EDITORIAL:
CVS is Destroying the Profession of Pharmacy - Part 3*
Along with Rite Aid, Walgreens, and Walmart!
*Editor's notes: 1) The first 2 parts are in the February and March 1 issues of The Pharmacist Activist; 2) Reader responses to the editorials have been so supportive and valuable (Thank you) that I will continue the recent schedule of publishing two issues each month.
When you think CVS management can't get any worse in damaging its own reputation and that of the profession of pharmacy, it finds a way to do it. Where to begin in the voluminous files of messages and news commentaries regarding CVS and other chain pharmacies just since March when I wrote my last editorial about CVS? Let's start with some headlines regarding lawsuits and selected quotes:
"Blue Cross Blue Shield insurers sue CVS, alleging drug pricing fraud" (Axios Health; May 28, 2020; Bob Herman).
- "…the pharmacy chain overcharged them based on 'artificially inflated prices' for generic drugs and concealed the true cash prices of those drugs."
- BCBS alleges "CVS offered lower cash prices on generic drugs to compete with Walmart and other low-cost pharmacies, but told insurers those cash prices were significantly higher than they actually were."
- "People enrolled in CVS' cash discount program in 2015 got a 90-day supply of blood pressure medication nadolol for $11.99. But CVS told BCBS of Florida that the cash price was $180.99 and overcharged $169 as a result, according to court documents."
"Big Pharmacy Chains Also Fed the Opioid Epidemic, Court Filing Says" (New York Times; May 27, 2020; Jan Hoffman).
- "A new court filing…asserts that pharmacies including CVS, Rite Aid, Walgreens and Giant Eagle as well as those operated by Walmart were as complicit in perpetuating the crisis as the manufacturers and distributors of the addictive drugs."
- "The retailers sold millions of pills in tiny communities, offered bonuses for high-volume pharmacists and even worked directly with drug manufacturers to promote opioids as safe and effective, according to the complaint filed in federal court in Cleveland by two Ohio counties."
- "CVS worked with Purdue Pharma, the maker of OxyContin, to offer promotional seminars on pain management to its pharmacists so they could reassure patients and doctors about the safety of the drug."
- "From 2006 through 2014, the Rite Aid in Painesville, Ohio, a town with a population of 19,524, sold over 4.2 million doses of oxycodone and hydrocodone. The national retailer offered bonuses to stores with the highest productivity."
- "Walgreens contract with the drug distributor AmerisourceBergen specified that Walgreens be allowed to police its own orders, without oversight from the distributor. Similar conditions were struck by CVS with its distributor, Cardinal Health."
- "Despite being repeatedly fined by the DEA (for failing to report suspiciously high orders), the companies continued to sell outsize quantities of opioids."
- "Walmart devised a workaround to that reporting requirement. In mid-2012, it fixed a hard limit on opioid quantities it would distribute to its stores, foreclosing the need for its pharmacists to report excessive orders. Yet Walmart simply allowed its stores to make up the difference by buying the remainder of their large opioid orders from other distributors.
- "The chains "rewarded pharmacists for churning volume rapidly and, in some instances, pointedly ordered them never to refuse a doctor's prescription."
- "Supervisors ignored store pharmacists who warned about pill mill doctors, including those who were ultimately convicted."
CVS Class Action Employment Lawsuit (California)
- The lawsuit alleges 10 claims against CVS for California Labor Code violations, and also alleges that CVS engaged in unfair competition by violating the California Labor Code for profit while its competitors were following the laws as required.
Other litigation against CVS
For CVS' own summary of litigation, I encourage you to access the CVS Health report (Form 10-Q) that it filed with the Securities and Exchange Commission for the quarterly period ended 3/31/20, and read the section on "Litigation and Regulatory Proceedings" on pages 28-33. Yes, 6 pages are needed and CVS must have an army of attorneys that it pays far more than its pharmacists, but not its executives.
CVS "Transform Health 2030" Report
On May 14, CVS issued its 13th annual corporate social responsibility (CSR) report and unveiled Transform Health 2030, the company's new CSR roadmap for the next decade. The report identifies many excellent programs for which the beneficiaries are very needy and deserving organizations and individuals. These commitments of CVS have a value of millions of dollars.
I read the report in its entirety, and the content reflects several additional important, but unstated, messages. The word "pharmacist" does not appear even once in the lengthy report. The words "pharmacy" and "pharmacies" only appear in two of the many sections of the report that may be accessed by those with the persistence to click on two links. The two sections are "Developing our diverse workforce" and "NBA Point Guard and Former Villanova Wildcat Donte DiVincenzo Helps CVS Health Kick Off Free Health Screenings in Philadelphia." The word "pharmacy" is included once in the press release, as an example of the CVS "commitment" to a Healthy Planet, in the following statement:
"Removed BPS from CVS Pharmacy customer receipts to increase their recyclability, while enrolling 1.1 million customers in digital receipts in 2019 for a savings of 48 million yards of receipt paper."
Think of how much more impressive that number would be if CVS had thought to express the length of receipt paper in inches (or centimeters if CVS could properly and fairly use 'metric[s]') rather than yards. There is a rumor that all the receipt paper that has been saved is to be used in making CVS brand toilet tissue, but I have not been able to confirm this.
One must question how the CVS wealth was accumulated in an amount so substantial that it is able to give millions away. CVS pharmacists, I, and many (but not enough) others recognize that its wealth has been accumulated at the expense of TMC (too many to count) customers who died or were harmed as a consequence of errors at CVS stores, pharmacists and pharmacy technicians who were terminated and can't find other employment, and current pharmacists, pharmacy technicians, and managers for whom the abysmal working environment is excessively stressful and even suicidal for some.
Recommendations
It is clear that CVS has forgotten its roots and has abandoned the profession of pharmacy. It is now time for our profession to abandon CVS, and the following recommendations are provided to start this process:
- CVS and other pharmacists with entrepreneurial interests should offer to buy or have a long-term lease to own the Pharmacy Department in CVS stores, so that the pharmacies can be operated properly, professionally, and profitably.
- Boards of Pharmacy, the DEA, and other law enforcement agencies should conduct very thorough investigations of the CVS organization and stores to identify illegal, fraudulent, dangerous, unprofessional, and unethical practices that place customers and employees at risk.
- The Federal Trade Commission and Department of Justice should conduct investigations of the monopolistic, anticompetitive, and illegal practices of CVS Health, and take action to require the divestment of Caremark, Aetna, and Omnicare (and other lesser-known subsidiaries that reduce competition) if CVS wishes to continue to own pharmacies.
- Pharmacy organizations and colleges of pharmacy should reject any grants or financial support (including meeting exhibits and "unrestricted" educational grants) from CVS because of its continuing actions that are so destructive to the profession of pharmacy. It may be too late to save the independent and smaller chain pharmacies that have closed or were acquired (often by CVS) because of the anticompetitive and destructive actions of CVS, but every effort must be made to save independent pharmacies and the rest of our profession.
- States and Boards of Pharmacy should enact legislation and regulations that require pharmacists to hold the majority ownership in pharmacies. North Dakota has set the standard that other states should follow.
- Pharmacists and other employees who have been unfairly terminated by CVS should individually and/or collectively explore legal action. Some former CVS pharmacists have already been successful in taking these actions, but it requires determination and patience. Pharmacists who are aware of attorneys who have been helpful and successful in these efforts are requested to provide their names and contact information to me at the email address below, and I am also actively exploring the best options to pursue this.
- More whistleblowers are needed. Current concerned pharmacists should document in detail medication/dispensing errors, as well as illegal, fraudulent, unethical, unfair, and excessively stressful management-imposed programs, activities, and workplace environments.
Editor's notes:
1) The next several issues of The Pharmacist Activist will include comments from anonymous (but with identities that I can confirm) CVS and other chain pharmacists, as well as from physicians and other healthcare professionals who are impacted by decisions and actions of CVS and other chain pharmacies.
2) My editorials regarding CVS and other chain stores are motivated by the purpose of supporting pharmacists in these stores, and the criticisms are directed at executives and other managers in policy-making positions.
3) Although the primary focus of this editorial is on CVS, pharmacists at Rite Aid, Walgreens, and Walmart should also be considering the above concerns that are pertinent to their employment. Future issues of The Pharmacist Activist will address concerns at these companies, including the continued sale of tobacco products.
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NEW DRUG REVIEW:
Solriamfetol hydrochloride
(Sunosi – Jazz)
Agent for Excessive Daytime Sleepiness
New Drug Comparison Rating (NDCR) = 4
(significant advantages)
in a scale of 1 to 5, with 5 being the highest rating
Indication:
To improve wakefulness in adult patients with excessive daytime sleepiness associated with narcolepsy or obstructive sleep apnea (OSA).
Comparable drugs:
Modafanil (e.g., Provigil), armodafanil (e.g., Nuvigil).
Advantages:
- Has a unique mechanism of action (dopamine and norepinephrine reuptake inhibitor);
- Is less likely to cause hypersensitivity/dermatologic reactions;
- Interacts with fewer medications;
- Dosage adjustment is not necessary in patients with severe hepatic impairment.
Disadvantages:
- Has not been directly compared with comparable drugs in clinical studies;
- Labeled indications are more limited (modafanil and armodafanil are also indicated to reduce excessive sleepiness in patients with shift work disorder);
- May be more likely to increase blood pressure and heart rate;
- Concurrent use with monoamine oxidase inhibitors is contraindicated;
- Dosage should be reduced in patients with moderate or severe renal impairment.
Most important risks/adverse events:
Contraindicated in patients being treated with a monoamine oxidase (MAO) inhibitor, or within 14 days following the discontinuation of an MAO inhibitor; increased blood pressure and heart rate (use is best avoided in patients with unstable cardiovascular disease, serious arrhythmias, or other serious heart problems; caution should be exercised in patients also taking other drugs that increase blood pressure and heart rate, and/or have a dopaminergic action); caution should be exercised in patients with psychosis or bipolar disorder; if used during pregnancy, women should be enrolled in a pregnancy exposure registry (1-877-283-6220); is included in Schedule IV; dosage should be reduced in patients with moderate or severe renal impairment.
Most common adverse events:
Headache (16%), decreased appetite (9%), nausea (7%), anxiety (6%), insomnia (5%).
Usual dosage:
Administered once a day upon awakening; should not be taken within 9 hours of planned bedtime; recommended initial dosage is 75 mg once a day in patients with narcolepsy and 37.5 mg once a day in patients with OSA; dosage may be doubled at intervals of at least 3 days to the maximum recommended dosage of 150 mg once a day; product labeling should be consulted for dosage recommendations in patients with moderate or severe renal impairment.
Products:
Tablets – 75 mg, 150 mg; 75 mg tablets are functionally scored so that they can be split in half to provide a dose of 37.5 mg.
Comments:
Medications with stimulant/wakefulness promoting activity are most often used in the treatment of conditions (e.g., narcolepsy, OSA) associated with excessive sleepiness, and include modafanil, armodafanil, amphetamine salts, and methylphenidate. The central nervous system depressant sodium oxybate (Xyrem) is also approved for the treatment of excessive daytime sleepiness and cataplexy in patients with narcolepsy. Solriamfetol is a phenylalanine derivative that is thought to act by inhibiting dopamine and norepinephrine reuptake. When used in patients with OSA, it does not treat the underlying airway obstruction, and interventions such as continuous positive airway pressure (CPAP) should be employed for at least one month before initiating solriamfetol.
The effectiveness of solriamfetol was evaluated in placebo-controlled studies in which patients were assessed using the Maintenance of Wakefulness Test (MWT), the Epworth Sleepiness Scale (ESS), and the Patient Global Impression of Change (PGIc) scale. Compared with the placebo group, patients with narcolepsy showed significant improvement in these measures with a dosage of solriamfetol of 150 mg daily, and patients with OSA showed significant improvement with dosages of 37.5 mg, 75 mg, and 150 mg daily.
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