CVS Defends Rx Opioid Policy

By Pat Anson, Editor

CVS Health has released new details about its plan to limit the dose of opioid pain medication and restrict new prescriptions for acute pain to a 7-day supply.

The new policy, which was announced last week, immediately sparked an online backlash from chronic pain patients, who fear they will no longer be able to refill their opioid prescriptions at CVS or will have to do it weekly.

“It's crazy what's going on. Every week going to doctors and pharmacists paying that extra money. This is a crime on the sick,” wrote Amy in a Facebook post.

“Even for new patients, this doesn't make sense,” wrote Jennifer in another online post. “After surgery some patients need these medications for longer than 7 days. Driving to the doctor to get a new script, then to the pharmacy to get more medication is not conducive to healing.”

“How can they single out medications and refuse when the doctor writes them for 30 days?” wrote Hazel. “Everyone should boycott them, not only for prescriptions but shopping there for anything. This is getting ridiculous!”

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Asked to comment on these and other concerns, CVS Health emailed a statement to PNN answering a series of questions we had about its new opioid policy. We were not allowed to interview anyone at CVS directly.

The questions and answers below were edited for clarity:

PNN: Many of your customers with chronic pain believe they'll have to go to a CVS pharmacy four times a month to get their refills. Can you clarify that for them? 

CVS: The seven day quantity limit on opioid prescriptions, going into effect on February 1, 2018 for CVS Caremark's pharmacy benefit management (PBM) clients, applies only to prescriptions written for acute conditions, such as a minor surgery or dental procedure, that generally last only for a short duration. 

We recognize that there are patients with a legitimate need for pain medication, and our approach is carefully designed to ensure that those patients can access their medication in an appropriate manner.  We are dedicated to ensuring our retail and PBM approaches do not negatively affect patients who are in need of their chronic pain medication.   

PNN: What happens when a patient recovering from surgery needs opioid medication for more than 7 days? Do they go back to their doctor and get a new prescription?

CVS: Our program encourages safe and appropriate utilization of opioids by managing utilization in a manner consistent with the Guideline set forward by the CDC.  Our efforts to ensure safe and appropriate opioid use are designed to improve the quality of care and health outcomes for patients.  If a prescriber feels patient care should exceed these limits, the prescriber can request an exception. 

PNN: What about limiting opioid prescriptions to 90mg morphine equivalent (MME) doses? Some pain patients are prescribed more than that.

CVS:  The CDC recommends that clinicians prescribe the lowest effective opioid dose and use caution when prescribing opioids at any dosage.  Further, the Guideline indicates physicians should carefully reassess evidence of individual benefits and risks when considering increasing dosage to ≥50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day. 

We are aligning our standard utilization to these limits for all patients who are not in active cancer treatment, palliative care, or hospice care.  However, if a prescriber feels patient care should exceed these limits, the prescriber can request an exception. 

PNN: You say you are following the CDC guideline, but the guideline is voluntary and only intended for primary care physicians treating chronic pain. You are making them mandatory for all doctors and all patients for all types of pain.

CVS: Given the toll opioid misuse has taken on our country, we believe it is appropriate to align our utilization management of opioids for our members with the Guideline set by the CDC.  Our efforts to ensure safe and appropriate opioid use are designed to improve the quality of care and health outcomes for patients.  Notably, if a prescriber feels patient care should exceed these limits, the prescriber can request an exception. 

PNN: Many patients complain that there's already a tendency by some pharmacists to refuse to fill opioid prescriptions to avoid hassles, extra work, etc. and to send them away without their medication. How will CVS make sure its pharmacists abide by your rules and not invent new ones?

CVS: Our opioid utilization management program will be consistently executed as a coverage determination across all pharmacies in our PBM retail network.  Pharmacists at CVS Pharmacy, or any of the other retail pharmacies in our network, will not be making independent medical judgments about the appropriateness of opioid prescribing or the length of such prescribing. Additionally, the program we have recently announced does not impact prescriptions filled for CVS Pharmacy retail customers who are not covered by the CVS Caremark PBM.   

Our pharmacists are committed to providing the highest level of care for their patients.  At our retail pharmacies, we are also strengthening counseling for patients filling an opioid prescription with a robust safe opioid use education program highlighting opioid safety and the dangers of addiction. 

'Cookie Cutter' Approach to Pain Care

CVS is not the first pharmacy to adopt rules that limit the dispensing of opioids, but it is the first major chain to set a 7-day limit on prescriptions for acute pain. Given recent trends, it is probably not the last.

Several states have already adopted laws that limit opioids to a few days' supply for acute pain. And yesterday a major pharmaceutical organization announced its support for a 7-day limit on new opioid prescriptions.  

Critics say this “cookie cutter” approach to pain care ignores the fact that when acute pain is poorly treated or untreated, it can turn into chronic pain in a matter of months or even weeks.

And chronic pain can worsen or cause other life-threatening health problems, including high blood pressure, stroke, heart attack, depression and suicide ideation.

Each patient is also different. A large new study published this week in JAMA Surgery looked at the different lengths of time patients needed opioid medication while recovering from 8 common surgical procedures.

While a 7-day supply of opioids was adequate for most patients recovering from an appendectomy, hysterectomy, hernia repair and other common surgeries, an analysis of over 215,000 surgery patients found that about 20 percent of them needed at least one refill of their prescription. Orthopedic and neurological procedures were the most likely to require a refill, and Medicare patients were the most likely group to need opioids for more than 7 days after a surgery.

“Although 7-day limits on initial opioid pain medication prescriptions are likely adequate in many settings, and indeed also sufficient for many common general surgery and gynecologic procedures, in the postoperative setting, particularly after many orthopedic and neurosurgical procedures, a 7-day limit may be inappropriately restrictive," wrote lead author Louis Nguyen, MD, of Brigham and Women’s Hospital, Harvard Medical School.

But not everyone finds fault in the cookie cutter approach. In an editorial also published in JAMA Surgery, a leading surgeon wrote that “any effort” to reduce the frequency of opioid prescriptions was a good thing.

“Unfortunately, we have reached a point that 100% elimination of pain has become not only the goal but the expectation. If a surgeon allows a patient to expect a pain-free recovery, he or she will see refill requests increase,” wrote Selwyn Rogers, MD, chief of surgery at the University of Chicago Medicine Trauma Center.

“Alternatives to narcotics should be recommended and incorporated as the foundation of pain management. It does not take much time to explain the use of acetaminophen and ibuprofen and then follow up with a stronger option if the pain is not adequately relieved. It is also useful to prepare the patient to expect some discomfort, realize that complete relief of all pain is impossible, and that the cost of trying is not worth it.”