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	James L. Holly, M.D.

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Your Life Your Health - CVS Plans to Change Prescriptions without Physician Approval - An Open Letter to CVS’ CEO

James L. Holly,M.D.

September 28, 2017

Your Life Your Health - The Examiner

September 23, 2017

Mr. Larry Merlo
CEO, CVS Care Mart

Dear Mr. Merlo:

I am traveling so this correspondence in regard to your plans is brief. Southeast Texas Medical Associates, LLP (SETMA} is a multi -specialty, private practice in Southeast Texas. The following link gives a brief introduction to SETMA. A Brief Summary of SETMA’s Achievements, Advances, Awards and Accreditations

The is my response to your announcement about CVS' plans in filling opioid prescriptions for only one week at a time. This correspondence has been sent to 500 health care leaders and educators. It will be published next week.

CVS Health Fighting National Opioid Abuse Epidemic With Enterprise Initiatives | CVS Health

On September 11, 2017, CVS announced a program which the company things will decrease the abuse of opioid medications. The following link describes their initiative:. https://cvshealth.com/newsroom/press-releases/cvs-health-fighting-national-opioid-abuse-epidemic-with-enterprise-initiatives

While CVS' goal is laudatory, their method is probably illegal. Each classification of health professionals is guided by and limited by state law as to what they can do in healthcare. CVS has already pushed that envelope by opening what they call “CVS Health” including employing Nurse Practitioners to staff medical clinics in CVS pharmacies. CVS did take the bold step in stopping the sale of cigarettes.

Many pharmacies already provide immunization to patients without a healthcare providers' order. Just last week, I saw a patient who had stopped a needed medication. When I inquired as to why, he told me his pharmacist had independently initiated a call to him and warned him about the medication. This frightened the patient and he stopped the medication.

It was only during my medication reconciliation during his visit that I discovered this. It turned out that the pharmacist was wrong about this patient's use of the medication and only confused the patient. The pharmacist did not counsel discussing this with the doctor only that the medication should be stopped. The medication was not an opioid.

Many health related professionals want to expand their authority in treating patients. Even chiropractors are lobbying to be able to prescribe pharmaceuticals. Pharmacists increasingly want to expand their roles in healthcare. Staff pharmacists in hospitals, nursing homes, clinics and other health care organizations are valuable members of the healthcare team. In consultation with physicians, nurse practitioners and physician assistants, pharmacists' expertise can increase the quality and safety of health care. Acting independently, as proposed by CVS and other pharmacy groups, they can do a great deal of harm.

CVS

According to the above-referenced CVS announcement, a pharmaceutical executive is now going to practice medicine. My understanding of the Texas Medical Practice Act judges this action by CVS to be illegal, and it can and will result in serious problems for patients and providers. The reality is this, if an opioid is prescribed appropriately and legitimately, it should be no more difficult to obtain than any other medication. If opioids are being prescribed inappropriately, the solution to the problem is not to create artificial barriers to make it difficult for patients to fill prescription as proposed by CVS. The solution is to stop the inappropriate prescribing of the medication.

SETMA has produced as extensive library of information about opioid use and abuse including the following:

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

ePrescribing of Controlled Substances Tutorial

Electronic Prescribing of Controlled Substances (e-PCS) and Auditing

The following link is to Part VIII in a series SETMA has published on the opioid crisis. This last article examines the solution to the problem which addresses the quality and safety of health care delivery in regard to the prescribing of opioids. SETMA’s solution is the first critical step in solving this problem and no part of the solution is focused upon making it more difficult to obtain needed medications. At the end of this article there are links to the other seven installments of this series.

The Opioid Epidemic: Part VIII - What is the Solution

SETMA

SETMA has been using electronic prescribing of regular medications for seven years and has been electronically prescribing controlled substances for three years. Each SETMA provider can and must audit their use of controlled substances at the point of care. And, SETMA has built tools which enable providers to eliminate the misdirection of medications and to document medication counseling.

SETMA providers’ medication reconciliation through our EMR is required at each visit and providers are required to check for opioid abuse through the Texas Pharmacy Database for each patient taking an opioid at least once a year

Opioids and Texas Law

I applaud CVS' desire to help with the opioid crisis but their decision will cause more problems than it solves and, I think, it is illegal for a pharmacists to change a prescription written by a healthcare provider without consulting with the physician. Physicians, Nurse Practitioners, Physician Assistants, Pharmacists and others have licenses which detail what each can and cannot do. Without a change in the Texas Medical Practice act, the CVS CEO cannot do what he proposes.

To Repeat

Finally, if any medication, including opioids, is prescribed legally and appropriately, one should be as easy to obtain as another. The way to deal with opioid abuse is not by making legitimately prescribed opioids more difficult to obtain, but by auditing the prescribing of potentially habituating medications and by eliminating inappropriate prescribing.

Additionally, I have worked with Hospice for twenty-five years. The use of opioids is a critical part of hospice care. To make it more difficult for hospices or hospice patients to obtain these medications is not an improvement in care.

CVS’ plan may be well motivated but the plan is addressing the problem of opioid abuse in an inappropriate way. Punishing those who need these medications by making it harder for them to be obtained is unethical and illegal. To make a patient, whose life is already complicated with pain and disability, go to the pharmacy every week to get a needed medication is cruel and unjustified.

Mr. Merlo, I hope you will reconsider this move so that we don't have to direct all of our patients to pharmacies other than CVS. And, I hope that you will consult with physicians and other healthcare providers who are addressing this problem before launching your program.

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 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 Response to Troy Brennan Letter and Health Affairs Blog Letter to 105 Pharmacies in our 5-county Area about CVS and Opioids My Initial Response to the Primary Care Week and the Center for Medical humanities and Ethics Transmittal Letter to Final Copy of Analysis of CVS Health’s Opioid Abuse Plan and Why it Should be Rejected

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