A CVS pharmacy recently sent me a standardized form by fax with a dire warning about one of my patients. The elaborate document was titled “CVS caremark.” It came from “Prescriber Services” and provided “Patient Information for Your Consideration.” This link takes you to the document sent to me by a CVS located a number of miles outside Ithaca, New York. It constitutes an enormous and potentially harmful infringement on the privacy of CVS customers.
Pharmacists and Pharmacies Do Have Responsibility to Report Medical Errors
There are many good reasons for pharmacists to contact prescribers. Out of ignorance or carelessness, or simple human error, doctors make prescription errors. In my forensic work, I have seen ethical pharmacists inform doctors that their patients were being prescribed addictive benzodiazepines, such as Xanax and Ativan, in doses that were too high for too long a time. I have also been an expert in legal cases in which pharmacies have warned doctors about potentially dangerous drug interactions.
In one case, an infant was brain-damaged over several months while being prescribed a whopping overdose of a CNS drug. A new pharmacy warned the doctor that the dose was much too large, and it turned out the pediatrician had made a mathematical error when calculating it for the infant.
Overall, I am strongly in favor of pharmacists reporting to a prescriber when potential errors have been made by the prescriber.
CVS Was Not Reporting a Medical Error; It was Tattling
So what about this warning distressed me? The form was called “MEDICATION NONADHERENCE THERAPY ADVISORY.” CVS instructed me, “A review of your patient’s retail and mail prescription history indicates that the patient has not obtained his or her first refill. Consider discussing your patient’s therapy to reinforce that nonadherence to his or her medication regiment could lead to a hospital or emergency room visit, or death.”
Notice the assumption that a patient’s failure to utilize a renewable prescription for a psychiatric drug was a form of disobedience! Notice the presumption that it was necessary and ethical to report this to the prescriber.
The drug was quetiapine 25 mg. Quetiapine or Seroquel is an antipsychotic medication and a dose of 25 mg is the smallest available. So why did the pharmacy care? Because, they assumed, as their form states, that my patient was suffering from “nonadherence,” more commonly called “noncompliance.”
Noncompliance or nonadherence is a sin among psychiatric prescribers. Nonadherence costs the pharmaceutical industry vast amounts of money and causes many prescribers to lose their patients. Noncompliance most commonly results from patients experiencing such intolerable adverse effects that they stop without “asking permission” to do so.
Spokespersons for psychiatric drugs complain mightily about noncompliance in the published literature, and prescribers too often lie to patients to make them feel safer about taking their neurotoxic drugs.
Treating Prescribers Like Idiots
In a bold print heading to a bulleted box, CVS advises in their nonadherence form for prescribers, “Please consider discussing the following with your patient:”
Some common reasons why patients may stop taking their medications are because they:
- Can’t afford it. Consider a generic alternative, if applicable.
- Forget to take it.
- Don’t like the side effects.
- Are unclear about what medication they are taking.
- Don’t understand the long-term consequences of not managing their condition.
I appreciate the irony of pharmacists lecturing psychiatric prescribers as if they are ignorant dunderheads who need the most elementary guidance from their brethren pharmacists; but I fear the consequences of their interfering in the lives of patients who may want to stop taking their medications without their doctor’s knowing it. Isn’t this still America—where you have a right to stop taking your medication with or without your doctor’s approval? Maybe not. Apparently not. Indeed, in America patients are commonly forced by doctors and the courts to take lifelong, life-destroying neurotoxins.
Refusing to Comply with Psychiatric Drugs Often Saves Lives and Prevents Tragedies
In my clinical and forensic work, I have seen many patients whose health or lives have been saved because they stopped taking drugs like Seroquel without telling their doctors. It can be dangerous to do so abruptly, and I do not advise withdrawing from drugs without experienced clinical supervision; but that does not justify pharmacists interfering in the lives of patients. Nor is withdrawal listed in the nonadherence form as one of the pharmacy’s concerns.
Seroquel, like all commonly used antipsychotic drug drugs, causes tardive dyskinesia, a potentially disabling disorder that afflicts any of the voluntary muscle systems in the body. Prescribers often fail to inform patients about these effects and the most unscrupulous ignore the symptoms while the patient gets worse. Often families must intervene to stop the medications against the doctor’s strong advice.
So what was actually going on with my patient? Working together and with her family, she and I had successfully withdrawn her from several psychiatric drugs over a five-month period. Fully informed, and with careful supervision from me and cooperation from her husband, she had come down from quetiapine (Seroquel) at 800 mg to 25 mg, and then stopped taking the drug. That is why she did not renew her prescription—she was drug-free!
In this patient’s case, she was obtaining her medication at a CVS outside of my immediate area. Because the pharmacy was unfamiliar with me, with my patient’s permission I had educated the pharmacist about what we were doing, so he would not be concerned about the unusual prescription pattern associated with withdrawal. He was very cooperative. This is one reason I suspect that my patient’s local pharmacy had little or nothing to do with the seemingly automatic warning sent to me as her prescribing psychiatrist. In fact, all of my experiences with CVS pharmacists have been positive.
CVS, Please Respond
I have always enjoyed good personal and professional relationships with CVS pharmacists both as a prescriber and a customer. I doubt that the pharmacists at my patient’s drugstore were involved in tattling. The warning sent to me was probably computer generated, but it had the potential to intrude enormously on the privacy and the autonomy of my patient. Sent to a different prescriber than myself, it could have resulted in the doctor pushing her into continuing to take a dangerous neurotoxic medication.
I hope that CVS will respond to the concerns expressed in this report. It is important to know if this policy is aimed at psychiatric drugs and perhaps especially at antipsychotic drugs, as I suspect it is. Did the company consider the ethical implications of trying to tattle on patients to enforce “adherence”? Why did it feel compelled to lecture psychiatric prescribers about the rudiments of how to relate to their patients?
Psychiatry’s Obsession with Noncompliance
Psychiatry’s obsession with enforcing compliance stems from the fact that patients often display sound reasoning and common sense when they refuse to continue taking their neurotoxins. To avoid pressure and even threats of involuntary treatment, it is in their interest to stop taking neurotoxic drugs without informing their doctors.
CVS and any other pharmacies involved in tattling should stop reporting to prescribers when their patients fail to renew prescriptions for psychiatric drugs. CVS should stop reporting on its customers, or its customers should stop going to CVS.
If you wish to withdraw from your psychiatric drugs, please do so carefully and with the best clinical supervision you can find.
Meanwhile, be wary: Your pharmacy may report you if you stop filling your renewal prescriptions for psychiatric drugs.