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Each issue will include an editorial on a topic that is important for the profession of pharmacy, as well as a review of a new drug that includes a comparison of the new drug with previously marketed drugs that are most similar in activity, and a New Drug Comparison Rating (NDCR) for the new drug. Read on for this month's issue.
June 2019 Issue [Download PDF format]
In this issue:
• Editorial
• New Drug Review
• Rays of Hope
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EDITORIAL:
They Must be Anonymous, But They Will Not be Silent!
The title for the editorial commentary in the May issue of The Pharmacist Activist is, "I believe I am a danger to the public working for CVS." That is a quote from a letter from an anonymous (but known to me) CVS pharmacist to a board of pharmacy. I have received so many responses to this issue, the majority of which are from current or former CVS pharmacists, that I am using this June issue to include excerpts and examples from the responses. With several responses, I have made minor editing changes to prevent the identification of the pharmacists who voiced the concerns, but the importance and strength of their concerns are not changed.
I would also reiterate that there are thousands of excellent pharmacists who work in CVS stores, and the concerns identified are not a criticism of them but, rather, are to support them by increasing awareness of conditions and situations that they can't even communicate within CVS because of their fear of being terminated. It is the CVS management-imposed metrics, working conditions, and understaffing that place consumers at risk and are the basis for this criticism.
Responses
From current CVS pharmacists:
"Subject: CVStress. All of what the anonymous pharmacist said is true, but there is more. Recently, CVS started a program where electronically sent prescriptions may be verified by another CVS store within the state. It is my feeling that eventually pharmacies will be operating without pharmacists. Everything will be done by some communications methods. I firmly believe this is what the chains want. Imagine the profits then!! This is part of the reason they are pushing to get their employees to be named to state boards of pharmacy. I've worked in hospitals, independents, and chains. My hours were cut and I didn't know about it for 2 weeks until after the starting date for the change. There is no more profit sharing. No more premium pay for covering extra shifts. Our health insurance premiums have skyrocketed. Working conditions are worse than you can possibly imagine.
While all of the above causes a financial and emotional hardship for me, the real people who suffer are the patients (customers to CVS). They are not getting the care and attention they deserve. They get bombarded by text messages and phone calls almost begging them to come in and spend their money. I have no time to do anything that I know I should be doing. I never thought I'd say this, but I can't wait until my retirement. I truly enjoyed being a pharmacist but now I'm just a highly paid robot who feels more like a liability than an asset to my employer.
What am I doing about it? I recently spoke with a pharmacy student with whom I work who was planning on working for CVS following graduation. I explained my experiences and feelings about working for CVS, and the student obtained another position and will be much better off. It may not be a lot, but everyone can do something. You may use any of this information you wish and I know you will respect my request for anonymity."
"I am losing my full-time status in my store and will have to pick up a shift elsewhere to stay full-time. Cuts and closures are happening everywhere. As pharmacist cuts occur, more techs are added and the tech: pharmacist ratio is far beyond the limit allowed in my state."
"I am aware of a pharmacist who is opening an independent pharmacy that will be near a CVS store. However, Caremark is purposely delaying the application into its provider network. Because this is a heavy Caremark provider area, a new pharmacy would have great difficulty opening without Caremark plans. Caremark is doing everything they can to delay the opening of new independent pharmacies, so that they can keep their profits in-house."
"Another scam, or as CVS would like to say 'patient care calls.' Added to our duties are 10 or 15 calls per day designated as pharmacist special message calls. We are to call patients and tell them that the pneumonia shot the doctor ordered is waiting for them at the pharmacy and to come on in to get the shot."
(Editor's note: I contacted this pharmacist and asked whether there were doctors' orders for the vaccine for specific patients. His response is below.)
"There are no doctor orders. We use one doc, as for all injections. CVS selects patients who are age appropriate and may be at risk. The way I have been handling this is asking them if they have any questions about meds and that this is a general call and that we appreciate them as a customer. I also tell them that we are offering pneumonia shots, and many respond that they have already had the shots."
"We get screamed at by customers because their prescriptions are not ready when promised. We get behind and the CVS response is 'too much red in this store today.'"
From pharmacists previously employed by CVS:
"I was let go from the company for 'business purposes' when district revenues were down. At least that's what I was told. However, I and others believe that CVS and some other chains are looking for reasons to fire older pharmacists. The work environment, stress, and inability to keep up with company metrics are only a few factors which contribute to an unsafe environment. I have many stories. Even when I was let go, I had to fight for my final paycheck and stock purchase withholdings.
Although I no longer work for CVS, I choose to remain anonymous at this time because I am concerned CVS will find a way to retaliate. However, there is a need to expose the truth. I once heard a sermon in which it was stated: 'To sit and watch evil IS evil.' Somehow, that thought keeps going through my mind."
"Since the time I retired from CVS, I have stayed in touch with my friends there. CVS lost a number of pharmacists in our area in just two months. They still can't find technicians and many who have been there for years are leaving. Customers are extremely unhappy with service and prices. There is no help."
From a board of pharmacy member:
"I will be bringing this up at the next board meeting."
From a former hospital pharmacist:
"What you describe in the May issue of The Pharmacist Activist is not unlike what occurs thematically in hospital pharmacies. I am SO glad that I'm out of that mess! I feel (and am) betrayed by our profession after all the work I put into it."
From an executive of a company that works closely with pharmacists:
"I empathize with all these pharmacists. Many of these chains and supermarkets have their performance metrics. That is bad news. There is even worse news!! Many State Boards of Pharmacy are CONTROLLED by the chains and supermarkets!! They have 'their own people' in place to knock down any and all complaints that come in that would adversely affect anything that the chains and supermarkets are doing!! I was shocked to learn that it does no good at all to complain to the Boards of Pharmacy."
From customers:
"I am so grateful to be back at Skippack Pharmacy! Between Express Scripts and CVS, I had enough. I was so tired of having no eye contact. Made me wonder if one of my pills fell on the floor, would they pick it up and put it in the pill bottle? Mayank (the new owner who reopened Skippack Pharmacy after CVS bought and closed it) is great and we love having him here." (Editor's note: Please also see the separate commentary about Skippack Pharmacy in this issue.)
(Editor's note: I also received many other responses voicing criticisms regarding CVS, but the comments provided above are representative of the concerns communicated to me. The comment below is the single response I received that is complimentary of CVS.)
"My experience at a local independent pharmacy was unsatisfactory, and I went to a CVS that I now patronize exclusively. The pharmacists and techs all wear white uniforms. When I have new prescriptions, the pharmacist, without being asked, always presented me with the new drug and asked if he or she could explain. I have found the personnel at our local CVS to be very professional."
From a producer of a television news program:
"Do you think the CVS pharmacist you wrote about would go on camera?"
I informed the anonymous pharmacist I quoted, as well as several other current CVS pharmacists who have voiced concerns to me, of the television producer's question. They declined to be interviewed on camera because they anticipate CVS would terminate them and there are not other positions for pharmacists available in their areas. I then contacted pharmacists who have voiced concerns, but who no longer work for CVS. Even these pharmacists are not willing to be interviewed on camera because they are concerned that CVS would find a way to retaliate against them. I responded that I understood their concern and assured them I would not place any pharmacist at risk by disclosing their identity. Another pharmacist with whom I communicated had been a pharmacist manager with CVS for several decades before he was terminated. He sued CVS and, following an extended legal battle, was successful in receiving a large settlement from CVS. I do not know the specifics of the settlement because CVS insisted that the terms of the settlement be confidential as a condition for the agreement. Therefore, the information is not publically available and the pharmacist is restricted from disclosing any information.
I asked the television news producer if interviews could be conducted in a manner that would disguise the identity and voice of those interviewed. He did not anticipate that this would be done, but is looking into it and the outcome is pending.
I wish to express my appreciation to the pharmacists who have had the courage to communicate their concerns to me and for their trust in me to protect their identity.
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NEW DRUG REVIEW:
Revefenacin
(Yupelri – Theravance; Mylan)
Bronchodilator
New Drug Comparison Rating (NDCR) = 2
(significant disadvantages)
in a scale of 1 to 5, with 5 being the highest rating
Indication:
For oral inhalation via nebulization for the maintenance treatment of patients with chronic obstructive pulmonary disease (COPD).
Comparable drugs:
Glycopyrrolate (Lonhala Magnair inhalation solution for nebulization).
Advantages:
- Is administered once a day (whereas glycopyrrolate is administered twice a day);
- May be used with any standard jet nebulizer (whereas glycopyrrolate should only be used with the Magnair system).
Disadvantages:
- Has not been directly compared with glycopyrrolate or other long-acting muscarinic antagonists (LAMAs) in clinical studies;
- Administration of a dose requires a longer period of time (approximately 8 minutes; compared with 2 to 3 minutes with glycopyrrolate via nebulization);
- Use should be avoided in patients with hepatic impairment;;
- Concurrent use with certain organic anion-transporting polypeptide (OATP) inhibitors (e.g., cyclosporine, rifampin) is not recommended.
Most important risks/adverse events:
Must not be used for the treatment of acute symptoms or in patients with acutely deteriorating COPD; hypersensitivity reactions; paradoxical bronchospasm (treatment should be discontinued); worsening of urinary retention; worsening of narrow-angle glaucoma; action may be increased by other agents with anticholinergic activity (e.g., tiotropium, tolterodine, diphenhydramine), and concurrent use should be avoided; should not be used in patients with hepatic impairment because exposure of active metabolite may be increased; active metabolite is a substrate of OATP1B1 and OATP1B3 and action may be increased by inhibitors of these transporters (e.g., cyclosporine, rifampin; concurrent use should be avoided).
Most common adverse events:
Cough (4%), nasopharyngitis (4%), headache (4%), upper respiratory tract infection (3%), back pain (2%).
Usual dosage:
175 mcg once a day using a mouthpiece and a standard jet nebulizer connected to an air compressor.
Products:
Inhalation solution for oral inhalation: polyethylene unit-dose vials – 175 mcg in 3 mL of sterile, aqueous solution; vials are wrapped in a foil pouch and should only be removed from the pouch and opened immediately before use.
Comments:
Revefenacin is the fifth long-acting muscarinic antagonist (LAMA) to be approved for use via oral inhalation as bronchodilators in the treatment of patients with COPD, joining tiotropium (Spiriva Respimat), aclidinium (Tudorza Pressair), umeclidinium (Incruze Ellipta), and glycopyrrolate (Seebri Neohaler). The LAMAs are most often administered via oral inhalation using metered-dose delivery devices. However, the effective use of these devices requires manual dexterity and coordination of actuation of the device and inhalation that deviates from regular breathing, which present a challenge for some patients. Approximately 10% of the patients treated for COPD in the United States administer bronchodilators by oral inhalation using a nebulizer. Glycopyrrolate was the first nebulized LAMA to be approved for the treatment of COPD, and it is administered over a period of 2 to 3 minutes twice a day. Revefenacin is the second LAMA to be approved for oral inhalation using nebulization, and the first to be administered once a day. The effectiveness of revefenacin was evaluated in two 12-week, placebo-controlled studies in patients with moderate to very severe COPD. The primary endpoint was the change from baseline in trough (predose) forced expiratory volume in one second (FEV1). In both studies, revefenacin demonstrated significant improvement in lung function compared to placebo.
Following oral inhalation, revefenacin is rapidly hydrolyzed to a major active metabolite that can potentially contribute to systemic anticholinergic effects at therapeutic doses.
Rays of Hope: Congratulations to Mayank Amin and Skippack Pharmacy!
Skippack Pharmacy opened in 1968 in the community of Skippack outside of Philadelphia. It served the community with distinction for almost 50 years, but the time arrived when the family that opened the pharmacy found it necessary to sell it. The family was committed to preserving its continuation as an independent pharmacy, and sold it to a pharmacist. Not long after that, the buyer sold the pharmacy to CVS which closed it in March, 2018.
Mayank Amin is a 2009 graduate of the Philadelphia College of Pharmacy at University of the Sciences, who was born and raised in the area served by Skippack Pharmacy. When he learned that the pharmacy had closed, he made a decision to purchase the building and re-open Skippack Pharmacy, which he did in early 2019. On June 8, he held an Opening Ceremony and Ribbon Cutting that was attended by many patients and other members of the community, and at which many community leaders voiced their appreciation. It was a wonderful celebration!
Mayank spoke of his commitment to serve the community, and his comments reflected a high level of professionalism and entrepreneurism. He had learned that one of the previous pharmacy employees (Bonnie), now 75 years young, had worked at the pharmacy for its entire period of operation. He asked her to join his staff, which she did and she also was a speaker at the ceremony. Mayank noted that many patients of the pharmacy are elderly, some more than 100 years of age, and have limited mobility. He announced that he and his pharmacists make house calls to facilitate the provision of services.
As one of Mayank's pharmacy faculty members, he asked me to make comments at the ceremony. In addition to paying tribute to him, I noted that he was committed to practicing pharmacy the way it should be practiced, and described what I consider to be a "win-win" situation. Mayank recognizes his responsibility to respect and personally know his patients, and to provide them with medications and services that will provide the anticipated benefit with the least risk. However, this is just one part of the prescription for success for his patients, the community, and for him personally. Residents of the community who are his patients also have a responsibility to share their positive experience at Skippack Pharmacy with their neighbors and friends, and encourage them to use this pharmacy.
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