ARCOS Opioid data WV. Where were all the pharmacists?

[Old]

ARCOS data on opioid usage showed 24 CVS pharmacies around Huntington WV over a 6 year period dispensed 80 million doses of opioids. Unless my math is wrong that works out to an average of 10,683 doses dispensed per week on average per each of those pharmacies.

My question is where were the pharmacists? Where were all the highly trained Pharmd's. where were all the clinical concerns. So many pharms are calling MDs about silly little things such as tablets vs capsules or possible side effects that are very rare. Did anybody there question anything and refuse to fill those scripts? Did anybody really care? Did anybody call about diagnosis codes and refuse to fill any of those rx's? How many people died? How much was sold on the street?

This forum always talks about all the good things pharms do (which they do) and they allow this to go on. Can't imagine working in one of those stores. Our profession has made us like robots. Just fill them. How can the profession survive with type of attitude from pharmacists. Provider status- what a joke. Sadly I think most of the pharms are just in it for the paycheck and have become numb.

---

Members don't see this ad.

 

[Subvisual]

RPh - "Is this prescription legitimate?"
MD - "Yes, it is not a fake."
RPh - "This seems like a bad idea. This dose is dangerously high."
MD - "Dispense it as I wrote it."

Repeat times a million and you've got the pharmacy side of the opioid crisis. We don't drive volume, physician prescriptions do that.

 

[sakigt]

$

 

[Old]

RPh - "Is this prescription legitimate?"
MD - "Yes, it is not a fake."
RPh - "This seems like a bad idea. This dose is dangerously high."
MD - "Dispense it as I wrote it."

Repeat times a million and you've got the pharmacy side of the opioid crisis. We don't drive volume, physician prescriptions do that.

So

 

[Old]

So, your saying no matter what your education says is incorrect or unsafe if the doctor says it is ok you just do it? If you feel it can do harm to the patient, in whatever setting you are in, but the doctor says its okay then it is? If the people know that a customer is a drug dealer but he MD says it is okay you fill it? You never counsel the patient with concern for high dose and their safety with an rx? You never turn down an rx for any reason if md says it is okay? So, basically a tech could do our job? Fill it all since the md said it was okay?

 

[Subvisual]

What would you propose if you're a pharmacist in the land that God condemned where everyone is already hooked on dangerously high doses of opioids? Refuse to dispense all of them? Presumably you'd get fired and have a local news story condemning you as a monster for denying medicine to people that are in pain. Even then, it wouldn't make any difference. The patients/prescribers can just fill at a different pharmacy.

You call the prescriber, you state your concerns, the prescriber blows them off if they deign to respond at all. You document. You tell your concerns to the patient. You die a little inside etc.

 

[Old]

What would you propose if you're a pharmacist in the land that God condemned where everyone is already hooked on dangerously high doses of opioids? Refuse to dispense all of them? Presumably you'd get fired and have a local news story condemning you as a monster for denying medicine to people that are in pain. Even then, it wouldn't make any difference. The patients/prescribers can just fill at a different pharmacy.

You call the prescriber, you state your concerns, the prescriber blows them off if they deign to respond at all. You document. You tell your concerns to the patient. You die a little inside etc.

Act based on you education and conscience. Sleep good at night. Get a new job if need be somewhere else. That way you don't die a little inside every time you read the obituary column in the paper.

 

[Subvisual]

So ultimately your ethics aren't based on the effects of your actions but merely assuaging your own guilt? Just move and it's no longer your problem and you can pretend it doesn't exist?

I know it satisfies that primal part of your brain to find individual scapegoats to attribute the problem to but the soul crushing reality is that the whole system is profoundly screwed up in ways that individuals have only an extremely limited amount of power to make any real change on.

And as this database shows: the DEA has had an enormous wealth of data at their fingertips to track these trends. They've done virtually nothing with said data.

 

[PharmtoCS]

My question is where were the pharmacists?

Busy paying off student loans while being terrified of losing our jobs.

 

[owlegrad]

If 10k/week is too much, what’s the right amount? Would 5k have been alright? 1k?

Just for fun, what’s your average weekly opioid dispensing? I don’t know what mine was in retail (or now for that matter) but I bet it was pretty high. In retrospect I was probably too loose but I erred on the side of wanting to believe my patients were not drug dealers or addicts.

 

[Old]

If 10k/week is too much, what’s the right amount? Would 5k have been alright? 1k?

Just for fun, what’s your average weekly opioid dispensing? I don’t know what mine was in retail (or now for that matter) but I bet it was pretty high. In retrospect I was probably too loose but I erred on the side of wanting to believe my patients were not drug dealers or addicts.

Unsure what our average is but not that high. There are always certain docs that are Dr. Feelgoods that most of the druggies go to. Its not really hard to tell. The clinics that only take cash for their patients visits or write vast quantities of c2 scripts for each of them. If you refuse a few of them they migrate somewhere else. They seem to communicate with each other quite well.

I guess I was just amazed that the pharms could go to work and fill that many c2s per week and not feel terrible about themselves, their education and values. Not to mention what it does to the community they live in.

Really devalues the profession in a lot of ways.

 

[Old]

Busy paying off student loans while being terrified of losing our jobs.

Yes, I am sure to some extent you are correct. However, being a fill everything pharm you risk losing your license. Sad the way the profession has gone

 

[owlegrad]

The clinics that only take cash for their patients visits or write vast quantities of c2 scripts for each of them.

How do you know which clinics are cash only?

 

[Chrish]

@Dr Wario works at non-24 hr cvs in that area that does 4000 scripts.. He has posted few times on this issue.

 

[Sine Cura]

87,700 tabs of opioids in one month, not including fentanyl. Most 30-100 MME/day range of total opioid but not a few up to 180/day

Even then I did not see crazy **** like I saw in California circa 2016 like methadone 450 mg/day or Exalgo 128mg/day

 

[APN-59 rph]

ARCOS data on opioid usage showed 24 CVS pharmacies around Huntington WV over a 6 year period dispensed 80 million doses of opioids. Unless my math is wrong that works out to an average of 10,683 doses dispensed per week on average per each of those pharmacies.

My question is where were the pharmacists? Where were all the highly trained Pharmd's. where were all the clinical concerns. So many pharms are calling MDs about silly little things such as tablets vs capsules or possible side effects that are very rare. Did anybody there question anything and refuse to fill those scripts? Did anybody really care? Did anybody call about diagnosis codes and refuse to fill any of those rx's? How many people died? How much was sold on the street?

This forum always talks about all the good things pharms do (which they do) and they allow this to go on. Can't imagine working in one of those stores. Our profession has made us like robots. Just fill them. How can the profession survive with type of attitude from pharmacists. Provider status- what a joke. Sadly I think most of the pharms are just in it for the paycheck and have become numb.

You can fall on the old sword I suppose..Just consider....Some state board..among others..will likely come charging in...tear into your files etc. and likely nail you for what they found.....some inevitable mistake or omission..etc. etc...Sooo go ahead and send up a flare.......It might work out... as you must realize..the moniker "Doctor of Pharmacy" does not really describe the actual job.

 

[WVUPharm2007]

It's Huntington. Everyone is on pain pills. They call the MDs. They get documentation. They can't refuse to fill if there are no red flags. I know people that work there. I even lived in Huntington for two months. It's freaking unreal how many people are addicted to opiates.

 

[zelman]

So, your saying no matter what your education says is incorrect or unsafe if the doctor says it is ok you just do it? If you feel it can do harm to the patient, in whatever setting you are in, but the doctor says its okay then it is? If the people know that a customer is a drug dealer but he MD says it is okay you fill it? You never counsel the patient with concern for high dose and their safety with an rx? You never turn down an rx for any reason if md says it is okay? So, basically a tech could do our job? Fill it all since the md said it was okay?

My education says there is no dose ceiling on opioids and pain is entirely subjective. Every CE put out regarding pain from OxyContin’s approval for over a decade was made by Purdue Pharma and said ER opioids are the best and least addictive option. The only objective problem with these dispensing rates is observation via hindsight. You wanna Monday Morning Quarterback the USA’s late entry to WWII next?

 

[BidingMyTime]

I guess I was just amazed that the pharms could go to work and fill that many c2s per week and not feel terrible about themselves, their education and values. Not to mention what it does to the community they live in.
Really devalues the profession in a lot of ways.

Without seeing the prescriptions and the pt's medical history, who are you to say there was anything wrong with the prescriptions? Maybe the area has a high rate of cancer, or people with chronic injuries from working in coal mines. Maybe these people actually took their prescriptions just as written, and never filled them early. I don't know, but neither do you. I think it devalues the profession for a professional pharmacist to 2nd guess the decisions other pharmacists have made, without any knowledge whatsoever on why those pharmacists made those decisions to fill.

 

[spacecowgirl]

Where were the wholesalers? Where were the drug reps, Perdue Pharma, the patients, the doctors - there is plenty of blame for all to share. We now have the luxury of hindsight and can only hope not to make a similar mistake in the future.

 

[Dr Wario]

@Dr Wario works at non-24 hr cvs in that area that does 4000 scripts.. He has posted few times on this issue.

Yup I have been in the slug of this crisis for almost a decade now and the simple truth is that there really is nothing we can do for most people that are so far gone. I agree with the recent trend to limit initial courses of therapy to a max of 7 day supply, but we really need a dramatic culture shift to really solve the problem. We have to help individual people understand that you should not be taking a pill every time you feel a minor ache or a little sadness. I remember putting on my pharmacy school admittance essay that my primary goal was to help people take fewer medications, I am sad to report that in this, I have utterly failed.

My former store once had the distinction of having the highest ratio of controlled substances for rx volumn, my partner and I were invited to speak to company attorneys to help get to the root of the problem.

As far as individual recommendations to pharmacists, I would tell you that the way to stave off the worst addicts and diversion is to strictly follow the CDC guidelines limiting doses to a max of 90 MME/day for those without cancer or palliative care. For those of you who say it should be easy to refuse all of these questionable scripts, I would like to remind you that up until about five years ago, your bosses were telling you to fill every script that came in your door or you would face disciplinary action.

 

[Old]

"As far as individual recommendations to pharmacists, I would tell you that the way to stave off the worst addicts and diversion is to strictly follow the CDC guidelines limiting doses to a max of 90 MME/day for those without cancer or palliative care. For those of you who say it should be easy to refuse all of these questionable scripts, I would like to remind you that up until about five years ago, your bosses were telling you to fill every script that came in your door or you would face disciplinary action. "

Couldn't agree more. Following the above guidelines means you are going to refuse some scripts. It truly is for the good of the patient and the community. Isn't it what we all went to school for? Don't we care about the patients well being? Most actual pain clinics that are legit run by hospitals etc never/rarely give doses and amounts that above the guidelines stated above posted by Dr. Wario.

As far as companies telling you to fill all rx's. I experienced that 15 + years ago. New pharmacy sup apparently was informed that I was unhappy filling c2 rx from new doc in the area writing huge quantities of multiple c2's. I explained my concerns. I was told how much profit there was in those rx's for the company. I got a piece of paper and asked him to write down that he was ordering me to fill all narc scripts without question and sign it so I would be protected. He didnt do it and I never heard another word about it.

Just because an MD says its okay do we just say ok and fill it. Is that really what we were taught? There are people that say there is no global warming and our election interference was some fat kid in NJ. Someone said it so its true?

 

[Chrish]

There have been few patients at my store whose scripts I questions sometimes; like should they be on it? But they have been filling these scripts before I even came to this place. And they get their non-control stuff filled too. It would be difficult to turn them away.

“Ms Smith, I know you been filling this script for past three years but going forward you will have to go somewhere else”.

Some areas have higher number of these prescriptions. Multiple psych and pain clinics in the area; higher percentage of elderly demographics etc. Our store fills around 10% controls out of total script count. I have heard of one store that fills unusually high number of Oxycodone scripts. I have been told they have security guard always standing at the pharmacy door! The cvs where I did my rotation literally filled 20 Suboxone scripts a day! At my current store, we barely do 3 or 4 of those a month.

So, the point is you will get higher percentage of controls in some areas and it’s not practical do deny every single one of them. There will always be “grey area”.

I always turn away new patients with questionable scripts. But turning alway folks who have a long history at your place? Easier said than done.

 

[SELDANE]

The OP asks a hard but fair question. As one who was practicing pharmacy during that time I have to submit a mea culpa for my part. That being said one has to take into context the school of thought regarding pain management twenty years ago. MME was not an acronym that rolled off the tongue until recently. Refusing to fill a prescription based on MME twenty years ago would be like someone using a cell phone in an episode of the Brady Bunch. Unrealistic. Having refused to fill pain scripts and arguing with providers regarding usage left one wrestling with the concept that their refusal to fill left a patient struggling with pain (granted that pain may have been more dopesick than pain but we didn't know it). Furthermore it caused one to wonder, "am I right and all of modern medicine is wrong?". In retrospect, yes. But like I said we just didn't know it.
As for Purdue Pharma, Mylan, Mallinckrodt, Abbott, etc.. and their ability to influence American medical education and practice lays bare capitalism's place in healthcare. I say these things not as an excuse but to merely provide context. As stated before I as a pharmacist bare some of the blame. For whatever it's worth I don't see this being the last wave to hit healthcare regarding drug usage. I see this same scenario being played out in the not to distant future regarding ADHD medications.

 

[spacecowgirl]

we really need a dramatic culture shift to really solve the problem. We have to help individual people understand that you should not be taking a pill every time you feel a minor ache or a little sadness.

This. So much this. I say that as someone who does take meds for depression and anxiety but who also used a nonpharmacologic methods. I also say that as someone with chronic pain for which I take no pain meds. Why does the US consume like 95% of the world's hydrocodone (I forget the actual figure but it is similar)? Do we have 95% of the world's pain? Lately I would say yes, but the pain isn't physical.

 

[Chrish]

Actually some countries don’t even have a concept of opioids. For something like tooth extraction or fracture, all you get is ibuprofen, or in “worst case scenario” diclofenac.

In US while it’s overprescribed, we are at least lucky to have this option. And long term NSAIDs or steroid regimen isn’t any better for patients from safety perspective.

 

[Old]

This. So much this. I say that as someone who does take meds for depression and anxiety but who also used a nonpharmacologic methods. I also say that as someone with chronic pain for which I take no pain meds. Why does the US consume like 95% of the world's hydrocodone (I forget the actual figure but it is similar)? Do we have 95% of the world's pain? Lately I would say yes, but the pain isn't physical.

Ditto for me for chronic pain. A couple of otc advil for the worse days seems to get me through. As far as depression goes I think we all have periods of depression and anxiety. I really think our profession causes a lot of it. Sometimes I, maybe all of us, go home after a long busy ,nasty day and lay down to sleep and scripts pop into your mind. did I fill that correctly, . I don't remember counting the blue tablets etc. Hazards of the job I guess.

As a side note. a local md office in the town where I work has a policy that if a patient complains about 3 things they give them an antidepressant. true story.

 

[maria1oh]

Cvs in bullhead city arizona was by far top cvs dispensing pain pills during that time. Cvs in woodbury nj was distant second.

 

[allantois]

I think suing pharmacies for dispensing legitimately written prescriptions is the dumbest thing and reflection on the abdication of personal responsibility that is so pervasive in our culture.

 

[Subvisual]

This. So much this. I say that as someone who does take meds for depression and anxiety but who also used a nonpharmacologic methods. I also say that as someone with chronic pain for which I take no pain meds. Why does the US consume like 95% of the world's hydrocodone (I forget the actual figure but it is similar)? Do we have 95% of the world's pain? Lately I would say yes, but the pain isn't physical.

The pain and the depression are linked in oh so many patients. I absolutely believe in the underlying reason why a huge number of patients start on opiates is that they're self-medicating primarily for the short term euphoric relief of depression or other mental health concerns. Of course in the long run this just makes the depression much worse, but mental health providers and counseling centers are understaffed and expensive, while pills are easy for both the healthcare system and patients.

 

[zelman]

I think suing pharmacies for dispensing legitimately written prescriptions is the dumbest thing and reflection on the abdication of personal responsibility that is so pervasive in our culture.

And I think these young kids with their saggy pants and skateboards are a nuisance on small town roads!

This is the “not related to the thread” complaint time, right?

 

[Old]

I think suing pharmacies for dispensing legitimately written prescriptions is the dumbest thing and reflection on the abdication of personal responsibility that is so pervasive in our culture.

Yes and No. Recently had a patient want to transfer where I work with massive c2 usage. Back pain was md diagnosis. The MME/day usage is 1096. 1096. not a typo. Has been on it for quite awhile. Would you fill them? If something happens to him will they come for you? If he is selling meds and something happens to the buyers will they come for you? Would you feel responsible or just fill it since it is a legitimately written( by a DO) rx? Your defense would be--- but the doctor wrote it? Thinks that will work?

 

[VictorOfHungerGames]

At my last job, I refused to dispense percocet b/c I thought it was too early and patient was already getting a Norco. Doctor actually told me not to fill when I called to ask him since Norco was from a different prescriber. The pharmacy owner got upset when patient complained to him about while crying her eyes out. The owner was a pu$$y anyways lol but he was all about making money and didn't care about PMP/day supply etc. I don't think this issue is black and white. As medical professionals, we should all feel responsible to a certain degree.

 

[Sine Cura]

Cvs in bullhead city arizona was by far top cvs dispensing pain pills during that time. Cvs in woodbury nj was distant second.

LOL how did you get this info?

Broward County, WV all over the news but Mohave County flying under the radar in comparison

Millions of opioid pills flooded Arizona communities during prescription drug boom

A staggering number of opioid pills were dispensed by Arizona pharmacies from 2006 to 2012. In Kingman, the damage may already be done.

www.azcentral.com

# of Opioid Rx per 100 residents for Mohave County was like 130-140 from 2014-2016 (national average 66-75), just as bad as Cabell County in WV

U.S. Opioid Dispensing Rate Maps | Drug Overdose | CDC Injury Center

www.cdc.gov

 

[Subvisual]

Yes and No. Recently had a patient want to transfer where I work with massive c2 usage. Back pain was md diagnosis. The MME/day usage is 1096. 1096. not a typo. Has been on it for quite awhile. Would you fill them? If something happens to him will they come for you? If he is selling meds and something happens to the buyers will they come for you? Would you feel responsible or just fill it since it is a legitimately written( by a DO) rx? Your defense would be--- but the doctor wrote it? Thinks that will work?

Relay your concerns to the prescriber and the patient, Probably in writing at this point. Document. Make sure they have Narcan. Recommend a very slow taper moving forward to the prescriber.

If it's a dose increase into or above the CDC danger zone I push a lot harder to try to get a modification out of the prescriber and even occasionally state I can't dispense this as is.

If the patient has been stable on a stupidly high dose though...God only knows. It's a problem with no good solutions at that point. Sure they never should have been put on dose that high, but if you inherit a patient on such a high dosage you need to balance your plan in such a way that they don't just go into withdrawal, seek out street Fent and OD.

Once again those in charge have utterly failed us. The CDC guidelines are great, but they are recommendations and nothing more. It was certainly within the power of the FDA to simply declare "no patient's dose of X opioid should ever exceed Y mg" and slap a REMS program on to enforce that. They're purposefully chosen not to do that though. Why are drugs like Accutane and Clozapine heavily restricted to prevent adverse events, but the opioid class hasn't even been touched? $$$$$$$$