AMA EVP/CEO James L. Madara, MD., writes to Walmart's President and CEO, and EVP of Consumables and Health and Wellness regarding Walmart's new policy on opioid prescriptions. Dr. Madara raises several concerns about the policy and its impact on patients.
August 16, 2018
President and Chief Executive Officer
702 SW 8th St.
Bentonville, AR 72716
Executive Vice President of Consumables
and Health and Wellness
702 SW 8th St.
Bentonville, AR 72716
Dear Mr. McMillon and Ms. Hays:
On behalf of the American Medical Association (AMA) and our physician and medical student members, I am writing to share our concerns resulting from new Walmart pharmacy policies. The concerns specifically focus on the new policy that was announced in May whereby “Walmart and Sam’s Club will restrict initial acute opioid prescriptions to no more than a seven-day supply, with up to a 50 morphine milligram equivalent maximum per day.” (See https://news.walmart.com/2018/05/07/walmart-introduces-additional-measures-to-help-curb-opioid-abuse-and-misuse) There are three main reasons for our concern:
First, contrary to the news release you issued, this policy is not in alignment with the Centers for Disease Control and Prevention’s (CDC) Guideline for Prescribing Opioids for Chronic Pain. (See https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm) The CDC itself has emphasized the voluntary nature of the guidelines and argued against using them as a prescriptive standard:
Clinical decision making should be based on a relationship between the clinician and patient, and an understanding of the patient’s clinical situation, functioning, and life context. The recommendations in the guideline are voluntary, rather than prescriptive standards. They are based on emerging evidence, including observational studies or randomized clinical trials with notable limitations. Clinicians should consider the circumstances and unique needs of each patient when providing care.
We acknowledge and agree with CDC that if opioid analgesics are indicated for the treatment of acute or chronic pain, the physician is well-advised to “prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids.” This advice, however, is not the same as a hard threshold, which has caused patients experiencing acute pain, and those suffering from chronic pain, to be denied medication in the false application of the CDC guidelines.
The AMA has received numerous reports of patients being denied care and of being verbally harassed and embarrassed at Walmart and Sam’s Club pharmacy counters when presenting a prescription outside of your new policy threshold limits. In addition, we have reports of Walmart pharmacists demanding extended medical record documentation that goes beyond their education and training, including asking for patient visit notes, signed pain care agreements, diagnostic codes, treatments tried and failed, and other information that goes beyond a pharmacist’s corresponding responsibility.
Second, the new policy threshold leaves many questions unanswered. The AMA was pleased that Walmart representatives sat down with us in March of this year along with representatives from the AMA Opioid Task Force, including the Arkansas Medical Society. That meeting was by all accounts highly collaborative, engaging, and helped identify ways we could work together to enhance patient care and reduce the harms associated with opioid-related misuse. We were particularly pleased to learn at that meeting that Walmart had no plans to follow other pharmacy chains and implement non-evidence based, arbitrary prescribing thresholds. We remain committed to working with you and other stakeholders to ensure there is balance and support for the therapeutic triad among the physician, pharmacist and patient.
In light of the March meeting, we were greatly surprised to learn of your new corporate policy based on a hard threshold of 50 MME or seven days for an initial opioid prescription for acute pain. In the spirit of collaboration from our March 1 meeting, AMA staff has repeatedly attempted to learn more from Walmart representatives, including:
• What communication about the new policy will be shared with physicians?
• How will Walmart pharmacists implement the policy when it is not clear if a prescription is for acute or chronic pain?
• How will Walmart pharmacists adjudicate a prescription that is for more than seven days or more than 50 MME?
• Will Walmart pharmacists be bound by the new corporate policy, or will they have the professional obligation and flexibility to review prescriptions based on their corresponding responsibility under the Controlled Substances Act?
• If a state law has a threshold that is above the new corporate policy, will Walmart abide by the state law or substitute its corporate policy instead?
These are a few of the main questions that we have – based largely on feedback from practicing physicians. We appreciate that representatives of Walmart attempted to discuss these matters with us following the release of the new corporate policy, but answers have yet to be forthcoming. As a result, the AMA has heard from several dozen state and national medical specialty societies about patient confusion and denials of care. We would greatly appreciate answers to these and other questions so that we might share that information with our colleagues in an attempt to alleviate some of the confusion as a starting point.
Third, as we have done in Congress, state legislatures and other venues across the country, we feel it necessary to point out that the focus on reducing the supply of opioid analgesics may be helpful to reduce diversion, but it will not, by itself, reverse the nation’s opioid epidemic. Walmart’s new corporate policy will almost certainly have two direct effects: it will reduce the supply of opioid analgesics, but it will also cause patients with pain to have increased suffering. Nationally, the AMA has been pleased that there has been a more than 22 percent decrease in opioid prescribing since 2013. Yet, it is distressing that this decrease has been accompanied by staggering increases in mortality from heroin and illicit fentanyl; and deaths due to prescription opioids also continues to increase. What also has increased is the stigma felt by patients with pain that by virtue of their care plan including opioid analgesics, they are deemed “drug seekers,” “addicts” and that somehow it is their fault for having pain. We know that this is not what Walmart intended from its new corporate policy, but this has been the inevitable effect of similar policies implemented across the nation. As such, we urge Walmart to revisit its policy and allow for the therapeutic triad to guide clinical decision-making rather than a hard threshold that cannot distinguish clinical needs.
We stand ready to work with Walmart and all stakeholders to help end the nation’s opioid epidemic. Please contact the AMA’s Daniel Blaney-Koen, JD, Senior Legislative Attorney at
firstname.lastname@example.org or (312) 464-4954 to continue this important discussion.
James L. Madara, MD
cc: Sandra Ryan, Vice President of Care Clinics, Quality Improvement & Clinical Services
AMA Opioid Task Force