PNN Survey Shows Strong Support for CVS Boycott

By Pat Anson, Editor

There is widespread support for a boycott of CVS for planning to have its pharmacists impose strict limits on the supply and dosage of opioid pain medication, according to a PNN survey of over 2,500 pain patients, caretakers and healthcare providers.

Nine out of ten (93%) said they would support a boycott of the pharmacy chain, which has nearly 10,000 retail locations nationwide.

“I already have to jump through multiple hoops to get my pain medication prescriptions. It is not the place of CVS to monitor or alter my prescriptions. That is my doctor's job,” one patient told us.

“My Rx needs have been determined by my physician and my case history,” another patient wrote. “CVS does not have my history, nor have they been seeing me as a patient. Therefore, they have no business dictating or changing the regimen my physician has set to try to help me control my chronic pain.”

CVS Health announced last month that its pharmacists would only provide a 7-day supply of opioids for acute, short-term pain. CVS will also limit the dose of opioid prescriptions – for both acute and chronic pain -- to no more than 90mg morphine equivalent units (MME). 

The policy begins February 1 and applies to about 90 million customers enrolled in CVS Caremark’s pharmacy benefit management program, which provides pharmacy services to over 2,000 health and insurance plans.

Many of the healthcare providers who responded to the online survey resent the idea of a pharmacist changing a doctor’s prescription or refusing to fill it.

WOULD YOU SUPPORT A BOYCOTT OF CVS?

“It is no one’s business how I prescribe but mine and the patient,” one doctor wrote.

“It is wrong on all levels. As a health care provider I am appalled by it,” said another.

“Pharmacies should not be interfering in doctor patient relationship and treatment. There are more and more rules and regulations, and where does it stop before you have tyranny? Their rule basically will accomplish nothing positive. I would also encourage others to boycott,” a healthcare provider wrote.

CVS Customers Support Boycott

Patients, caretakers and healthcare providers all support a boycott about equally. So did nearly 92 percent of those who identified themselves as current CVS customers.

“Treating patients like they are drug-seeking criminals is just plain cruel. Our lives are hard enough without having to jump through hoops to get even a few minutes of relief. I will never fill another prescription at CVS pharmacy,” one patient wrote.

“I have gone to the local CVS for my scripts for years because they had the best prices,” wrote another patient. “But since I heard about this new policy I refuse to even set foot in a CVS.”

“They (CVS pharmacists) think they are my doctor with rude comments to me and other customers. They are too big for their britches. I am switching to Walgreens,” another patient wrote.

“A boycott will happen whether organized or not. Patients who need more than 90 morphine equivalent mgs will have to take their business elsewhere,” said another patient.

“Boycotting solves nothing. A letter writing campaign or calls to corporate to voice our opinions would be a better way to explain why we disagree with the new policy,” another patient suggested.

There is still a fair amount of confusion about the CVS policy. Many chronic pain patients are worried the 7-day limit on opioids applies to them (it does not) and others believe a pharmacist doesn’t have the legal right to refuse to fill a doctor’s prescription (they do).  

CVS says “the prescriber can request an exception” if a patient needs a larger dose or more than a 7-day supply, but hasn’t released details on how that would work or how long it would take.

The pharmacy chain says its opioid policy is designed to “give greater weight” to the Centers for Disease Control and Prevention's opioid guideline, which discourages primary care physicians from prescribing opioids for chronic pain. But the CVS policy actually goes far beyond the voluntary recommendations of the CDC, making them mandatory for all physicians and for all types of pain.  

As PNN has reported, preventing abuse and addiction may not be the only reason behind CVS’ decision. In recent years, the company has been fined hundreds of millions of dollars for violations of the Controlled Substances Act and other transgressions, many of them involving opioid medication.

“Corporate self-interest is impetus for this policy. This CVS ploy is to avoid further scrutiny by the DEA and avoid additional monetary penalties,” one patient wrote.

“Money and bad press is the only thing that large companies like CVS pay attention to. Until the leadership and major investors feel some considerable financial pain themselves, they will continue to make or support decisions that hurt and endanger the lives of people in pain,” said another.

U.S. Pain Foundation Endorses 7 Day Limit

CVS is not the first pharmacy to adopt policies that limit the dispensing of opioids, but it is the first major chain to set a 7-day limit on opioids for acute pain. Several states have already adopted laws that limit new prescriptions to a few days' supply. The Pharmaceutical Research and Manufacturers of America (PhRMA), an industry trade group,  recently announced its support for a 7-day limit, as did a patient advocacy group.

“We are on board with limiting new prescriptions for acute pain, but we do believe there should be a specific, written exemption for chronic pain, palliative pain, and cancer pain in order to ensure they are protected,” said Paul Gileno, founder and president of the U.S. Pain Foundation, which lists CVS Health and PhRMA as corporate sponsors on its website.

“A number of states, including Massachusetts, have adopted laws limiting first-time opioid prescription to seven days, and this part of the new CVS policy is consistent with these restrictions” said Cindy Steinberg, U.S. Pain’s national director of Policy and Advocacy. “We are in agreement with this limit for new, acute conditions; however instituting dosage limits for all patients is troubling.”

Not all of the comments in our survey were negative about CVS. Some patients expressed appreciation for CVS pharmacists who helped them save money with discounts or by suggesting cheaper medications. Others are happy to see any kind of action aimed at reducing opioid addiction. 

“It may anger some, but there is a major opioid problem in my area and sometimes it takes making a bold decision to create change, even at the risk of losing customers,” wrote one patient. “Notice nobody complains about CVS not selling cigarettes. They have lost billions in revenues since, but it was for the greater good of peoples’ health.” 

One healthcare provider is worried what will happen when her patients can’t get the pain medication they need.

“When that happens, we as providers become part of the problem because these patients will go to the street for help. They will do anything to get pain relief - not to get high. I won't boycott them but I think they ought to rethink what they are doing and the impact it will have,” she wrote.

“I have children with horrific chronic pain issues and other children who have had addiction issues that were not started with pain meds. I know both sides of this issue.”

Would You Support a Boycott of CVS?

By Pat Anson, Editor

One of the most talked about issues in the pain community over the last two weeks has been CVS Health’s announcement that its pharmacists would soon start restricting doses of opioid pain medication and limit the supply of opioids for acute pain to 7 days.

The policy only applies to customers enrolled in CVS Caremark’s pharmacy benefit management program, but it quickly triggered an online backlash from pain patients – including many who called for a boycott of CVS.

“I refuse to patronize companies that practice medicine without a license,” wrote Jeannette on PNN’s Facebook page.

“Don’t go there anymore. Hit them in their pocketbook,” wrote Lauren.

“I very rarely use a CVS and will never go there for prescriptions or anything else,” said Jackie.

“I left CVS years ago for Walgreens and I’m guessing many more will be doing so,” wrote Amanda.

"CVS has some nerve. The use of opioids, or any other drug, really, is up to the doctor and his or her patients, not a pharmacist. This is a terrible precedent, which will drive an even bigger wedge between physicians and patients,” cardiologist Arthur Kennish, MD, told the American Council on Science and Health.

The CVS boycott soon had its own hashtag on Twitter.

“Wrong way to handle, CVS! I will join the #BoycottCVS. You make it more difficult for the sick w/ no impact on the crisis,” Stephanie tweeted.

The online outrage even spilled over onto CVS’ Facebook page, where many negative posts were apparently deleted by the company.

“CVS Pharmacy, why did you take down all your Posts and comments regarding your big announcement over overriding doctor's orders and limiting patients' rights to their pain medication?” asked Lauri. “Where did they all go?”

People are so passionate about this issue that we started an online poll asking if they would support a boycott of CVS. Click here if you’d like to participate.

Would a Boycott Work?

But while there’s plenty of online enthusiasm for a boycott, it’s unlikely to be effective without the support of patient advocacy groups.  An informal survey of pain organizations by PNN found most were critical of CVS’ decision, but opposed to a boycott.

“I think boycotting CVS is not a good idea. I think a better idea is working with them for better care and finding the good in what they are doing and amplifying the bad.  They want better education, they want better disposal, and many other things we all fight for,” said Paul Gileno, President of the U.S. Pain Foundation.  “I don't think a boycott would work or be effective and can come across in a negative way. We need a loud conversation with CVS.”

“I don’t typically like boycotts” said Barby Ingle, President of the International Pain Foundation and a PNN columnist. “But if enough people have a bad experience or don’t like the CVS policies, they will see a drop in the market and will have to reevaluate what their policies will be.

“I wouldn’t call it a boycott, I would call it a shift in patients understanding that we have power and that we can choose to go to the healthcare places that fulfill our needs. Unless CVS changes their practices, I can see them continuing to lose business.”

Penney Cowan of the American Chronic Pain Association did not respond to a request for comment.

One patient advocate who gave full support for a boycott was Cynthia Toussaint, the founder of For Grace, a non-profit that supports women in pain.

“The lack of patient advocacy support for the boycott is totally surprising,” Toussaint wrote in an email. “We’ve all been beating the ‘don’t get between a doctor and a patient’ drum for years, and now that we can put our names behind that, we’re being sheepish.

“For Grace is ON BOARD with the boycott! This is chilling news for the pain world - and I hope our support helps many people. We understand CVS’s very real concern about the opioid crisis, but this new policy is too heavy handed and will greatly harm the chronic pain community!”

CVS is not the first pharmacy to restrict access to opioid medication. In 2013, Walgreens gave its pharmacists a “secret checklist” to help them screen patients with opioid prescriptions. Any red flags, such as a prescription written by a new doctor or a patient paying in cash, could result in a prescription not being filled. The policy was implemented after Walgreens was fined $80 million by the Drug Enforcement Agency for violating the rules for dispensing controlled substances.

CVS has also been fined hundreds of millions of dollars for violations of the Controlled Substances Act and other transgressions, many of them involving opioid medication.

A Florida pharmacist who was fired this year by Sam’s Club for not following the company's opioid policy says pharmacies are driven by profit, not patient care, and a boycott is unlikely to change their bottom line. 

“Patients won't need to boycott. CVS doesn't want the business anyway,” says Karl Deigert, who was fired after complaining that patient rights were being violated at Sam’s Club, which is owned by Walmart.  “Corporations are only acting in their own best interest and have no concern for the patient. Patients can save their breath and energy as any complaints filed will fall on deaf ears. 

“Overzealous corporate policy makers have no desire or interest to protect the patients' well-being. Their policy making is self-serving to protect their assets from DEA scrutiny and monetary penalties. The corporations and the majority of retail pharmacists simply do not care to help the chronic pain patient population.”

The new opioid policy at CVS doesn’t go into effect until February 1, 2018. But CVS Caremark is already tightening the rules for some opioid prescriptions. 

A Caremark client who has been getting fentanyl pain patches at CVS for years was recently notified by letter that new limits are being placed on the patches “to help ensure that your use of opioid medication for pain management is safe and appropriate.” 

But is it really about safe and appropriate use?

The letter goes on to say the patient will still be able to get the fentanyl patches, but without prior authorization they “will have to pay 100 percent of the cost.”

CVS Defends Rx Opioid Policy

By Pat Anson, Editor

CVS Health has released new details about its plan to limit the dose of opioid pain medication and restrict new prescriptions for acute pain to a 7-day supply.

The new policy, which was announced last week, immediately sparked an online backlash from chronic pain patients, who fear they will no longer be able to refill their opioid prescriptions at CVS or will have to do it weekly.

“It's crazy what's going on. Every week going to doctors and pharmacists paying that extra money. This is a crime on the sick,” wrote Amy in a Facebook post.

“Even for new patients, this doesn't make sense,” wrote Jennifer in another online post. “After surgery some patients need these medications for longer than 7 days. Driving to the doctor to get a new script, then to the pharmacy to get more medication is not conducive to healing.”

“How can they single out medications and refuse when the doctor writes them for 30 days?” wrote Hazel. “Everyone should boycott them, not only for prescriptions but shopping there for anything. This is getting ridiculous!”

Asked to comment on these and other concerns, CVS Health emailed a statement to PNN answering a series of questions we had about its new opioid policy. We were not allowed to interview anyone at CVS directly.

The questions and answers below were edited for clarity:

PNN: Many of your customers with chronic pain believe they'll have to go to a CVS pharmacy four times a month to get their refills. Can you clarify that for them? 

CVS: The seven day quantity limit on opioid prescriptions, going into effect on February 1, 2018 for CVS Caremark's pharmacy benefit management (PBM) clients, applies only to prescriptions written for acute conditions, such as a minor surgery or dental procedure, that generally last only for a short duration. 

We recognize that there are patients with a legitimate need for pain medication, and our approach is carefully designed to ensure that those patients can access their medication in an appropriate manner.  We are dedicated to ensuring our retail and PBM approaches do not negatively affect patients who are in need of their chronic pain medication.   

PNN: What happens when a patient recovering from surgery needs opioid medication for more than 7 days? Do they go back to their doctor and get a new prescription?

CVS: Our program encourages safe and appropriate utilization of opioids by managing utilization in a manner consistent with the Guideline set forward by the CDC.  Our efforts to ensure safe and appropriate opioid use are designed to improve the quality of care and health outcomes for patients.  If a prescriber feels patient care should exceed these limits, the prescriber can request an exception. 

PNN: What about limiting opioid prescriptions to 90mg morphine equivalent (MME) doses? Some pain patients are prescribed more than that.

CVS:  The CDC recommends that clinicians prescribe the lowest effective opioid dose and use caution when prescribing opioids at any dosage.  Further, the Guideline indicates physicians should carefully reassess evidence of individual benefits and risks when considering increasing dosage to ≥50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day. 

We are aligning our standard utilization to these limits for all patients who are not in active cancer treatment, palliative care, or hospice care.  However, if a prescriber feels patient care should exceed these limits, the prescriber can request an exception. 

PNN: You say you are following the CDC guideline, but the guideline is voluntary and only intended for primary care physicians treating chronic pain. You are making them mandatory for all doctors and all patients for all types of pain.

CVS: Given the toll opioid misuse has taken on our country, we believe it is appropriate to align our utilization management of opioids for our members with the Guideline set by the CDC.  Our efforts to ensure safe and appropriate opioid use are designed to improve the quality of care and health outcomes for patients.  Notably, if a prescriber feels patient care should exceed these limits, the prescriber can request an exception. 

PNN: Many patients complain that there's already a tendency by some pharmacists to refuse to fill opioid prescriptions to avoid hassles, extra work, etc. and to send them away without their medication. How will CVS make sure its pharmacists abide by your rules and not invent new ones?

CVS: Our opioid utilization management program will be consistently executed as a coverage determination across all pharmacies in our PBM retail network.  Pharmacists at CVS Pharmacy, or any of the other retail pharmacies in our network, will not be making independent medical judgments about the appropriateness of opioid prescribing or the length of such prescribing. Additionally, the program we have recently announced does not impact prescriptions filled for CVS Pharmacy retail customers who are not covered by the CVS Caremark PBM.   

Our pharmacists are committed to providing the highest level of care for their patients.  At our retail pharmacies, we are also strengthening counseling for patients filling an opioid prescription with a robust safe opioid use education program highlighting opioid safety and the dangers of addiction. 

'Cookie Cutter' Approach to Pain Care

CVS is not the first pharmacy to adopt rules that limit the dispensing of opioids, but it is the first major chain to set a 7-day limit on prescriptions for acute pain. Given recent trends, it is probably not the last.

Several states have already adopted laws that limit opioids to a few days' supply for acute pain. And yesterday a major pharmaceutical organization announced its support for a 7-day limit on new opioid prescriptions.  

Critics say this “cookie cutter” approach to pain care ignores the fact that when acute pain is poorly treated or untreated, it can turn into chronic pain in a matter of months or even weeks.

And chronic pain can worsen or cause other life-threatening health problems, including high blood pressure, stroke, heart attack, depression and suicide ideation.

Each patient is also different. A large new study published this week in JAMA Surgery looked at the different lengths of time patients needed opioid medication while recovering from 8 common surgical procedures.

While a 7-day supply of opioids was adequate for most patients recovering from an appendectomy, hysterectomy, hernia repair and other common surgeries, an analysis of over 215,000 surgery patients found that about 20 percent of them needed at least one refill of their prescription. Orthopedic and neurological procedures were the most likely to require a refill, and Medicare patients were the most likely group to need opioids for more than 7 days after a surgery.

“Although 7-day limits on initial opioid pain medication prescriptions are likely adequate in many settings, and indeed also sufficient for many common general surgery and gynecologic procedures, in the postoperative setting, particularly after many orthopedic and neurosurgical procedures, a 7-day limit may be inappropriately restrictive," wrote lead author Louis Nguyen, MD, of Brigham and Women’s Hospital, Harvard Medical School.

But not everyone finds fault in the cookie cutter approach. In an editorial also published in JAMA Surgery, a leading surgeon wrote that “any effort” to reduce the frequency of opioid prescriptions was a good thing.

“Unfortunately, we have reached a point that 100% elimination of pain has become not only the goal but the expectation. If a surgeon allows a patient to expect a pain-free recovery, he or she will see refill requests increase,” wrote Selwyn Rogers, MD, chief of surgery at the University of Chicago Medicine Trauma Center.

“Alternatives to narcotics should be recommended and incorporated as the foundation of pain management. It does not take much time to explain the use of acetaminophen and ibuprofen and then follow up with a stronger option if the pain is not adequately relieved. It is also useful to prepare the patient to expect some discomfort, realize that complete relief of all pain is impossible, and that the cost of trying is not worth it.”