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	James L. Holly, M.D.

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Letters - CVS Health Dr. Lembke and Limiting Dispensing of Opioids to a Seven-Day Supply

October 8, 2017

Dr. Lembke:

After our last exchange, my son, who is SETMA’s Chief Information Officer and Co-Chief Operations Officer, called me. His close friend, who is a pharmacist, had received a copy of SETMA’s letter to 105 pharmacies about CVS Care Mark’s plans to limit opioid dispensing to only one week’s supply. (To review the letter see, Letter to 105 Pharmacies in our 5-county Area about CVS and Opioids.). The letter included a copy of my September 28, 2017 Letter to CVS Health’s CEO. (See: CVS Plans to Change Prescriptions without Physician Approval - An Open Letter to CVS’ CEO)

In addition to correcting my use of the name “Care Mart,” instead of the correct name of CVS’ Pharmacy Benefit Manager (PBM) Care Mark, his friend, who is not a CVS pharmacist, indicated that if a prescription were presented to him for one of SETMA’s HMO patients, whose pharmacy benefits are managed by CVS Care Mark, he would only be allowed to dispense a seven-day supply of the drug.

In conjunction with your last note, which expressed the value of only one week’s supply of drug being dispense, I realized that you and I are both right.

If a PBM mail-order prescription, which limits dispensing to a one-week supply of an opioid at a time, can assure an uninterrupted delivery of medicine, the benefits you noted would be achieved, I.e., preventing patients “borrowing” drugs from next week’s supply. The discipline would contribute to the decreasing of this method of abuse.
The problem will be that mail and other delivery methods are not dependable enough to make sure that the medication will predictably arrive every seven days. How many of us have paid significant additional fees to get next-day, or two-day delivery only to get delivery five or six days later? The additional anxiety and stress this will add to the life of people already living under great stress, will be accompanied with significant additional cost added to the obtaining of these medications. Who will pay that cost?
While CVS Health and their PBM, Care Mark, assures us that hospice and cancer patients will be excluded from their plan, how will CVS determine that the patient is on hospice or that they remain on hospice?
As my son’s pharmacist friend affirms, our worst nightmare is real. If the patient is not receiving their medications by mail, with the problems that creates as detailed above, CVS Health’s PBM plan will require the patient, the patient’s family, or the patient’s care giver to go to the pharmacy weekly. If that is a block away, it is problematical enough, but what if it is 25 miles away? Of course, CVS Health can provide an exemption, but who will administer that and how?

I do not believe that the pharmacies are not going to charge additional fees for these more frequent services. Who will pay?

We need to solve this problem. It is complex and requires effort by all of us. I think CVS Health’s plan is not going to help.

Excuses SETMA Will Not Accept

In your address you talked about the excuses which patients give for needing an early refill of pain medicine. Fifteen years ago, SETMA designed and deployed a “pain management” tool which detail for our patients the excuses we would not accept. See: Pain Management Tutorial. We still maintain that standard as indicated in this 2015 article: Prescribing Pain Medications: A Conundrum for Patient and Provider. Part of hue declares that SETMA will not accept, “I dropped my medicine into the sink, the sewer, the swimming pool or into other watery bodies.”

The following details some of our standards about opioid use - SETMA Tools for e-prescribing controlled substances, pain management policy and Urine Drug Screens.

Thank you for engaging in this discussion.

James (Larry) Holly, M.D.

C.E.O. SETMA
www.jameslhollymd.com

Adjunct Professor
Family & Community Medicine
UT Health San Antonio
Joe R. and Teresa Lozano Long School of Medicine

Clinical Associate Professor
Department of Internal Medicine
School of Medicine
Texas A&M Health Science Center

Related Articles

	CVS Health Controlling Dispensing of Opioids Through Caremark - Part I CVS Health Controlling Dispensing of Opioids Through Caremark - Part II CVS Plans to Change Prescriptions without Physician Approval - An Open Letter to CVS’ CEO The Opioid Epidemic: Part I The Problem The Opioid Epidemic: Part II Better Record Keeping The Opioid Epidemic: Part III - Electronic Prescribing of Control Substances The Opioid Epidemic: Part IV - Medication Reconciliation and the Electronic Medication History The Opioid Epidemic: Part V - The Real Surprise in Medication Reconciliation The Opioid Epidemic: Part VII - Public Health and Opioids The Opioid Epidemic: Part VI - Texas Medical Board and the Prescribing of Habituating Medications The Opioid Epidemic: Part VIII - What is the Solution
Related Tutorials

	Tutorial for Individual Provider Assessing Patients Screener and Opioid Assessment for Patients with Pain (SOAPP)
Related Letters

	CDC Checklist for Prescribing Opioids for Chronic Pain, Primary Care Providers Treating Adults 18+ CDC Guideline for Prescribing Opioids for Chronic Pain CVS Health and Opioids - Dr. Lembke’s Question About Pharmacists and Opioids and Dr. Holly’s Response CVS Health Response to Troy Brennan Letter and Health Affairs Blog CVS Health Summary of September and October, 2017 Ten-Part Conversation About Opioids Abuse Letter to 105 Pharmacies in our 5-county Area about CVS and Opioids October 7, 2017 Response to Dr. Lembke’s Helpful Analysis CVS Health and Opioids Summary of Analysis and Recommendations About CVS Health’s Use of Their Pharmacy Benefits Management to Limit Opioid Dispensing Transmission Cover Letter for Final Summary of Analysis of CVS Health CareMark Opioid Plan Transmittal Letter to Final Copy of Analysis of CVS Health’s Opioid Abuse Plan and Why it Should be Rejected

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