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"Administer true justice, show mercy and compassion to one another." Zechariah 7:9b
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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.
November 2021 Issue [Download PDF format]
In this issue:
• DEATH at CVS [Ashleigh M. Anderson]
• Tobacco (continued) – The Great American Smokeout – November 18, 2021
• To be Forewarned is to be Forearmed
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EDITORIAL:
DEATH at CVS
Pharmacist Ashleigh Anderson died on September 10, 2021. I did not know her but almost feel like I did from the loving and kind tributes of her family, friends, and colleagues that are posted on the website of the funeral home (Soller-Baker in Lafayette, Indiana). I extend my heartfelt sympathy to her family.
Ashleigh was employed at a CVS store in Indiana. While working at CVS on September 10 she felt ill and considered it necessary to leave. She contacted her supervisor who, according to several individuals, responded that she needed to stay at the store for up to 2 hours until a covering pharmacist arrived. One pharmacist informed me that "she was threatened with job abandonment" if she left before then. Before another pharmacist could arrive, she collapsed in the store. Ashleigh Anderson was 41.
I have complete confidence in the information that several pharmacists have provided me. I have attempted to contact CVS corporate headquarters and have left multiple voicemail messages to obtain information about this tragedy and to determine if the company is establishing a memorial fund and/or other tribute to honor Ashleigh. There has been no response. Some allege that CVS does everything possible to suppress news that would result in criticism and questions.
Many individuals provide me with social media postings in which they believe I would be interested, and I appreciate their doing that. Many of the comments are accolades for Ashleigh, the joy derived from working with her, and expressions of grief following her death. Other postings direct anger and outrage at CVS, with the following being just several examples.
"CVS has been killing its patients for years! Now they are apparently killing the staff too?"
"Every time I see the red heart logo, all I can think about is Ashleigh Anderson."
This tragic situation demands answers and actions including:
- A police investigation;
- A state board of pharmacy investigation that includes a review of CVS policies and quotas/metrics pharmacists are expected to meet and criteria for determining hours of staffing;
- The establishment of a policy by CVS that authorizes pharmacists or other employees who feel ill at work to leave immediately, even if the store must be temporarily closed.
- The disclosure of the name of the CVS supervisor who "discouraged" Ashleigh from quickly leaving the pharmacy, and the names of the CVS personnel in the administrative hierarchy above the supervisor up to the CEO;
- The establishment by the Indiana and American Pharmacists Associations of a memorial fund in honor of Ashleigh Anderson that would support efforts to protect the well-being of pharmacists and improve workplace conditions.
On the same day as I am writing this commentary, I received in the mail a large postcard from CVS Health to inform me that "We're hiring pharmacists at CVS Pharmacy stores in Pennsylvania." It continues: "Do you have a passion for helping patients navigate their health care journey? We do! Join our pharmacists as they bring their heart to patients and local communities." I accessed the website identified (cvs.jobs/pharmacists) to learn more. I urge CVS pharmacists to review this information to confirm that your experience matches the description. Is this false advertising? We can't continue to tolerate dangerous working conditions, and we can't be silent! If it is important that you not be identified as the source of information, make your concerns known to me or others you trust to assure your confidentiality.
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Tobacco (continued) - The Great American Smokeout – November 18, 2021
More than 50 years ago, the late Fred Mayer, a pharmacist and public health advocate, started the Great American Smokeout, observed on the third Thursday of November. This was just one of many creative initiatives through which Fred called attention to the hazards and consequences of smoking (the cause or an important contributing factor to the deaths of 480,000 Americans each year) and strongly supported smoking cessation programs. My advocacy for smoking cessation programs was first inspired by Fred Mayer, and continues because of the excellent research, programs, and leadership of pharmacists Robin Corelli (University of California San Francisco) and Karen Hudmon (Purdue University).
Very regrettably, there are others who are in a position to take action to reduce the use of and harm from tobacco products, but refuse to do so. The hypocrisy of those who say they promote health but sell tobacco products should be exposed. They primarily include certain large chain stores (e.g., Rite Aid, Walgreens, Walmart) and grocery stores that include pharmacies. Consumers should be urged not to patronize them. Rite Aid and Walmart have even gone through the ludicrous exercise of discontinuing the sale of certain consumer products that contain alleged toxins, while ignoring their continued sale of tobacco products.
The primary roles of state boards of pharmacy are to license pharmacies and pharmacists for the purpose of safeguarding citizens of their states with respect to the appropriate and safe use of medications and related products. They should refuse to initially license or relicense pharmacies that sell tobacco products or are in facilities that sell tobacco products. But they don't.
I used to think that I understood the roles of the Food and Drug Administration. However, recent events are great cause for concern. In addition to its failures in assuring the quality and potency of generic drug products made in China, India, and elsewhere (please see Bottle of Lies – The Inside Story of the Generic Drug Boom by Katherine Eban; HarperCollins; 2019), its charade of concern about the use of tobacco products and other nicotine-containing products is absolutely baffling. The recent press releases from the FDA regarding its authorizations to market certain e-cigarette products and oral tobacco products are double-speak clouds of statements, terminology, and self-promotion. The press release of October 12 announces its authorization for marketing three new tobacco products, "marking the first set of electronic nicotine delivery system (ENDS) products ever to be authorized by the FDA through the Premarket Tobacco Product Application (PMTA) pathway." The press release of October 19 announces its authorization for marketing of four new oral mint-flavored tobacco products, also using the PMTA pathway. Both press releases include statements such as, "Ensuring new tobacco products undergo a robust premarket evaluation by the FDA is a critical part of our mission to protect the public – especially kids," and "stringent marketing restrictions will help prevent youth exposure." Particularly confusing are further statements in the press releases that the authorizations allow the tobacco products to be legally sold and distributed in the U.S., but do not mean the products are safe or "FDA-approved" because all tobacco products are harmful and addictive, and there are no safe tobacco products. The FDA has also declined to authorize marketing of numerous other tobacco products, and the inevitable lawsuits with respect to the distinctions between authorized and unauthorized products can be expected to follow soon.
At the same time the FDA is trying to explain this maze, many products containing varenicline (e.g., Chantix), the most effective agent to help individuals stop the use of tobacco products, are being withdrawn from the market because of the presence of trace amounts of nitrosamines that are thought to be carcinogenic but have not been implicated in any deaths.
If the FDA continues to insist that products containing tobacco and its harmful components can be legally sold, it should require the removal of nicotine, the agent responsible for dependence, addiction, and continued use of the products known to be harmful. This requirement must also apply to cigarettes and other previously-available tobacco products, and the FDA should permit their promotion as NICOTINE-FREE!
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To be Forewarned is to be Forearmed
One of the most fulfilling benefits of my writing The Pharmacist Activist is to hear and learn from readers. Your experiences and perspectives enhance my understanding of the multiple dimensions of the topics being addressed, and increase my motivation to provide thought-stimulating commentaries and opinions that will result in positive action. Dan Hoffman is the President of Pharmaceutical Business Research Associates in Pennsylvania. He has had extensive experience as an investigator, analyst, and writer regarding health care in general and the pharmaceutical and corporate chain store industries in particular. He often provides insightful responses to my commentaries, and I have his permission to share the following excerpts from his message to me on October 18, 2021.
"Commentaries by Walgreens executives at last Thursday's earnings report provide some insight on where they and CVS may be going with respect to the issues of pharmacy integrity you have been reporting. Walgreens and CVS have been battling each other to become comprehensive ‘go-to treatment centers' for patients with chronic conditions. Toward that end, Walgreens just paid $5.2 billion to acquire a controlling stake (63% of the equity) in Village MD, a company in which they already held a 30% share. They believe this will allow them to open 600 physicians' offices by 2025 and an additional 400 by 2027. Walgreens will also acquire a majority stake in home health benefits manager CareCentrix.
For both Walgreens and CVS, the strategic move to chronic care and mental health counseling results from the fact that prescription sales, their largest source of revenue, have been declining largely as a result of losses to online pharmacies. It has become very clear that the chains view pharmacy as a lower margin, slower growth business. During the transition, the chains seek to implement rigorous cost controls. That can potentially exacerbate the quotas and other abuses detailed in your newsletters. This process will require pharmacy personnel to spend more time on inventory management and less on such matters as pharmacist consulting. These discretionary activities that pharmacists previously handled on an unstructured, ad hoc basis will become the prerogative of physicians and nurse practitioners. The companies will increasingly subject pharmacists to quotas whose allocated costs must come under closer control because they do not believe pharmacists can generate desirable margins. The management at pharmacy chains is totally driven by the mindset of finance, with the result that appeals based on matters such as professional integrity fall on deaf ears."
(Editor's note: Subsequent to Dan Hoffman's message to me, an article titled, "CVS Seeks Primary-Care Doctors," was published in The Wall Street Journal [Sharon Terlep and Matt Grossman, Nov. 4, 2021, pB1], in which the CEO of CVS notes that the company is working with "speed and urgency" to create physician-staffed primary-care practices).
Dan Hoffman respects and values the professional role of pharmacists and notes that he hopes his expectations are wrong. He encourages our attention to the responses of some groups of physicians in integrated delivery networks (i.e., hospital-based networks that have been buying up medical practices, etc.) and nurses who have organized to reverse the same abuses they suffer in their professions. He further notes that unions across the country in a variety of occupations recognize that the country's acute labor shortage has provided them with a rare leverage they can use in bargaining with employers.
I agree with Dan's observations and warnings about what might lie ahead for pharmacy. We observe the experience and the reality of changes that have already occurred, and the role and integrity of pharmacists in chain stores will be threatened even more. Pharmacy must not make the mistake of thinking the challenges only involve the chains. The issues threaten our entire profession! The awareness of and identity with pharmacy for most Americans and our legislators and other decision makers are based on their experience in their chain stores that are ubiquitous. Independent pharmacies are highly valued but their numbers are declining and the owners face challenges that threaten their financial survival. The responsibilities of pharmacists employed in hospitals, pharmaceutical companies, colleges of pharmacy, and pharmacy organizations are unknown and/or invisible to most in the public sector.
To be forewarned is to be forearmed! We can't expect others to defend, protect, or promote pharmacy. It is our responsibility and that of our professional organizations and institutions to do so. We (all pharmacists!) must insist on accountability of our professional organizations, colleges of pharmacy, and boards of pharmacy in providing leadership in protecting and extending the professional roles of pharmacists in assuring the quality of medications and their effective and safe use in achieving positive therapeutic outcomes for patients and the public. Our entire profession must support the preservation, and further growth in numbers and professional roles and services, of independent pharmacists.
Individual pharmacists must be motivated by the awareness that, if we don't act now, employment experiences will become even worse than they are at present. I understand that some chain pharmacists hold their employer in high regard and are fulfilled in their responsibilities. However, most are experiencing deplorable and stressful working conditions. I also understand that for many pharmacists, there are no or very limited other employment options and that it is essential for yourself and your family that you don't resign from or be at risk of losing your current position. I understand, respect, and do not question the decision that you are in the best position to make for yourself, as long as your decision doesn't place your physical and mental health at risk.
Many pharmacists and pharmacy students, however, do have options in identifying professionally fulfilling employment. New or soon-to-be graduates should not succumb to the offer of a higher salary, even for the laudable goal of removing oneself from the burden of student loan debt as quickly as possible. The profession of pharmacy offers many different career options and I urge you to explore all of them that are a good match for your interests before you consider a position with a chain store.
For pharmacists who are currently employed at chain stores and whose employment experience is intimidating and stressful, I recognize that management is not receptive to criticism, concerns, or even questions about working conditions. There are, however, actions that you can consider. Your concerns can be supported by the extent that you can involve additional pharmacists at the other stores in your district. Learn the names and obtain personal contact information for the other pharmacists in your district for the purpose of facilitating communication and off-site meetings. If this "network" can be extended to include pharmacists at other chain stores in your areas (e.g., CVS, Rite Aid, Walgreens, Walmart), that will be advantageous. It is your companies that are such fierce competitors, not the pharmacists. The response to any questions or challenges from district leaders or others is that all discussions and actions being considered are motivated by the importance of the personal health and well-being of the pharmacists and the inseparable relationship with error avoidance and protection of the safety of your customers/patients.
Potential actions that may be considered and/or taken include the following, with my recognition that some may not be feasible in your personal circumstances.
- Protect your personal physical and mental health; consider taking medical leave, if appropriate;
- Be aware of other employment opportunities; pharmacy organizations and colleges of pharmacy may be helpful;
- If there is an independent pharmacy in your local area, ask if they have an opening for a pharmacist; although it is unlikely that they do, you know the names and contact information for the individuals who obtain the most prescriptions at your chain store and who might be "recruited" to transfer to the independent pharmacy if you make that change;
- For those with an entrepreneurial spirit and interest in doing so, consider opening a low-overhead independent pharmacy as close as possible to the location of the chain store where you are now employed; you have a head start in knowing and contacting an initial base of customers/patients;
- Document errors, "near-misses," and other factors that jeopardize patient safety for your personal files;
- Regardless of metrics/quotas, work at the pace that you consider appropriate for assuring safety of your customers;
- Do not work "off-the-clock" unless you wish to do so, will be paid for it, and will not incur excessive stress;
- Give higher priority to completing prescriptions that are needed on a timely basis, than to requests for immunizations; decline requests for immunizations when the safety and timely fulfillment of other responsibilities may be compromised;
- Decline or reduce participation in store promotions (e.g., Carepass, auto-refill calls);
- Close the drive-thru window if safety in fulfilling other responsibilities is compromised;
- If there is solid documentation of employee and patient safety being placed at risk, consider becoming a whistle blower;
- Share this issue of The Pharmacist Activist with other pharmacists and pharmacy students and encourage them to also access previous issues on related topics on the website (www.pharmacistactivist.com);
If you are questioned/challenged by management or customers, respond that your actions are based on your commitment to protect the safety of your customers. If you are terminated or disciplined by your company, consider a lawsuit. There may be an attorney who would provide services on a contingency basis.
It is not selfish to give the highest priority to your personal physical and emotional health. If your commitment to protect the health of your customers is compromised by your personal health issues or your having to be on medical leave, you are not able to adequately protect your customers and corporate will be responding only to protect sales, but not the safety of its customers. If errors occur and customers experience serious harm or die, it will be your license and livelihood, and the welfare of your family, that are at greatest risk. Your employer will come up with whatever amount of money is necessary to settle lawsuits and avoid negative publicity for itself, while it identifies ways to fault you for the error.
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