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Retail-induced panic attack?!!

https://www.reddit.com/r/pharmacy/comments/alyudx/retailinduced_panic_attack/

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Combating the opioid crisis one doctor at a time

https://www.washingtonpost.com/national/health-science/combating-the-opioid-crisis-one-doctor-at-a-time/2019/02/01/9d11c1a0-1a71-11e9-8813-cb9dec761e73_story.html

GLENSIDE, Pa. — Sandeep “Sonny” Bains pulled up to Lyons Family Medicine in the pre-dawn dark armed with coffee, doughnuts and glossy brochures about pain treatments.

“What can I help you with for acute pain?” he inquired of ­father-and-son primary-care doctors Michael and Zachary Lyons as he was ushered into a wood-paneled back office.

Bains’s quick drop-ins are modeled on those used by pharmaceutical sales reps to pump up sales. The similarity ends there, though: Bains, a pharmacist, is part of a fledgling movement co-opting the drug industry’s tactics to deliver a different message to doctors — that narcotics are not only addictive but also often no better at managing pain than safer, over-the-counter medicines.

“I’m cold-calling them, picking up the phone: ‘I’m Sonny . . . a pharmacist providing free education,’” Bains said. “It does sound like a drug rep’s pitch.”

The opioid crisis and a series of high-profile lawsuits against drugmakers, including Purdue Pharma and Insys, have put a national spotlight on aggressive pharmaceutical marketing campaigns to persuade doctors to prescribe their drugs, sometimes with scant attention to safety issues — a $20 billion-a-year effort for all drugs sold in the United States, according to a recent study. It has also given new energy to a countermovement that borrows the style, if not the substance, of that outreach.

Late last year, Aetna invested nearly $7 million in the counterprogramming strategy, partnering with a nonprofit, Alosa Health, to bring its pain treatment education to doctors in Pennsylvania, Maine, Illinois, Ohio and West Virginia — states hit hard by opioid overdose deaths. The health system Kaiser Permanente and the Department of Veterans Affairs also use the approach.

Bains is one of about 30 trained academic detailers, as they call themselves, who will be knocking on doctors’ doors for the next year, deploying their knowledge about drugs and their people skills to provide the best evidence about how to treat pain. Aetna will measure how well the intervention works and could expand it to other states — or to other health problems, such as overuse of antibiotics.

“What’s fascinating about this program is that . . . the cause of the opioid epidemic was inappropriate and aggressive marketing of opioids by these sales reps,” said Daniel Knecht, vice president of clinical strategy and policy at Aetna.

Holly Campbell, a spokeswoman for PhRMA, a lobby for the drug industry, said that ethical relationships between drugmakers and health care professionals were beneficial for patients and aided in the development of new medicines.

“An important part of achieving this mission is ensuring that health care professionals have the latest, most accurate information available regarding medicines,” Campbell said.

Policymakers often favor top-down approaches to change how doctors practice: Some states, for instance, set limits on pain prescriptions, or send doctors report cards on their prescribing habits in hopes of quelling a crisis that now kills more Americans each year than AIDS at the height of the HIV epidemic.

Bains’s approach, in contrast, adopts the very method of building relationships with doctors that helped seed the opioid crisis.

“The message is not: ‘Don’t use opioids,’ ” Bains said, after quizzing Michael Lyons on when he would consider using narcotics to treat pain. “It’s . . . be cautious. Use immediate-release and not necessarily long-acting drugs. Short course of treatment.”

He sees himself as peddling evidence, often championing treatments that may be too old or too unconventional, like Advil and Tylenol or acupuncture, to have a sales force dropping by to remind doctors to use them.

“The drug company is frankly much smarter about how to get into people’s heads,” said Jerry Avorn, a Harvard Medical School professor and critic of the drug industry’s influence. As a primary-care doctor, “I would definitely have sales reps trying to get to see me to talk about this amazing medication, [to] tell me that pain is undertreated, it’s the fifth vital sign and every patient should be asked if they are in pain.”

The idea of using the drug companies’ own playbook is familiar to Avorn, who first showed the strategy could work nearly four decades ago in a research project. But only recently has Avorn seen broader embrace of the idea that the drug industry’s outreach may drive up the use of expensive medicines and push physicians to use them inappropriately.

Bains makes these visits not just for opioids, but also to help physicians manage dementia, lung diseases, diabetes and other conditions, through an Alosa Health program supported by the Pennsylvania Department of Aging. In brief meetings that often take place off-hours, he builds relationships with doctors, listening to their questions and challenges.

The interactions are collaborative and respectful, even if doctors practice in ways that don’t conform with evidence. Bains said doctors are often dismissive when confronted with a new idea or evidence, but then they bring it up with greater interest next time he sees them.

These unconventional education efforts have often started as one-off contracts or experiments, but they are growing as studies show they work. Michael Courtney, director of physician engagement at the Capital District Physicians’ Health Plan, now deploys his experience as a pharmaceutical sales rep for companies such as Pfizer and Johnson & Johnson to dissuade doctors from unnecessary use of expensive drugs, drawing on relationships built over time.

“Even in the pharmaceutical industry, it wasn’t a one-time call,” Courtney said. “You were going in there because the data said you have to hear something six to eight times to make it change or resonate.”

A recent study in JAMA Network Open found a possible link between the number of office visits that drug reps made, building trust over time, and the number of overdose deaths — although the research couldn’t show that the visits caused the deaths.

For doctors, these visits amount to a different way to stay abreast of research in their fields. Normally, physicians learn about new findings piecemeal, at best, when they have time to read medical journals or to sit in darkened hotel rooms watching slides flash by. Or they get a highly selective version of the data from drug company representatives, along with free samples.

Bains, by contrast, comes with prescription pads already filled out for treatments like Tylenol or rest, ice and compression — and with warnings about risks and side effects of opioids.

“Being in primary practice, it would be very easy to be in isolation — to take the medical knowledge from the time you finish residency, really not bulk it up, or update it, and really veer off of what is the current evidence-based medicine,” said Zachary Lyons, the son.

The Lyonses, trained three decades apart, were both aware of the risks of opioids, but they debated with Bains about when to turn to steroids, which are not recommended for short-term pain relief for acute low-back pain.

“The wonderful thing about doing what we do is — you and I can disagree, but we’re all on the same side. We all want the patient to get better,” Michael Lyons said of their chats with Bains. “Drug salesmen come, but they have motivation — they’re trying to sell.”

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Trump Targets Drug Middlemen With ‘Devastating’ Rebate Plan

https://www.bloomberg.com/news/articles/2019-01-31/trump-to-curb-protections-for-drug-rebates-blamed-for-high-costs

The Trump administration proposed ending a complex system of drug rebates that influence tens of billions of dollars in U.S. pharmaceutical spending, a move that could upend the relationship between drugmakers and pharmacy benefits middlemen.

The proposal, a long-awaited part of the administration’s plan to target high list prices of drugs, would ban rebates paid by drugmakers to pharmacy benefit managers, or PBMs, in government programs like Medicare.

Those rebates have been called anticompetitive by critics, who blame them for forcing many patients to pay more out of pocket. Under the administration proposal, rebates would instead be passed along directly to customers.

The proposal comes ahead of President Donald Trump’s State of the Union address scheduled for Tuesday, handing him a potential win on drug pricing — a major issue for both parties. The measure, released by the Department of Health and Human Services Thursday, would roll back so-called safe-harbor protections for such rebates, which kept them from running afoul of federal antikickback laws. The plan isn’t final and will be subject to a 60-day period for public comment.

The changes are “potentially devastating to the current pharma ecosystem,” said Eric Coldwell, an analyst with Baird Equity Research. “The U.S. health-care system is a sandcastle and the tide is coming in.”

Shares of major drug-plan providers fell. CVS Health Corp., which oversees drug benefits for more than 90 million Americans, fell 2.4 percent in late trading in New York, and Cigna Corp., which last year bought PBM giant Express Scripts, declined 1.4 percent.

Drugmakers pay rebates to insurers and PBMs in exchange for preferred status with those plans’ customers. Some of those rebates go toward insurance premiums, while the middlemen keep some for themselves. The pharmaceutical industry has said PBMs prefer higher-priced drugs so they can negotiate bigger rebates and pocket more of the money.

In a statement announcing the proposal, HHS Secretary Alex Azar blasted PBM rebates as “a hidden system of kickbacks to middlemen” that increases drug costs for Americans every day.

“This proposal has the potential to be the most significant change in how Americans’ drugs are priced at the pharmacy counter, ever, and finally ease the burden of the sticker shock that millions of Americans experience every month for the drugs they need,” Azar said in a statement.

Reporting by Bloomberg News over the past three years has examined a variety of pricing practices at PBMs that have been criticized by politicians and others for making it hard to tell where the money is going. In addition to the debate over rebates, PBMs also are under scrutiny over a practice known as spread pricing, a contractual arrangement that allows PBMs to pay pharmacies one price for a generic drug while charging higher prices to their health plan customers.

CVS said drugmakers were to blame for drug costs. “While PBMs have become a convenient target in the fight against skyrocketing drug costs, in reality they serve as a last line of defense for the consumer,” the company said in a statement.

Brian Henry, a spokesman for Cigna, said that rebates had helped keep premiums down overall. “It is short-sighted to look at one component of our offering as having a disproportionate impact on our business model,” Henry said in an email.

Under the proposal, safe-harbor protection would be eliminated for rebates drugmakers pay to pharmacy-benefit managers, Medicare Part D plans and Medicaid managed-care organizations. A new safe harbor would be created for rebates on drug discounts offered directly to patients, as well as fixed-fee service arrangements between drugmakers and PBMs. Without safe-harbor protections, rebate money pocketed by PBMs could be considered an illegal kickback.

Congress

While the out-of-pocket cost for many people picking up drugs at the pharmacy would decline, the premiums they pay for coverage would rise. Premiums for Medicare drug plans under the proposal could increase anywhere from 8 percent to 22 percent while average costs patients pay out of pocket would fall 9 percent to 14 percent, according to the Department of Health and Human Services.

It would be up to Congress to write new laws banning rebates in commercial plans that cover most working-age Americans, and the reception on Capitol Hill was mixed. In the Democrat-controlled House of Representatives, the chairmen of two key committees overseeing health care criticized the proposal.

“The majority of Medicare beneficiaries will see their premiums and total out-of-pocket costs increase if this proposal is finalized,” Ways & Means Committee Chairman Richard Neal of Massachusetts and Energy and Commerce Committee Chairman Frank Pallone of New Jersey said in a joint statement. “We are concerned that this is not the right approach.”

House Speaker Nancy Pelosi likewise urged Trump to work with lawmakers on drug costs.

“President Trump must work with Congress to deliver the real, tough legislation needed to actually drive down the price of prescription drugs for seniors and families across America.” she said in a statement criticizing the plan.

The Pharmaceutical Care Management Association, an industry group for PBMs, said it was reviewing the proposed rule.

“We stand ready to work with the administration to achieve our shared goal to reduce high drug costs,” PCMA Chief Executive Officer JC Scott said in a statement.

The Pharmaceutical Research and Manufacturers of America, the main drug industry trade group, applauded the move. The proposal would “fix the misaligned incentives in the system” that now result in insurers and PBMs favoring medicines with high list prices, PhRMA CEO Stephen Ubl said in a statement.

A few days ago I made this post Saving Money For Medicaid in WV      where WV got rid of their middlemen on their state Medicaid program in 2017  and saved 30 million dollars. WV is not all that large a state ..population about 1.8 million.

The PBM industry started when I was in my last year of Pharmacy school and have watched the industry grow from a nuisance to Pharmacists to a entity that is controlling of the price and approval to pay about 80%-90% of all the prescriptions filled in the country.

They have gained so much control from their beginning that they can now demand discounts/rebates/kickbacks from the pharmas in exchange for the PBM’s to put their medications of the PBM’s approved list of “paid medications”

We have had for years Silver Scripts which is part of CVS Health and last year they started charging higher copays for having prescriptions filled at non-preferred pharmacies and last year there was only two independent pharmacies that were preferred pharmacies.  As of Jan 2019, in three adjacent counties the only PREFERRED PHARMACIES are CVS pharmacies and if a pt with Silver Scripts uses a non-preferred pharmacy the copays they are charged will be 50%-100% higher.

All of these PBM’s are licensed insurance companies and they have fought every attempt to regulate how they run their business by parts of our bureaucracy.  Basically they have fought not to be forced to operate in a TRANSPARENT WAY.  Also the insurance industry has one of the top funded lobbyist funds.  If this gets much traction in Congress i suspect that there will be a whole herd of lobbyists descending on Congress to see if they can get this proposal greatly modified to cause less financial harm to the PBM industry.

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5 police officers injured in Houston shooting, 2 suspects dead, officials say

https://www.foxnews.com/us/5-police-officers-injured-in-houston-shooting-officials-say

Did anyone pay attention to this raid on a suspected drug house in Houston…  Apparently all the police involved in this raid was from the city of Houston and/or Harris county.

Does it seem strange to anyone but me, but the DEA has a district office in Houston , TX but apparently they were no where to be found or involved in this raid.

Maybe because there were probably no real assets to seize/confiscate and/or there was a high probability of a fire fight… ?

If this had been a prescriber’s office… where there is little/no change of getting shot and high probability of sizeable assets to be seized and a high profile court case to be sending out endless stream of press releases on their BUSTING A PILL MILL DOC ?

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Civil Rights Case Gives Hope to Pain Patients

https://www.painnewsnetwork.org/stories/2019/2/1/civil-rights-case-gives-hope-to-pain-patients

Selma Medical refused to schedule a new patient appointment for a man who was taking the addiction treatment drug Suboxone. He filed a civil rights complaint asserting that his rights were violated because has a disability.

According to the complaint, Selma Medical “regularly turns away prospective new patients who are treated with narcotic controlled substances such as Suboxone.”

The DOJ and Selma Medical settled the complaint out-of-court. The full agreement can be read here.

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Jan. 31, 2019 – 2:00 – Investigation by the California State Board of Pharmacy finds that a Walgreens employee in the Bay Area who worked as a pharmacist for nearly 11 years and wrote 745,00 prescriptions never had a license

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Pharmacies can make deadly mistakes while keeping the public in the dark

http://www.weny.com/story/39891507/pharmacies-can-make-deadly-mistakes-while-keeping-the-public-in-the-dark

Ohio (WEWS) — A secret crisis is unfolding inside pharmacies in the state and across the country. The struggle to fill an increasing number of prescriptions has fueled growing concerns over harmful and sometimes deadly prescription mistakes.

But Ohio pharmacies and others nationwide can make these mistakes and the public can be kept in the dark, a 5 On Your Side investigation has found, because they are not required to report these errors to state regulators.

Our findingsState regulators do not maintain comprehensive data on how many people have been harmed or killed as a result of prescription mistakes made by pharmacies.

In an effort to piece together how often these mistakes occur, our team reviewed four years of Ohio Pharmacy Board minutes, court dockets and autopsy reports.

We found there have been at least 491 complaints — filed largely be consumers involving prescription mistakes. In addition, we uncovered two people were killed and 31 people were harmed as a result of being given the wrong medication at local pharmacies across the state.

Alarmingly, industry experts are convinced those numbers are likely much higher. Our investigation found no one is certain just how many are harmed because pharmacies in Ohio are not required to report those complaints.

‘Try your best not to kill anyone’At the same time, demand and workload for Ohio’s 20,349 pharmacists and 20,649 pharmacy technicians is growing, according to Ohio Pharmacy Board records.

The Ohio Pharmacists Association , which represents pharmacists and pharmacy technicians, is concerned that 150 local pharmacies have closed their doors and small pharmacies are being bought out by large chains that the association believes fail to adequately staff pharmacies.

“It’s fill as fast as you can — try your best not to kill anyone,” said Antonio Ciaccia, the association’s Director of Government and Public Affairs.

Our investigation found heartbreaking and tragic mistakes:

Michael James Carmack was just 25 years old when he died in April of 2015 as a result of being given the wrong medication at his local pharmacy, according to the lawsuit that was settled and dismissed, as well as pharmacy board disciplinary reports . Court records reveal Carmack “ingested the wrong medication,” and an autopsy report confirmed “the pills in the prescription bottle did not match the prescription on the prescription label.” The pharmacist “neither admits nor denies the allegations,” according to the disciplinary records. However the pharmacy board said it has “evidence sufficient to sustain the allegations” and levied a $3,000 fine that the pharmacist agreed to pay.

In another case, a lawsuit alleged that 68-year-old Johnny Shepherd died as a “result of pharmacy negligence” after dispensing medication that was “mislabeled.” His wife Molly Shepherd is convinced “the medication killed him.”

“I loved him, and he loved me,” Shepherd said. “[His death] caused me to be miserable, living by myself.”

Tabatha Gonzalez said she was five months pregnant when she discovered she had been taking prescription medicine belonging to someone else. But fortunately, it turned out to be the identical medication and dosage. Even so, she remembers worrying, “Is my baby going to be OK?” she said.

The mother of a now 20-year-old remembers how a pharmacy mistake hospitalized her son when he was just 5 years old. Carrie Klein said her son, Freddie, suffered from a rare brain disorder since birth and required medication to control his seizures. “I got a magnifying glass and looked at the pill and sure enough, it was double the dosage,” she said. “They could have killed him.” The mistake was never reported until Klein filed a complaint on her own.

Doing ‘more with less’Last year, more than 171 million prescriptions were filled at pharmacies across Ohio, according to the Henry J Kaiser Family Foundation . The Ohio Pharmacy Association said, “that number is skyrocketing” while pharmacies are “being forced to do more with less.”

“That is incredibly dangerous,” Ciaccia said. “We should not be sitting around waiting for the next error or the next death to occur.”

Even longtime pharmacists like Ray Carlson are taking the highly unusual step of voluntarily becoming “whistleblowers” to bring conditions inside pharmacies to the public attention. Carlson owns a successful compounding pharmacy in Poland, Ohio that provides specialized prescriptions for patients and hospitals in Northeast Ohio.

“This is very unusual for a pharmacist to not have his face blocked out or his voice garbled,” Carlson said in an interview.

For example, in a highly public move, Carlson took the Ohio Pharmacy Board to court in order to compel the board to survey Ohio’s pharmacies to ensure they were following both state and federal laws governing dispensing.

With Ohio’s growing opioid crisis, Carlson grew concerned over workplace conditions that may be leading pharmacists to be too busy to ask consumers a comprehensive list of questions regarding their medication and drug reactions, among others.

Carlson’s goal was to warn the public of the “impact and danger” if safe dispensing practices were not adhered to, including the potential for errors.

“Absolutely, it leads to errors,” Carlson said. “We know it’s being under reported if not reported at all.”

The case was ultimately dismissed, but Carlson continues to stress that pharmacies appear to be failing to spend adequate time with consumers simply because they are overworked and too busy.

In fact, he said the next time consumers pick up their prescriptions, they should notice the box they check that seems to indicate only that they have picked up their medication. By checking it, he said, consumers are also surrendering their rights to counseling and questions from the pharmacist.

“I can remember when it once took five pharmacies to fill just 100 prescriptions a day,” Carlson said. “Now, you got one pharmacy with two pharmacists doing 500 a day.”

“If I make you do more with less time and less resources—will you do better?” Ciaccia asked. “I don’t think anybody wouldI think everybody would actually say they would do worse.”

Pharmacies respondIn a statement to News 5, the National Association of Chain Drug Stores (NACDS), which represents 40,000 pharmacies nationwide, said “while some have attempted to link” prescription errors “with pharmacist’s current responsibilities,” the NACDS warns against a “rush to judgment” or “assume a causal relationship.”

The NACDS also supports “voluntary reporting of medical and prescription errors in a non-punitive forum” as opposed to mandatory reporting without fear of being subjected to lawsuits. You can read NACDS’ full statement here.

NACDS also points to a report by the Institute for Safe Medication Practices that “emphasize strongly the importance of voluntary reporting rather than mandatory as well as findings by the Agency for Healthcare Research and Quality within the U.S. Department of Health and Human Services.

The nation’s two largest pharmacies provided written statements to News 5 but declined on-camera interviews.

A spokesperson for Walgreens responded saying, “Prescription errors are rare and we take them very seriously. In the event there is an error with a prescription, our first concern is always for the patient’s well-being.” You can read Walgreens’ full statement here .

A CVS spokesperson also insisted “errors are rare,” saying the pharmacy “has comprehensive policies and procedures in place” to ensure safety. You can read CVS’ full statement here .

Walmart, the nation’s fourth largest retail pharmacy, said only, “We don’t have anything to add to your story.”

We shared our findings with the Ohio Pharmacy Board that is now promising to move forward with proposed rules that would require mandatory reporting of pharmacy errors.

Pharmacy Board Executive Director Steven Schierholt said the debate has long been that if pharmacist and technicians were fearful of possible criminal charges, it would have the opposite effect and encourage less reporting — not more.

He said the board has been working toward mandatory reporting that would encourage more accurate and full reporting without criminalizing pharmacists.

“The board is in the process of promulgating rules that would require a pharmacist to report instances of reckless behavior that resulted in a dispensing error, or unprofessional conduct that resulted in a dispensing error,” Schierholt said.

New rules regarding mandatory reporting of pharmacy errors will be proposed and released in the next few months.

There are some 4 + Billion prescriptions filled each year in the USA. I don’t know what the definition of “rare error ” is that is used by the chains.. But if 99.9 percent of prescriptions are filled without a ERROR… that means that FOUR MILLION PRESCRIPTION ERRORS are happening EVERY YEAR…  ABOUT ELEVEN THOUSAND A DAY – 7 days a week

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Last Sunday Barb and I decided to go out to Brunch at O’Charlie’s… by Monday neither one of us was feeling all that well…

but about 6PM Monday evening we both started taking turns over the next 18-24 hrs..  There could not have been more than 10 minutes between each of us starting…. Normally we don’t eat the same foods but this day – for some odd reason we both ordered a scrambled egg mess of potatoes, green peppers and a couple of meats.  Apparently, while not being able to taste/smell anything wrong with the meal… THERE APPARENTLY WAS  !!!

It is probably going to take me most of the weekend to go thru all the backlog of emails – some 600 already … FB messages and other things that have “piled up ” …

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