EDITORIAL:
CVS is Destroying the Profession of Pharmacy: Part 6
With each issue in this 6-part series of commentaries regarding CVS, an even larger number of responses and experiences are forwarded to me. There appears to be no limit to the evil, greed, and lies of this company. This commentary includes the experiences of two very courageous, and now former, CVS pharmacists, as well as excerpts from Ellen Gabler's third article on the dangerous working conditions, errors, and harm to patients, at CVS and other chain pharmacies in the July 16th issue of The New York Times.
Lisa Cairo's experience
I first came to know Lisa at the beginning of the Pharmacotherapeutics course in which I was one of the faculty participants. As the course coordinator, I would come to the classroom around 7:30 am to be certain that the AV equipment, etc. were ready for the start of the 8 am classes. One student, Lisa Cairo, was already in the classroom studying when I would arrive. I was surprised by her early arrival and learned that she had two young children, had a 2-hour commute each way between her home in New Jersey and Philadelphia, and that to arrive in time for her 8 am classes, her train's departure time from her hometown was 5:30 am. The hours each day of her train commute and early arrival at our college were the primary times that she could devote to studying her coursework. I was very impressed by her commitment to learn and attend classes, while also fulfilling her responsibilities as a wife and mother and working part-time in a pharmacy.
Following her graduation I did not have any communication with Lisa for a number of years until I received the following email message from her at 12:55 am on June 20:
"I am writing in regards to your articles about CVS. I was employed with CVS for 16 years both as a technician and as a pharmacist. During my last few years at CVS, pharmacy supervisors were constantly changing. I had been at my store during that time for about 8 years and was currently the PIC (pharmacist in charge). I had a 24-hour store where on a Monday dispensing 750 prescriptions was typical. I was maintaining the numbers and doing everything I was supposed to. I gave excellent customer service and because I lived in the area and had 6 children in the school system, customers felt comfortable confiding in their pharmacist.
One day I was called to the office and told I was immediately being moved to their slowest store which barely did 100 prescriptions a day. Rumor had it that a pharmacist from another store who liked to play teacher's pet wanted my hours, worked her magic, and got what she wanted. My customers were so upset that they were calling me at my new store and I would tell them to call the 1-800 number and voice their opinion. There were so many angry customers that the supervisor called me and told me to stop giving out the 1-800 number. I was one of the strongest pharmacists in the district put into a store where I was useless. The supervisor refused to move me to a busier store.
During that time I became pregnant with my daughter. One day while entering information into the computer I looked down at the floor and saw a puddle of blood. I excused myself from the pharmacy to clean up and then went back to work. Within a few minutes there was another puddle of blood on the floor despite the layers of paper towels I had used to prevent something from occurring. At this point, my technician's face was white as a ghost and I was afraid for my baby. I called the store manager and said that I had to lock up and drive myself to the hospital. I told the manager that I would call the supervisor along the way. I did call the supervisor who scolded me for closing up before a replacement arrived. My visit to the emergency room determined that I was most likely pregnant with twins and that the heavy bleeding was the result of losing one of them. My discharge papers from the emergency room stated that I should take one week off from work, and work no more than 8-hour shifts unless a stool was provided for my use. My supervisor said stools were not allowed and that 8-hour shifts were not available. Eight-hour shifts were available at my previous 24-hour store so that was a lie I was being told. I was told that, if I could not work when I was scheduled, I would need to go on early disability. I was capable of working but they refused to make exceptions for my condition. I continued to work but I hid a bunch of boxes in a corner as a makeshift stool to get me through until I went on disability. I knew that once I had the baby I was moving on to another position. CVS didn't actually fire me but they did everything they could to make it difficult and uncomfortable for me.
My marriage was never a solid one and I had made a mistake. Several years later I filed for divorce. Because I received a higher salary than my ex, I had to pay him out. When I filed for divorce, I also applied for a PharmD program because I knew that the PharmD would be necessary to remain stable in the work force as a single parent. I didn't want to be at risk for a lay-off or unable to find a job like so many pharmacists with a bachelor's degree in pharmacy are now discovering. So I now have student loans to repay. It's okay. I now have my PharmD degree.
There was one other big change in my life. I began pharmacy school when my oldest daughter, Nicole, was 6 months old. I wanted to give her everything I didn't have as a child. She saw me walk the stage at graduation when she was in kindergarten. I tried to lead by example. I did my very best to be a good role model. But it wasn't enough. Nicole became addicted to drugs. I saw it early on and intervened. My ex denied that there was a problem and said it was a phase that she would grow out of. It was a very tough period of time with her lying and stealing from me, and my waiting up late at night wondering where she was. I was the disciplinarian while my ex was not concerned.
I received my PharmD degree in May 2017. I was on top of the world. My world crashed July 22, 2017. Nicole died from an overdose of heroin that was laced with fentanyl. Life has not been the same. I missed many of my kids' events because I worked endless hours for CVS. My relationship with my children would most likely be different if I didn't work the grueling shifts I did. I hope something comes about with what you are doing. I felt helpless when I left CVS."
I responded to Lisa that her message brought me to tears and asked that she provide me with her phone number so that I could speak personally with her. She provided it to me and we spoke later that day. Lisa followed with a quick email and photo "to show you how beautiful my Nicole was." I responded:
"She is beautiful, Lisa, and could have been a model. Her beauty is an inspiration looking forward to help your younger children achieve what Nicole might have achieved."
Most of Lisa's experience at CVS was during the last 20 years. However, more recently she has been working as a hospital pharmacist. Many current CVS pharmacists would say that the working conditions at CVS are even worse now than when Lisa was employed there. I highly commend and greatly appreciate her sharing her experience with me so that I may communicate it with the hope that other pharmacists can learn from it and take action to avoid circumstances that can have such a destructive impact.
Shayra Ramirez's experience
Shayra Ramirez worked for CVS for more than 25 years, most recently in Florida UNTIL last August. Ellen Gabler's comprehensive coverage in two stories in The New York Times earlier this year ("How Chaos at Chain Pharmacies is Putting Patients at Risk") captured what Shayra has experienced and motivated her to share her own experience:
"In the last two years patient service/care in CVS has been declining steadily, mostly due to the lack of technician hours. Our technicians have a key role in keeping the pharmacy going, by entering the prescriptions in the system, physically counting and preparing the medication, attending the register, dealing with insurance, etc. The lack of tech hours made our work very hard, as we had to deal with a bigger workload with no help, and the situation became so hectic that, after months of written complaints to CVS management, I led a meeting of five pharmacists with the District Manager in April, 2019. Our main complaint was that the lack of technician help did not allow time for pharmacists to keep proper track of expired medication, interactions, appropriate drug and dosing, etc. We asked for a solution in order to avoid putting patients at risk. In that meeting it became crystal clear that CVS was only worried about meeting metrics (immunizations, prescriptions, etc). We were told that increasing the hours for technical help was out of the question, and that we were obligated to meet the metric scores required. When I asked how we were supposed to do so, the District Manager said that he didn't have an answer and that that was our problem. They showed no interest whatsoever in dealing with our concerns about patient safety. I was very vocal at that meeting and it was obvious that neither my District Manager nor my Supervisor were happy with my comments. My colleagues who attended the meeting, as well as myself, immediately became persona non grata for CVS management.
From that moment on, we kept receiving pressure from management to increase the metrics while they continued cutting technician hours, and some of these pressures included write ups for some of my colleagues with the threat of termination. Finally, my time came: in late August last year, my District Manager had me come to the office, after more than ten days pressuring me personally to persuade our patients to receive vaccines (I guess there is monetary gain from it, as it is a big part of the metrics). I then challenged him when he was saying that 'the company stresses immunizations because they care about the well-being of our patients,' because it seems that what they really want is to meet their goals with the vaccines; and he did not like that.
On August 29th, I was out of town on vacation while West Palm Beach was under Hurricane Alert. I entered in the CVS Human Resources website and I found no access to most of my regular things on my account and a note encouraging me to apply for Cobra to cover my medical expenses…starting August 30th!! With my arrival date in Florida unclear due to the weather, I was fired and nobody in CVS had the decency to warn me. A funny thing is that the Sunday after (9/1/19) my District Manager sent me an email telling me that all my shifts for that week were covered. I guess he meant 'next' and all the weeks of my life because I had been fired, but not even there did he have the decency to communicate it to me.
A few days later, I received the letter of termination in the mail. The formal reason for my being fired is that I contradicted a company policy because I rang up a personal sale for myself in the register for one of my own medications (again, due to a lack of help and trying not to distract my technicians from more important work). Under normal circumstances, this would have resulted in just a verbal or written warning (our policy was that personnel in charge are to be given 3 formal warnings before letting people go). In my case, I was immediately terminated. In my case, this is a clear case of retaliation.
I mention all this because I felt very angry when I read in The New York Times article, 'When a pharmacist has a legitimate concern about working conditions, we make every effort to address that concern in good faith,' CVS said in a statement. This is not true. There is no concern at all, and CVS management does not like to be challenged in order to improve the quality and safety of the pharmacy service for their patients.
Obviously, they don't want me working for the company anymore because I speak too clearly for them. I told the District Manager that I felt we were harassing patients to get vaccines and that I also felt like I was selling myself in order to meet the metrics, the goals, and ultimately, his bonus. It is disappointing that with 25 plus years of service, I was terminated this way only for trying to address something we pharmacists knew long ago: we are putting our patients at risk, and I believe it has not been a fair way to treat me or the patients."
Shayra Ramirez wrote personally to Ellen Gabler at The New York Times to voice her appreciation for her articles about the terrible working conditions at CVS and the subsequent increased risk of harm to patients, and for Ms. Gabler so effectively increasing public awareness of these dangers at CVS stores. Shayra has demonstrated exceptional courage in voicing her concerns to CVS management. Her concerns for the safety of her patients resulted in retaliation and termination, but will have the result of emboldening others to take a strong stand against a company whose greed and evil must no longer be tolerated. CVS will be hearing more from Shayra and those of us who support her!
Ellen Gabler and The New York Times
As I prepare this issue of The Pharmacist Activist on July 16, I have received Ellen Gabler's story in today's New York Times, titled, "CVS Fined for Safety Issues at Oklahoma Pharmacies." The article begins:
"In a rare public rebuke of the nation's largest retail pharmacy chain, state regulators in Oklahoma cited and fined CVS for conditions found at four of its pharmacies, including inadequate staffing and errors made in filling prescriptions.
While the fine of $125,000 on Wednesday was small for CVS Health –
it paid its chief executive $36.5 million in total compensation last year and is the country's fifth largest company – the move validated concerns raised at multiple drugstore chains across the country by pharmacists and technicians who say understaffed workplaces are putting the public at risk."
The article includes a number of examples of errors, and the results of a visit from Oklahoma Board compliance officers to a CVS store at which they "witnessed a chaotic scene including the phones ringing almost all of the time, along with constant foot traffic and drive thru traffic." In an audit, "the officers found an error rate of nearly 22 percent, or 66 errors out of 305 prescriptions." In another CVS store, "inspectors said a computer screen showed more than 99 prescriptions waiting to be filled and more than 99 calls needing to be made." The article also includes an interview with a former CVS district leader who had the courage to repeatedly voice concerns about the budgets for staffing, and who was subsequently terminated.
Ms. Gabler has provided a valuable service for consumers and the profession of pharmacy by exposing the consequences of corporate greed and negligence. This article and her two previous articles earlier this year should be required reading for all pharmacists and pharmacy students. Pharmacists and pharmacy students should challenge our professional organizations and colleges of pharmacy to take actions in addressing the dangerous workplace conditions that exist. We should no longer tolerate their silence!
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NEW DRUG REVIEW:
Bremelanotide acetate
(Vyleesi – AMAG)
Agent for Female Sexual Dysfunction
New Drug Comparison Rating (NDCR) = 4
(significant advantages)
in a scale of 1 to 5, with 5 being the highest rating
Indication:
Administered subcutaneously for the treatment of premenopausal women with acquired, generalized hypoactive sexual desire disorder (HSDD) as characterized by low sexual desire that causes marked distress or interpersonal difficulty and is NOT due to a coexisting medical or psychiatric condition, problems with the relationship, or the effects of a medication or a drug substance.
Comparable drugs:
Flibanserin (Addyi).
Advantages:
- Has a unique mechanism of action (is a melanocortin receptor agonist);
- Is administered prior to anticipated sexual activity (whereas flibanserin is administered on a continued daily basis);
- Does not cause hypotension and syncope (whereas this risk is in a boxed warning with flibanserin);
- Alcohol avoidance is not necessary (whereas alcohol increases the risk of hypotension and syncope with flibanserin and administration should be separated by at least 2 hours [boxed warning]);
- Is less likely to interact with other medications (whereas concurrent use of flibanserin and moderate or strong CYP3A4 inhibitors is contraindicated [boxed warning]);
- May be used in patients with hepatic impairment (whereas flibanserin is contraindicated).
Disadvantages:
- Is administered subcutaneously (whereas flibanserin is administered orally);
- May cause transient increases in blood pressure;
- Nausea is often experienced;
- Focal hyperpigmentation may occur.
Most important risks/adverse events:
Transient increase in blood pressure and decrease in heart rate (contraindicated in patients with uncontrolled hypertension or known cardiovascular disease); focal hyperpigmentation (e.g., of the face gingiva, breasts; risk is higher in patients with darker skin and with daily dosing); nausea (antiemetic therapy may be necessary); may slow gastric emptying and reduce the rate and extent of absorption of other oral medications (e.g., antibiotics, analgesics); may reduce the systemic exposure of orally-administered naltrexone (concurrent use should be avoided); pregnancy (use should be discontinued if pregnancy is suspected; women should use effective contraception during treatment); is not indicated for the treatment of HSDD in postmenopausal women or in men, or to enhance sexual performance.
Most common adverse events:
Nausea (40%), flushing (20%), injection site reaction (13%), headaches (11%), vomiting (5%).
Usual dosage:
Administered subcutaneously in the abdomen or thigh – 1.75 mg at least 45 minutes before anticipated sexual activity; not more than one dose should be administered within a 24-hour period, and the use of more than 8 doses per month is not recommended.
Products:
Single-dose prefilled autoinjectors – 1.75 mg in 0.3 mL.
Comments:
HSDD is designated as "acquired" when it is experienced by a woman who previously had no problems with sexual disorder. It is designated as "generalized" when it is not apparently related to a specific partner, the situation, or type of sexual activity. HSDD had been included in the Diagnostic and Statistical Manual of Mental Disorders, but has recently been removed and replaced by Sexual Interest/Arousal Disorder. Flibanserin was the first drug to be specifically approved for the treatment of premenopausal women with HSDD. Bremelanotide is a melanocortin receptor agonist with a labeled indication that is the same as that for flibanserin. Its effectiveness was evaluated in two 24-week placebo-controlled studies in which it increased the sexual desire measure and decreased the sexual distress measure. However, fewer than 40% of patients in both studies experienced improvement in either measure, and there was not a statistically significant difference in the drug and placebo groups in the number of satisfying sexual events.
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