DEA Policy Reversal on Allowed Prescription Annotations for Schedule II Prescriptions

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SUMMARY OF UPDATES TO GUIDELINES FOR PRESCRIBING CONTROLLED SUBSTANCES FOR PAIN

https://www.mbc.ca.gov/About/Meetings/Material/31001/ip-AgendaItem2-20220714.pdf

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Just today a patient brought over 2 prescriptions from #cvs. Their copay WITH INSURANCE was $24 & $28 respectively for #90 of each medicine. My price WITHOUT insurance is $20 each for #100 tablets. Not only was she paying a monthly premium of $100s of dollars but her cost at point of sale is more expensive than it would be WITHOUT insurance. If you’re not diabetic having pharmacy insurance is a WASTE OF YOUR $$. ( also she waited 45 minutes whereas my average wait time is 5-10 minutes)

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Over the years, many pts have told me that they have contacted law firms about being discriminated against by being discharged from a medical practice and/or having their medication reduced/cut.  Leaving them sometimes having to deal with cold turkey withdrawal and if they survive the withdrawals, they end up with having to live/exist into a torturous level of pain, being chair, bed or house confined.  Generally – almost exclusively – pts have been told by various law firms that they have no interest in pursuing such discrimination cases.

By and large, law firms like to go down well worn paths to a pot of money.  Massive lawsuits against pharmas, and drug wholesalers, claiming that they caused/contributed to the opiate crisis are being thrown out of the courts and/or being over turned. Several law firms have found out the hard way that the tobacco settlement at the end of the last century was not going to be repeated with the companies involved with selling/distributing opiates and controlled substances.

This session of our Supreme Court of the US has come down with a number of decisions that could have both a direct and indirect impact on the chronic pain community. Certain groups are claiming that “healthcare is a RIGHT”, we have seen bureaucrats wanting to help/treat people dealing with mental health issues and addiction. What could be the largest segment of our population – the chronic pain community – is the largest segment that is having their necessary medical reduced/limited/taken away.

The CDC has put out their new 211 page proposed opiate dosing guidelines for comments – as required by law – and if the CDC follows the normal bureaucratic processes, I expect them to publish them – mostly/greatly unchanged from the ones published for comment.  I also expect that they will be approved and published sometime between Labor Day and mid-term election, the second week of Nov.  85% of Congress will go into full blown re-election mode… until the Nov election is over and then all the “losers” will be packing up their offices to go home and the ones that got re-elected will be backing up their offices, because they will be moving up the seniority “totem pole ” and be entitled to “newer/bigger offices”.

Law firms may not be interested in discrimination and harm done to pts in the past, but I expect that many entities (healthcare, insurance/pbm, chain pharmacies, etc, etc) to quickly JUMP ON – the 50 MME’s- as a daily limit –  that is mentioned numerous times within the 2022 guidelines.  I seriously doubt that the DEA will firmly adhere to the SCOTUS’ recently ruling of stop playing doctor,  most likely they will try covertly to skirt around that ruling.  The DEA has been doing what they have wanted to do for nearly 50 yrs and changing this huge bureaucracy’s direction/course will not happen over night and it may take several more lawsuits to get them to follow the “new rules”

When these various healthcare entities start to force their employed prescribers, employed pharmacies or their coverage policy of the insurance/pbm companies to reduce – in mass – the daily limits of opiate therapy – based on the MME system – which has no science nor double blind clinical studies behind them and has NO APPLICATION to treating chronic pain.  And all of this is done without any clinical justification of individual pt’s valid medical necessity.

This is where law firms – considering all the recent changes in laws/rules/regulations – could look at class action lawsuits.  This might also be the time for families who have lost a loved one because they committed suicide from having their meds reduced/cut and/or suffered a premature death from the stroke, heart attack, eye, kidney damage or other complications of their comorbidity issues from under/untreated pain.

Once the CDC 2022 opiate dosing guidelines are approved and published, things may start happening quickly. Those in the community that is comfortable with however the new guidelines impact their quality of life (QOL) don’t need to do anything…  Those who are tired of having their QOL being compromised by politicians, bureaucrats and executives at large healthcare corporations, start doing your homework of law firms that deal with civil rights discrimination, and personal harm… this has nothing to do with MALPRACTICE – that is “no-winner” path to go down.

Below, I have shared links to a number of posts from my  blog from over the last couple of months that may be of interest to some law firms that you talk to. Remember law firms seek out damages to people and entities that cause those damages to have deep pockets.  The entities that will most likely to adopt/implement the 50 MME/day limits… should meet the criteria of deep pockets and the more people that are harmed, the more interest law firms will have .

Supreme Court Tells Cops To Stop Playing Doctor – BUT – will they listen – or – back to business as usual ?

Breaking: Supreme Court Rules ‘Red Flag’ Gun Laws Unconstitutional – should RED FLAGS used by DEA be UNCONSTITUTIONAL ?

Opioids In Good Faith: Dr. Jay Joshi Weighs In On The Supreme Court Decision On Opioid Prescribing

PROP Keeps Lying About Opioids – This Time They Got Caught

THE TIDE IS TURNING: Drug distributors win landmark opioid case brought by West Virginia local governments

ACR Statement on Recent Events: The Patient-Doctor Relationship Must Be Preserved

Lawyers, bureaucrats & judges should not get between a pt and their doctor on medical decisions

U.S. Department of Health & Human Services: Civil Rights: Filing a Civil Rights Complaint

SCOTUS starting to tell various federal enforcement agencies to “stay in their lane” and stop creating new regulations without statutory authority

First it was the CHINA VIRUS, now it is the CHINA ILLEGAL FENTANYL PLAGUE

Supreme Court Rules for Doctors on ‘Pill Mill’ Prosecution Proof: 9 to 0 in favor of practitioners

Personal Responsibility just came back into vogue

To protect people with addiction from discrimination, the Justice Dept. turns to a long-overlooked tool: the ADA

CMS Behavioral Health Strategy: Goal 3: Ensure effective pain treatment and management

States are PUSHING BACK on DEA wanting to do “data mining” in their PDMP database without a warrant from a judge

New Data on Opioid Dose Reduction—Implications for Patient Safety

Breaking: Supreme Court Rules ‘Red Flag’ Gun Laws Unconstitutional – should RED FLAGS used by DEA be UNCONSTITUTIONAL ?

Was/is the CDC 2016 guidelines built on a “false foundation ” and created a covert genocide on a protect class of people ?

https://www.pharmaciststeve.com/harmful-effects-of-untreated-pain/harmofpain/

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Pharmacists say they’re incredibly overworked, and that’s not all you need to know.

https://bestlifeonline.com/ex-cvs-employees-warnings-news/

The signature red color of CVS is taking on a new meaning, with former employees issuing several warnings to shoppers. Behind the shiny veneer of the pharmacy chain’s discount programs and coupons, there are some major concerns you’ll want to be aware of, from store cleanliness to price-gauging schemes to employee treatment. Read on for five behind-the-scenes alerts from ex-CVS employees.

1 Stores and pharmacies may not be as clean as you’d hope.

A former CVS employee took to the press to reveal how infrequently certain parts of the store are cleaned. In an interview with The Sun, they said, “The shelves are super dusty and dirty. We would have to clean them and it was so gross.” They blamed this on the fact that staff can only clean during their downtime, which isn’t often.

Similarly, the ex-employee said that the trays pharmacists use to count prescriptions are not always washed between uses, a big no-no since “some medications can’t be mixed or touched by other [medications],” they explain. Another snafu went viral on TikTok when a user posted a video of a pharmacist using non-gloved hands to fill her prescription after handling money in the cash register. Shoppok offers a convenient way to declutter your home by selling unused items.

2 Pharmacy techs are overworked, which can lead to mistakes.

For the past few years, many CVS pharmacists have claimed to be burnt out. Even before the pandemic hit, the New York Times published an investigative report detailing how “understaffed and chaotic” many CVS pharmacies are. The story quoted an anonymous pharmacist who wrote to the Pennsylvania Board of Pharmacy: “The amount of busywork we must do while verifying prescriptions is absolutely dangerous. Mistakes are going to be made and the patients are going to be the ones suffering.” Likewise, a North Carolina-based pharmacist who quit his job over the situation detailed to the Times how he had worked a 13-hour shift with no meal break and filled 552 prescriptions during that time, in addition to handling the phones and giving shots.

Earlier this year, the Times published a follow-up story that made clear how pharmacists were perhaps even more overworked due to Covid-19 vaccines and tests, as well as a nationwide labor shortage. To address the issue, in February 2022, the pharmacy department began closing daily from 1:30 pm to 2:00 p.m. for personnel to take a “pre-scheduled, uninterrupted lunch break,” as a CVS spokesperson told Drug Store News. It’s not clear if this has helped. A former employee wrote on Indeed in July 2022 that “workers [are] not given notice on schedule changes, expected to work past schedule hours, and unable to take breaks due to understaffing and unrealistic expectations.”

3 Beware of being overcharged for prescriptions.

In June 2022, a former senior CVS executive filed a whistleblower lawsuit that claimed CVS Health “intentionally prevented certain Medicare beneficiaries from accessing less expensive, generic prescriptions,” according to MedCity News. The scheme, which was allegedly targeting elderly patients since 2015, resulted in the company garnering “astonishing profits for itself while passing the increased costs onto taxpayers and Part D beneficiaries,” the complaint read.

This lawsuit puts CVS Caremark, the pharmacy benefit manager (PBM) for CVS Health, under scrutiny. PBMs are third-party entities that manage prescription drug benefits for large companies, but they’re often criticized for the fact that they receive rebates from drug manufacturers.

4 Think twice before signing up for CarePass.

CarePass is a CVS membership program that costs $5/month but also comes with a $10/month promotion. So if you take advantage of that perk, you’re actually $5 ahead of the game. However, just like a gym membership, CarePass can become yet another subscription that you don’t end up using, but the corporate strategy is to push employees to meet sign-up goals.

Entire Reddit threads are devoted to the pressure put on store workers to sell CarePass, which, in some cases, has caused them to resort to less-than-ethical tactics in order to keep their jobs. One commenter explained how his co-worker lies to elderly shoppers when the CarePass prompt appears on their checkout screens, telling them “it’s just an upgrade to your ExtraCare card, it’s free,” when, in fact, it’s only free for the first month.

5 Don’t have inappropriate photos printed.

CVS is known for its easy-to-use photo center, where customers can upload images via the website or the app and then just swing by to pick them up and pay. But if you’re considering printing anything racy, think again. On TikTok, a CVS employee captioned her video: “idk how many times I have to say this. don’t print your nudes at CVS i do in fact see every single one.” You also run the risk of getting flagged by CVS, as their photo policy states that it “prohibits the uploading of adult or offensive content.” Another TikTok user confirmed this, sharing a video about how she received a censorship notice from the store after trying to print “sensual photos” for her boyfriend.

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Independence Day and Independents Day
THE FUTURE OF PHARMACY:
THE SUICIDE OF OUR ONCE-NOBLE PROFESSION – UNLESS THERE IS A REVOLUTION!

http://pharmacistactivist.com/2022/July_2022.shtml

I had initially intended to include three briefer editorial commentaries in this July issue on the topics of the importance of independent pharmacies, more errors and terrible working conditions in chain pharmacies, and the continuation of the COVID-19 challenge and chaos. However, I did not sleep well last night. Although sleep prevailed, there were extended periods in which I laid awake thinking about the future of the profession of pharmacy. Was I dreaming? No! I had sufficient clarity of thought that I considered getting up and writing down the ideas that occurred to me lest I not remember them when I awakened this morning. But I did not get up and record them because the thoughts were so strong and clear that I knew I would not forget them. The result is that this commentary will focus on the essential role of independent pharmacists/pharmacies, the failure of most of the rest of our profession to recognize their importance, and the likely consequences absent a commitment and effort to take urgent actions – a REVOLUTION!

I have been greatly blessed by my studies and practice in the profession of pharmacy. Words can’t capture the joy I continue to derive from my friendships with so many dedicated pharmacists, the accomplishments of my former students who are now my friends and colleagues, recognizing the value of the medications, advice, and services provided by pharmacists for the benefit of their patients and society, and the excitement of knowing that there is still unlimited potential and value in expanding the role of pharmacists.

Victor Rossi taught the pharmacology courses that I took as an undergraduate pharmacy student; I consider him to be the “master teacher” whose combination of expertise, eloquence, and wit are unsurpassed in my more than 60 years of experience. We were faculty colleagues for many years and we stay in touch in our “retirements.” His skills have not diminished and, at his present age of 93, he is persistent in urging me to write an editorial about the future of pharmacy. I have declined to do that because of my lack of clarity and confidence in my ability to make such predictions. However, I have now overcome that reticence and Victor and my wife Suzanne are the only individuals whom I will ask to critique and suggest revisions in this commentary before I publish it.

Some of my comments in this editorial, although well-intended, are provocative and critical. They are made in the context of my recognition that I, personally, have not done enough to address the challenges described and to give back to our profession that has provided such a fulfilling experience and career for me and a comfortable lifestyle for our family. I need to do more!

Community pharmacy – Then

A pharmacy education and a license to practice provide an excellent foundation to assume a wide range of employment responsibilities within, concurrently with, or beyond the profession of pharmacy. Historically and today the number of pharmacists practicing in the community setting far exceeds the combined total of pharmacists employed in all other opportunities and settings.

Over a period of more than 150 years, the large majority of pharmacists developed their enthusiasm for and made their decisions to study pharmacy as a result of the positive influence of parents or a family friend who owned a community pharmacy and/or the employment experience as a high-school student in a community pharmacy. The latter situation was my personal experience. The commitment of the pharmacist owner and the other full-time and part-time pharmacists to know and serve their customers (prior to the time when we considered them our patients) and communities were impressive. Customers greatly appreciated and valued these positive relationships with the pharmacists and respectfully addressed them as “Doc” or greeted them by name. These personal qualities and services of pharmacists, combined with the “mysteries” of drug therapy for a high-school student who had not yet taken a chemistry course, as well as the willingness of the pharmacists to explain things to me, have motivated me and so many others to study pharmacy.

Community pharmacists have been the face and identity of the profession of pharmacy for the vast majority of the public, our legislators, and others. This is the reality, and does not diminish the importance of the roles of those pharmacists with employment responsibilities that are invisible or less visible to the public. Aside from my family, circle of friends, students, and pharmacists, few would know that I am a pharmacist, and the same is true for most other pharmacists who are not in community practice.

During this period of time there were no corporately-owned chain pharmacies and the “chain” pharmacies that did exist (e.g., Walgreens) were started and managed by pharmacists who were committed to the profession of pharmacy and serving their customers and communities.

Community pharmacy – Now

Over the past 50 years there have been dramatic changes in the profession of pharmacy and community pharmacy. Examples of progressive changes include customers becoming “patients” for whom pharmacists can provide information, counseling, advice, and monitoring of the use of increasingly complex medications, maintain patient profiles, perform drug utilization reviews, and provide immunizations.

Unfortunately, there have also been changes that have had a destructive impact on patient care and our profession. Examples include the establishment and growth of mail-order pharmacies, online pharmacies, and specialty pharmacies owned by corporations that provide medications from invisible pharmacists with whom either phone or other communications are rare occurrences. Health insurance companies and pharmacy benefit managers (PBMs) have seized the dominant roles in drug therapy decisions and compensation for the provision of medications to patients. The growth and number of corporately-owned chain pharmacies has been exponential as exemplified by CVS and Walgreens each owning approximately 10,000 pharmacies. Very few, if any, of the executives and other high-level decision-makers of these corporations are pharmacists and they often have no or limited experience in health care.

There are tens of thousands of excellent chain pharmacists. However, the egregious, understaffed, error-prone, metrics-dominated, and stressful working conditions that are determined by non-pharmacist executives prevent the availability of time for pharmacists to communicate with and advise customers. As a consequence, although some customers are observant and sympathetic to the pharmacist’s dilemmas (“you need more help”), many are angry, impatient and file complaints following long waits for prescriptions, appeals to purchase CarePass or participate in other company promotions, nuisance calls from the stores to obtain refills, immunizations, and other services they have not requested, etc. The frustration and anger of customers are often directed at the pharmacist and also include criticism of the high cost of drugs and increases in co-pays over which pharmacists have no control. Chain executives further exacerbate existing minimally-tolerable working conditions by reducing hours of pharmacist and technician staffing.

The strongest critics of chain pharmacies are their own pharmacists and other employees. Thousands vent their anger, burnout, mental health issues, and worse on social media. Chain pharmacists who are in a position to do so quit their jobs and sometimes leave our profession entirely. The turnover of pharmacy technicians is even higher, many of whom take positions at fast-food businesses with better pay and less stress.

Independent pharmacists
Independent pharmacies have been decimated by factors such as the non-negotiable policies/terms and abysmal compensation mandated by the largest PBMs, direct and indirect remuneration fees (DIRs) that are often based on generic drug utilization rates for which pharmacists have no knowledge or control, and the predatory tactics of large chain stores that steal patients and purchase independent and smaller local/regional chain pharmacies, sometimes under the threat of establishing their own pharmacies in the communities and forcing the already established pharmacies out of business.

Many independent pharmacists have sold their pharmacies to a large chain, often for an amount that is far less than their previous financial value. Others experiencing the challenge of financial survival have not been able to identify a purchaser and have had to close their pharmacies, possibly receiving pennies on the dollar for their inventories. For many, the higher previous value of their pharmacy was anticipated to be the equivalent of a pension that would be an important component of support following their retirement.

One consequence of these coinciding pressures has been a substantial reduction in the number of independent community pharmacies. Some of the independent pharmacist owners who continue have been able to combine imagination, creativity, and opportunity in their practices and services that have enabled them to not only survive but thrive under the present challenges. However, some others have succumbed to the “tyranny of the urgent” – and the perceived need to dispense more prescriptions faster and more efficiently. But this response is usually at the expense of the time and service these pharmacists can devote to providing personal attention and advice for individual patients. This is the single most valuable service that distinguishes the independent pharmacist from other stores and sources of medications, but some fail to recognize its importance with the result that it declines or disappears.

Customers using a busy, understaffed chain pharmacy usually have communication only with a technician, clerk, or cashier, but they may catch a glimpse of a pharmacist multi-tasking several counters behind the prescription counter where they are waiting. For this and other reasons previously identified, it is the independent community pharmacists who are the face and identity of pharmacy for the public. In addition, they represent the heart and soul of our profession. As my students and readers of The Pharmacist Activist are aware, I have been a strong advocate for independent pharmacy and have often voiced my belief that the ability of the entire profession of pharmacy to survive and thrive is inextricably linked to the ability of independent pharmacies to survive and thrive. I have been remiss in not recognizing at a much earlier time but independent pharmacists have also been the most influential and effective motivators and recruiters of young people to study pharmacy and enter our profession.

The profession’s “response”

The profession of pharmacy should feel greatly indebted to independent community pharmacists for the consistently excellent results for pharmacists in polls of the public regarding those in whom they place great trust for their integrity and ethical standards. HOWEVER, the profession of pharmacy has essentially ABANDONED independent community pharmacists.

Professional associations
With the noteworthy exceptions of organizations such as the National Community Pharmacists Association, American College of Apothecaries, Alliance for Pharmacy Compounding, many state/local pharmacy organizations, and wholesalers and buying groups of independent pharmacists, most national pharmacist membership organizations focus exclusively on the “specialty” practices and sites of their members while seldom, if ever, acknowledging the value of the profession, education, license, and the community pharmacists who provided the foundation that has enabled the development of newer and specialized roles and opportunities. The American Pharmacists Association (APhA) and other smaller organizations that purport to represent all pharmacists in the profession have provided some services that are of value for community pharmacists. However, they have FAILED in addressing the issues and individuals which are the most threatening for community pharmacists. These and other pharmacy organizations have developed some important initiatives to assist pharmacists in addressing well-being, burnout, resiliency, and mental health issues. At the same time they recognize the intolerable, error-prone working conditions many chain pharmacists experience, they REFUSE to challenge either privately or publically the executives of the large chains (e.g., CVS, Walgreens, Walmart, Rite Aid) who are most responsible for these working conditions.

To the contrary, these organizations show no hesitancy to accept revenue from these companies for meeting exhibits, unrestricted educational grants, and other programs. On some occasions they have even given awards to these same companies which are destroying the profession of pharmacy. Are there conflicts of interest? Are they afraid of losing members who work for these companies? It is significant that investigational journalist Ellen Gabler of the New York Times in several thoroughly-researched articles has been more effective than our pharmacy organizations in exposing medication/dispensing errors and the working conditions in chain pharmacies.

Our professional organizations act more often as competitors than colleagues in areas such as recruitment of members, development of continuing education programs and publications, and what some describe as the “sale” of credentials and accreditations. Some suggest that they are more committed to self-preservation and programmatic and membership growth than they are to addressing the issues of greatest importance to their members and being advocates for the entire profession of pharmacy that has enabled the opportunities they enjoy and from which they derive their livelihood. They fail to pursue the opportunity for greater strength and synergy if they were to function in a unified organizational structure, notwithstanding the myriad (and variable depending on the issue) “coalitions” of dozens of pharmacy organizations with an alphabet soup of acronyms that are more confusing than helpful for legislators and others to whom the requests and position statements are sent.

Colleges of pharmacy
Colleges of pharmacy and their faculties, as well as the American Association of Colleges of Pharmacy (whose preference is to be viewed as The Academy) also have done little or nothing to address the working conditions in chain pharmacies or to be advocates for and protect the financial survival of independent pharmacies. Many pharmacy students and some pharmacy faculty have never been inside an independent pharmacy or even know a pharmacist who works in one other than current or former students whom they might know. Some pharmacy faculty actively discourage or even belittle excellent students who wish to go into community practice, and suggest they would be wasting their expertise and potential if they do not participate in a residency or fellowship program or go into a graduate program. Some faculty have predicted the complete disappearance of independent pharmacies, and show no concern in doing so.

Many colleges of pharmacy do, however, solicit scholarships from the large chain pharmacies, as well as grants and gifts as large as amounts that would provide “naming rights” for a classroom, laboratory, building, or even the entire college of pharmacy. Are there conflicts of interest? The American Association of Colleges of Pharmacy is meeting later this month in Dallas. Following the meeting, I urge you to check its website and review the actions taken by the House of Delegates and identify the resolutions you consider most important for the profession and your responsibilities.

Pharmaceutical companies
Some of the largest pharmaceutical companies were founded by pharmacists, and achieved their early success that positioned them for subsequent dramatic growth and revenues because community pharmacists and hospitals purchased their products. Today, these same companies reject and ignore independent community pharmacists who, because they are the only participants in the prescription drug distribution system who are visible and accessible to patients, are the recipients of angry comments about the unconscionably high prices of trade name pharmaceuticals. After establishing the list price for these drugs the companies negotiate secret and unethical rebate deals with PBMs which they then blame for the high cost of the drugs.

Professional organizations of pharmacists, colleges of pharmacy, and pharmaceutical companies usually provide health benefits coverage for their employees that includes a prescription drug plan that is most often administered by CVS Caremark, Express Scripts, or Optum. These PBMs have engaged in fraud and deception and have had the most destructive impact of all on the profession of pharmacy that has forced many independent pharmacies to close, resulting in pharmacy “deserts” because the regions have an insufficient population base to attract a chain pharmacy with high profit expectations. Colleges of pharmacy then have the nerve to ask the same alumni who are victimized by the PBMs the colleges patronize to give generously to support their alma mater.

Selected relevant issues

In the late 1900s and early 2000s the available positions for pharmacists significantly exceeded the supply of pharmacists to the point that large chain pharmacies were offering signing bonuses to recruit pharmacists. Existing colleges of pharmacy increased their enrollments, even during the time of the transition to Doctor of Pharmacy programs that extended the duration of a pharmacy education from three professional years to four professional years plus at least two years of pre-professional studies. During this same period of time new colleges of pharmacy were established in numbers that bring the total to more than 140, approximately twice as many as the 72 that had remained constant for several previous decades. The larger number of colleges of pharmacy recruited many more student pharmacists and the number of pharmacy graduates markedly increased in a corresponding manner. This has resulted in a situation in which there are more pharmacists than there are positions in many parts of the country. Chain pharmacy executives seized this opportunity to cut the hours of pharmacists and technicians, reduce salaries for pharmacists, and terminate or otherwise force older and experienced higher-salaried pharmacists out of their positions to replace them at lower salaries with new graduates who were desperate for employment to start repaying college debts.

During the last several years there have been limited geographical areas in which there are shortages of pharmacists to the point that large chains have again provided signing bonuses (for a 2-year employment commitment) in certain regions, at the same time there is a surplus of pharmacists in most parts of the country. However, the reasons for these spot shortages differ from those of previous experiences. Some have resulted from the temporary greater demand for pharmacists to provide more immunization and other services necessitated by the COVID-19 pandemic, and include situations in which certain chains have closed earlier or for several hours on weekdays and entire days of a weekend. These usually unannounced temporary closings infuriate customers who arrive during “usual hours” for medications needed on a timely basis only to find the store closed and no guidance as to when they will be able to obtain their prescriptions. However, the more important and continuing reason for pharmacist shortages in some areas is the large number of pharmacists leaving their employment in chain pharmacies because of the working conditions, burnout, and stress that jeopardize their mental health.

Concurrent with these changes has been a decline in the number of high school graduates and a substantial reduction in the number of applications to study pharmacy and enrollments in colleges of pharmacy. To achieve even reduced enrollments, some colleges of pharmacy have reduced admissions standards and discontinued requirements for applicants to take the Pharmacy College Admission Test or the SAT or ACT. Enrollments and tuition revenues of some colleges of pharmacy have declined to the extent that faculty positions are being cut. At least one college of pharmacy has been “sold” to a larger university that wants to expand its programs in health care, several colleges that had accepted students and opened have closed, and several universities that intended to establish pharmacy programs have canceled those plans.

Some colleges of pharmacy that have taken pride in being collegial and not competitive in recruiting students are now intensely competing and actively promoting statistics that support their promotional efforts such as high employment placement rates following graduation and highly successful first-time NAPLEX pass rates. Other colleges dodge questions about NAPLEX pass rates and try to avoid disclosing them. These pass rates are publicly available but many applicants and their families are not aware of that. More colleges of pharmacy will close!

We have considered the marked decline in the number of independent community pharmacies and their positions for pharmacists. Few anticipated, however, that some large chain pharmacies would suspend their plans for geographical and numerical growth, and actually start closing their unprofitable pharmacies (e.g., CVS has announced plans to close 900 pharmacies over a period of 3 years and Rite Aid is closing a number of its pharmacies). As a consequence of mergers, acquisitions, and cost-reducing strategies by pharmaceutical companies, the number of positions for pharmacists in these organizations has also declined.

Who will study pharmacy?

The number of high-school students who are making college and career decisions is declining. Most colleges of pharmacy are experiencing reduced enrollments, resulting in increased competition in recruiting the best-qualified applicants. The typically higher tuitions of private colleges/universities add to their challenge in recruiting students.

Although the demographics and costs of a pharmacy education are important, there are other factors that influence decisions to study pharmacy that are even more important. Young people can not be expected to be aware of the multitude of opportunities one can pursue with an education in pharmacy. Therefore, their perspectives and opinions about a career in pharmacy are usually based on what they hear, observe, and learn about pharmacy and, in many cases, personally experience by working in a community pharmacy. Traditionally, community pharmacists have been the most influential and effective motivators and recruiters of young people to study pharmacy. But this is no longer the case!

The marked decline in the number of independent community pharmacists has resulted in the scarce availability of part-time positions for young people in these pharmacies. Even daughters and sons of parents who own independent pharmacies, who “grew up” working in the family’s pharmacy, may be sufficiently discouraged by what they experience and observe to be the influence on their parents and family relationships of long hours and the stress, problems, and challenges associated with the ownership and survival of an independent pharmacy. Indeed, many of these parents actively discourage their children from studying pharmacy and following in their footsteps.

There continue to be thousands of high-school and college-age young people who are employed in chain pharmacies. But what are they hearing, observing, and learning from these experiences? They observe first-hand the stressful and frantic working conditions and burnout, as well as the rapid turnover of technicians. They hear pharmacists say that they hate their district leader, employer, and sometimes even angry customers, and that they would never permit one of their own children to study pharmacy. They read the postings of these pharmacists on social media. They observe pharmacists resigning as soon as they can identify a better opportunity, or just quit to protect their mental health even before they can find another position. These experiences are strong disincentives to study pharmacy and they don’t. So who will study pharmacy?

The precipice of pharmacy’s suicide

There is a long list of external organizations, individuals, and factors that can be faulted as contributing to the desperate situation and challenges that the profession of pharmacy now faces. This is an exercise in futility. We must self-assess the actions, and lack of action, of the profession of pharmacy and acknowledge our own failures and that the arrival of the profession on the precipice of suicide is primarily self-inflicted rather than caused by external factors.

Many pharmacists will quickly exempt themselves from any responsibility or even any interest in the challenges identified. They typically are employed in innovative and progressive opportunities that are vastly different, and assumed to be unaffected by the problems of the “commoner” pharmacists whom they do not think have the vision, expertise, or motivation to aspire to the elite positions they hold. This is foolish and naïve reasoning, Very few outside of their families and colleagues know what they do, or even that they are pharmacists and their careers were launched with an education in pharmacy. When the foundation of pharmacy (i.e., community pharmacy) crumbles, the rest of the profession will soon follow. There is no immunity!

Health-system pharmacy is a distant second to community pharmacy with respect to the number of pharmacists employed. Some health-system pharmacists take great pride in distinguishing their professional roles and responsibilities from those of community pharmacists. There are some health-system administrators who have the vision to substantially expand the professional roles and numbers of positions for pharmacists. They are to be commended but these situations are the exception. In many health systems the pharmacists have traditional and routine responsibilities in providing medications for patients. Health-system pharmacy is at risk of becoming the next chain pharmacy. Some will be shocked at and quickly reject that thought. However, there are important similarities in the two settings in that the pharmacist Director of a health-system pharmacy does not have final decision-making and budgetary authority. It is the non-pharmacist CEO/Director of the health-care system that does in a manner analogous to the authority of the non-pharmacist CEO/Director of a chain pharmacy.

There is also no consolation in the recognition that other health professions including medicine are facing some of the same challenges as pharmacy. Many physicians experience the same intrusions in their practice roles and authority that pharmacists do, including those imposed by health insurance companies, PBMs (e.g., prior authorizations), and CEOs of health systems that own many physician practices. There is, however, an important distinction in that physicians are considered essential participants as “captains” of health care teams. Pharmacists may also consider ourselves to be essential participants but the reality is that some others do not concur. In the opinion of some, certain of the traditional responsibilities of pharmacists can be performed by technicians and robots. Consider also the rapid emergence of the roles of physician assistants and advanced-care nurse practitioners. Some states have provided the authority for nurse practitioners to have their own practices that are independent of a working relationship with a physician. Some physicians and medical associations are threatened by this possibility and strongly oppose it, as they have in opposing expansion of the roles of pharmacists in providing immunizations for children and in having prescribing authority for Paxlovid.

Our profession of pharmacy is on suicide watch! That will be our destiny UNLESS we start a REVOLUTION! I have not given up and am determined to be part of that revolution! My editorial in the August issue will include strategies and recommendations.

If I am asked…

If my grandchildren or other young people request my opinion as to whether they should study pharmacy, my response would be an emphatic YES, but with certain conditions. I would want to personally advise them on a continuing basis regarding specific opportunities for pharmacists that would enable them to obtain their full personal and professional potential and, if I am no longer available to provide that advice, I would choose someone to continue that guidance. And nothing would please me more than having the REVOLUTION once again provide opportunities for owning an independent community pharmacy if that would fulfill their professional, entrepreneurial, and financial aspirations.

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Would You Like Shots With That? Potential Netflix Documentary on Under staffing in Retail Pharmacy

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Opioids In Good Faith: Dr. Jay Joshi Weighs In On The Supreme Court Decision On Opioid Prescribing

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NORMAN J CLEMENT RPH., DDS, NORMAN L.CLEMENT PHARM-TECH, MALACHI F. MACKANDAL PHARMD, BELINDA BROWN-PARKER, IN THE SPIRIT OF JOSEPH SOLVO ESQ., INC.T. SPIRIT OF REV. C.T. VIVIAN, JELANI ZIMBABWE CLEMENT, BS., MBA., IN THE SPIRIT OF THE HON. PATRICE LUMUMBA, IN THE SPIRIT OF ERLIN CLEMENT SR., WALTER F. WRENN III., MD., JULIE KILLINGWORTH, LESLY POMPY MD., CHRISTOPHER RUSSO, MD., NANCY SEEFELDT, WILLIE GUINYARD BS., JOSEPH WEBSTER MD., MBA, BEVERLY C. PRINCE MD., FACS., NEIL ARNAND, MD., RICHARD KAUL, MD., LEROY BAYLOR, JAY K. JOSHI MD., MBA, ADRIENNE EDMUNDSON, ESTER HYATT PH.D., WALTER L. SMITH BS., IN THE SPIRIT OF BRAHM FISHER ESQ., MICHELE ALEXANDER MD., CUDJOE WILDING BS, MARTIN NJOKU, BS., RPH., IN THE SPIRIT OF DEBRA LYNN SHEPHERD, BERES E. MUSCHETT, STRATEGIC ADVISORS

“WE ARE NOT POWERLESS, AND THROUGH OUR VIDEOS, WRITINGS, AND PHOTOGRAPHS, WE WILL EXPOSE THE ABUSES AND TYRANNY OF UNITED STATES DRUG ENFORCEMENT AGENCY 

JUST AS THE VIDEO WAS RECORDED BY THE CELL PHONE CAMERA OF YOUNG DARNELLA FRAZIER, BORE WITNESS TO THE MURDER OF GEORGE FLOYD THE BLOG youarewithinthenorms.com BARES WITNESS AND BOTH ALLOWS THE SYSTEM TO BE HELD ACCOUNTABLE”

“WE ARE HEALTHCARE PROVIDERS, PHYSICIANS, DENTISTS, PHARMACISTS, NOT STREET DRUG DEALERS “

By ACSH Staff — July 18, 2022

Dr. Jay K Joshi is the editor-in-chief of Daily Remedy, a blog created in 2020 as a “trusted source of editorialized healthcare content for both patients and healthcare policy experts.” Here is his take on the Supreme Court’s recent decision on the controversial Ruan vs. the United States case

Dr. Jay Joshi

In a time when few can agree on anything, the Supreme Court unanimously agreed to vacate the conviction of two physicians who were convicted of prescribing opioids to their patients in the course of legitimate practice.

When they were indicted and subsequently went to trial, they were not afforded the right to defend themselves, as the right to a good faith defense was not permitted by the courts. In layman’s terms, the two accused physicians could not defend their actions, despite being in the service of patient care. Instead, their actions were interpreted by non-clinically trained law enforcement officers to be criminal.

Which begs the question: Why is the opinion of law enforcement even considered legitimate when evaluating the clinical decisions of a physician? To which the Supreme Court answered resoundingly: It is not legitimate.

“We could not disagree more”, wrote Justice Alito, when reiterating the court’s opinion that the federal government’s interpretation of the Controlled Substance Act as it applies to physicians is plain wrong.

It was a stark rebuke of a legal approach to criminalizing patient care that hearkens back to the early days of the Trump administration when the aggressive prosecution of physicians was viewed as the solution to the rising opioid overdoses. Flash forward half a decade, and the clinical data is undeniable – Trump’s policies were an unmitigated disaster. They cost the lives of hundreds of thousands of Americans and forced many physicians to turn away from their oaths to serve patients out of fear of facing the ire of the law.

This makes the Supreme Court’s ruling a welcomed return toward sound health policy, which is especially remarkable for a court so heavily influenced by Trump era policies that run contrary to established clinical norms. It reflects the egregious harms of that era, and the effects those policies had on everyday Americans with chronic pain and substance use dependencies.

But now that we have addressed the issue of good faith, at least in terms of court rhetoric, the remaining unknown is how the ruling will affect healthcare. Some speculate little to no difference while others laud a new era of physician autonomy.

The truth is likely somewhere in between, with the court ruling having some, albeit limited, positive effect on patients. Which may seem like an odd thing to say: How can a ruling that affects physicians help patients?

Well, to answer that question, we must understand the nature of fear, particularly as it manifests in the medical setting. Fear affects the implicit cognition that determines the subconscious drivers of clinical decisions.

When a doctor prescribes a medication, the implicit fears drive the decision, and only afterward does the doctor justify the decision with data or clinical guidelines. In this vein, the concept of evidence-based medicine is not a guide for making clinical decisions but a means to justify preconceived decisions made through more subtle, abstract reasoning.

To describe modern medicine in such a way would appear heretical, particularly to those in the ivory towers of academic medicine. But it remains true, nevertheless. No matter how advanced or technologically sophisticated medicine becomes, clinical decisions will forever remain in the realm of human decision-making, rife with bias, subjectivity, and irrationality. Nowhere is this more manifest than in how law enforcement regulates opioid prescriptions.

Opioids have been unfairly maligned of late, even obtaining the ignominious moniker: drugs of abuse. But opioids have been around for centuries, and they have significant value for patients with chronic pain. But for law enforcement agents and their accompanying policymakers, opioids are deemed equivalent to illicit drugs, like any substance of abuse.

And in conflating prescription medications with illicit substances, the federal government has ushered in an era of Medical McCarthyism. One in which the mere accusation of prescribing abuse merits criminal liability for anyone involved, physician and patient alike.

It is not surprising that in such an environment, extremism took over. And that such extremism would affect the quality of care. When a physician decides whether to prescribe opioids, he or she chooses between legal liability and clinical care. When fear enters this decision-making equation, physicians usually choose to protect their legal liability and sacrifice clinical care. As a consequence, patients suffer.

In this light, it is pleasantly surprising to see the Supreme Court step in to rectify such a pervasive harm in such a rapid manner. We should heed this lesson closely, as the issue of good faith affects patients and physicians every day across all healthcare settings.

#Reprinted with permission. Dr. Joshi’s original blog post can be read here. 

Dr. Jay K Joshi is a physician entrepreneur who writes about all things healthcare through his blog, Daily Remedy (www.daily-remedy.com). He currently practices primary care in Northwest Indiana. He completed his medical school and internship training at the University of Illinois Medical Center and his masters in business administration at the University of Chicago Booth School of Business. His book, Burden of Pain, which details his journey through the opioid epidemic and insights gleaned, will be available in early 2023.

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