The roadblocks for prescribing pain medicine are still there. Even after the state introduced a safeguard to help physicians spot illicit prescription use and doctor-shopping, barriers remain.
Those hurdles, set up by large, mostly national pharmacy chains, are frustrating physicians. As for their patients, it’s not uncommon for them to feel suspected of drug abuse, stigmatized, and driven to tears.
Pain physicians aren’t the only doctors saying their scrips are being held up. Nacogdoches obstetrician-gynecologist Benjamin Thompson, MD, who performs C-sections and other gynecologic surgeries, says Walmart pharmacies often deny a prescription unless they receive a written diagnosis or clinical data supporting the prescription’s legitimacy.
“These aren’t high volumes of medication coming out, either,” Dr. Thompson said. “They’re low doses, low tablet count. Usually, I prescribe 15 tablets for my postoperative patients.”
It’s been going on for a while, with Texas physicians implicating Walmart and other large national pharmacies for impeding lawful prescription-filling – for example, demanding treatment plans, or requiring a change in morphine milligram equivalents (MMEs) because of company policy. (See “Opioid Overreach?” December 2018 Texas Medicine, pages 40-43, www.texmed.org/opioidoverreach.)
Physicians, including pain specialists, say it’s still pervasive, despite a state law requiring all prescribers to check the state’s prescription monitoring program (PMP), known as PMP Aware, before prescribing an opioid.
“I check the PMP every time, as you’re supposed to. But [the pharmacies are] still holding up prescriptions going out,” Dr. Thompson said. “And there’s a discrepancy there, because some pharmacies aren’t doing this and some pharmacies are. It’s another [hoop] that the physician and the patient have to go through to get pain control. It’s a pharmacy interfering with the doctor-patient relationship.”
Walmart defends its policies on training pharmacists to identify suspicious prescriptions and says it supports its pharmacists who don’t feel comfortable filling a prescription.
Patients feel the stigma
One of the kickers for Dr. Thompson is that pharmacies also have access to PMP Aware.
The mandate for prescribers to check it not only covers prescriptions for opioids, but also benzodiazepines, barbiturates, and carisoprodol. Pharmacists also must check the PMP before dispensing drugs in those four classes – “so they can screen for opioid use as much as we can without having to question the order,” Dr. Thompson said.
But the wrangling over scrips isn’t staying behind the scenes between physician and pharmacy. Brian Bruel, MD, president of the Texas Pain Society (TPS), told Texas Medicine that patients – whether suffering from chronic or acute pain – are getting “a very hard time” from pharmacists and pharmacy technicians when trying “to get these medicines that I prescribe reasonably, to the point that they call our office in tears because they feel stigmatized. And this is not a rare occurrence,” Dr. Bruel said. “This is often.”
Pharmacists also will press him for the ICD-10 code that corresponds to the health problem that requires the pain medicine.
“But sometimes, they go so far to ask, ‘Oh, what is the treatment plan? Have you done injections? Have you had the patient do physical therapy? Have you talked to the patient about weaning the dose?’ I don’t know why they’re asking me these questions,” Dr. Bruel said. “I get it in a sense that they’re part of the treatment team, and I get it if what information I’m giving them will allow them to educate the patient a little bit more about their medicine. But honestly, I think what they’re just doing is typing something in their electronic record just to document it. But I don’t really think that it’s [improved] overall care.”
Mesquite pain physician C.M. Schade, MD, says he’s only seen the issue with chain pharmacies, not independent ones. The pharmacists appear to be simply trying to follow corporate policies, he said. His practice had begun noting the ICD-10 diagnosis code on the prescription order to head off pharmacy holdups.
“Our patients typically have chronic pain syndrome, which is G89.4, and so we put the ICD-10 code ‘G89.4’ on there, and it’s been working OK. But then over the last month, pharmacists are now calling back and saying, ‘No, we’ve got to know more specifically what it is.’ In other words, they want a low-back code or neck code or foot code, pancreas code, or some other code,” Dr. Schade said. “That really is unnecessary. Many patients have more than one painful area, so it’s becoming an additional hassle factor and a burden.
“So our policy is that when this happens, we advise the patient to change pharmacies.”
Dr. Bruel says he’s consulted other physicians and that although many large pharmacies are similarly demanding more information before they’ll fill an opioid prescription, including CVS and Walgreens, the consensus is Walmart is the most challenging.
Dr. Thompson agrees. He’s convinced, though, that the pharmacists aren’t at fault.
“I’ve gotten hold of a pharmacist or two about it, and they tell me, ‘This is not my decision.’ They always tell me it’s the company’s decision for them to do this.”
Walmart: “A difficult task for pharmacists”
Walmart responded to written questions from Texas Medicine with a statement from Thomas Van Gilder, MD, Walmart’s chief medical officer. Dr. Van Gilder said Walmart’s limit on initial acute opioid prescriptions doesn’t apply to chronic conditions, cancer patients, and other categories. In 2018, the retailer introduced a seven-day limit on initial acute prescriptions, with a limit of 50 MMEs per day.
“Determining whether a controlled-substance prescription is legitimate is a difficult task for pharmacists, who don’t have as much information about patients as prescribers, insurers, and others,” he said, adding that Walmart provides guidance and training on how to detect and resolve concerns that a prescription might be illegitimate.
“Sometimes, our pharmacists contact prescribers for more information about a patient or a prescription to help determine if a prescription is medically legitimate. Unfortunately, some prescribers refuse to cooperate, and even accuse pharmacists of second-guessing their medical judgment, or even threaten litigation,” he said. “Because our pharmacists have less information about our mutual patients than prescribers, we hope prescribers will work together with our pharmacists when they call. When our pharmacists decide, in their professional judgment, that they are uncomfortable filling a specific controlled-substance prescription or all controlled-substance prescriptions from prescribers they find concerning, we support their decisions.”
Dr. Van Gilder added the company “blocks all Walmart pharmacists from filling controlled-substance prescriptions from prescribers who meet a higher threshold of concern.”
CVS acknowledged Texas Medicine’s interview request but did not make anyone available by press time. Walgreens did not respond to an interview request.
Earlier this year, ProPublica reported that Walmart nearly faced federal charges in the Eastern District of Texas for the opposite issue about two years ago: being too permissive with opioid prescriptions.
Walmart pharmacists “all over the country” had reported “hundreds of thousands of suspicious or inappropriate opioid prescriptions,” according to ProPublica’s report, but Walmart “repeatedly admonished pharmacists that they could not cut off any doctor entirely” and an opioid compliance manager told an executive “that Walmart’s focus should be on ‘driving sales.’” ProPublica reported that U.S. Department of Justice (DOJ) officials killed a potential indictment after “Walmart escalated concerns to high-ranking officials at the DOJ, who then intervened.”
Walmart reiterated to Texas Medicine its statement to ProPublica, in which it said the Eastern District “engaged in misconduct multiple times as it investigated Walmart.” The retailer strongly denied criminal wrongdoing.
Match game: A proposed solution
The Texas State Board of Pharmacy (TSBP) would be in a position to pursue action against any pharmacists who might violate board rules. But pharmacies and pharmacists have latitude to set their own prescription limits, and the discretion to refuse to fill prescriptions.
For example, Walmart’s seven-day limit on initial acute-pain prescriptions is shorter than the 10-day limit on acute-pain opioid scrips the Texas Legislature put in place in 2019. TSBP doesn’t consider it a violation if corporate limits are shorter than what the state allows, pharmacy board Executive Director Allison Benz said. Also, nothing prevents pharmacies from requiring diagnosis information, for example.
“If the pharmacy wants to have that policy that they want that information before dispensing a controlled substance, then that would be something that they can do, and not something that we have prohibited,” Ms. Benz said.
And while opioids have been a prominent topic nationally the last few years, during the majority of 2020 the COVID-19 pandemic has stepped into the forefront ahead of everything else, including opioids, Ms. Benz notes.
“Opioids have, it seems like, taken a backseat a little bit,” to COVID-19, she said. “I haven’t heard recently anything about [pharmacy overreach]. A lot of those things are corporate policies and not something that we regulate.”
Dr. Schade says a big piece of the solution could come from enacting policy TPS supported in recent sessions of the Texas Legislature.
Drug distributors report their wholesale deliveries for controlled substances to the U.S. Drug Enforcement Administration’s Automation of Reports and Consolidated Orders System (ARCOS), a tracking database. The Texas State Pharmacy Board receives the ARCOS data, but Dr. Schade says state law should require the board to do something with it: namely, compare whether the “in” data for the controlled substances that pharmacies receive matches the drug quantities going out, as recorded in the PMP.
“If they don’t match, we’ll find out why,” he said. “Do you really think pill-mill pharmacies are reporting all this data, or reporting it in a way you can track it? … It’s very easy. If you want to find the bad guys, you crunch that data, and it’s there and the pharmacy has it. But it takes plenty of manpower to look at it. All the legislature’s got to do is say, ‘A should equal B.’ And if it doesn’t, go see what the problem is.
Tex Med. 2020;116(9):40-43
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