

[lobelsteve]

I respect your desire to keep your exact location discreet, but can you share the state? I think Missouri is the only state without a database, correct?

No DB in GA yet.

 

[SSdoc33]

No DB in GA yet.

not true. plenty of douchebags in georgia. i think we can all agree to that

as far as the OP is concerned, it appears that your problem is more one of geography than particular prescibing practices. i think you are doing everything correct, and doing your due diligence. dollars to doughnuts, that you happen to be smack dab in the middle of several pill mills, which is the reason for you top 0.5%. your regional manager or whoever should be alerted to the prescribing patterns of the local docs, which is the real problem, rather than your particular opioid policy

 

[SeniorWrangler]

It might be easier and also less risky to focus on specific prescribers rather than specific patients. If you start grabbing patients at random to curtail prescribing for, it's going to generate angry customers, bad press, and maybe a lawsuit if this person belongs to a protected group.

On the other hand, every study of opioid prescribing that I've seen shows that a relatively small group of prescribers account for most of the opioids prescribed. Those docs might be the "treater of last resort" or the specialist in cancer pain in the community or they might be doing risky things. You can then reach our to those providers in confidence without being discriminatory to any specific patient, and see where it gets you.

 

[Aether2000]

Or just stop accepting all Medicaid patients. Opt out.