A pharmacist's look at the supermarket and beyond

Drugs and US

Many of the shady practices of our healthcare system are getting lit up as we continue to question exponentially increasing drug prices, the legalized creation of millions of opioid addicts, exorbitantly paid health insurance and pharmaceutical executives, and cancer doctors that benefit from expensive drug treatments that may or may not work. This is what happens when we let free-reign capitalism takes over our health care. Greed rules, patients pay, suffer, and die.

Once upon a time, I thought Mylan was a pretty good generic company. They produced a good product and had fair pricing. Then they got greedy. Heather Bresch has been CEO of Mylan since 2012 and with the help of her family pushed profits and her salary to the point where we started to notice. The $608 price tag for Epi-Pen has garnered headlines and congressional hearings. Plenty came to light in these hearings, including that Heather thought her $18.9 million salary was fairly normal for her industry. Last year, Mylan incorporated in the Netherlands, dodging millions in US taxes.

It turns out that Heather’s dad is a US Senator (since 2010) who was instrumental in landing Heather a job at Mylan. Daddy Joe Manchin is known as a “bipartisan” senator by many and as a “DINO” (Democrat In Name Only) in other circles, because of his breaks with Democratic leadership in voting to defund Planned Parenthood, support of coal, and not endorsing Obama in the 2012 election. To be fair, Sen. Manchin did co-sponsor a balanced budget amendment, introduced the Silver Alert Act, and helped put hydrocodone into schedule II.

Mom got into this act also. In 2013 Gayle Manchin became president of the National Association of State Boards of Education. This followed her appointment to the West Virginia Board of Education by her husband, who was at the time, governor of West Virginia. Momma Gayle thought that Epi-Pens were the coolest thing around and that every school in the nation should have several on hand. She was quite successful in her campaign and Epi-Pen popularity skyrocketed right along with its price.

We call all that shenanigans. Congress calls for a possible anti-trust investigation. A few politicians even dared to mention that we end the ban on Medicare being able to negotiate drug prices! Why the Hell not??!!?? We are being exploited by these greedy corporate weasels and their tools in Congress! There are over 10,000 congressional lobbyists, 100 Senators and 435 Representatives. That’s almost 20 lobbysits for each of our elected “representatives” and I use that term loosely. Look here for the top 20 BIG spenders! OpenSecrets.Org has some good info, including looking at the new phenomenon of “almost a lobbyist, a la John Boehner. As I said, tools, bought and paid for! Be very careful who you re-elect!

We discussed health insurance CEO salaries last year in this very blog. What about pharmaceutical manufacturers? Well, Johnson & Johnson’s William Weldon, took in $29.8 million, and Pfizer’s Ian Read, received $25.6 million. Abbott was right up there in the $25 million range and we know that even a generic company like Mylan paid its CEO close to $20 milllion. Is that really necessary? Even more unnecessary is that over the last ten years Big Pharma has plundered over $700 Billion in profits from the sick and the dying.

Speaking of the sick and dying…
A fairly meticulous study based on an analysis of the results of all the randomized, controlled clinical trials (RCTs) performed in Australia and the US, reported a statistically significant increase in 5-year survival due to the use of chemotherapy in adult malignancies. Survival data were drawn from the Australian cancer registries and the US National Cancer Institute’s Surveillance Epidemiology and End Results (SEER) registry spanning the period January 1990 until January 2004. The authors deliberately over-estimated the benefit of chemotherapy if the data was uncertain. Even with that fudge factor, they concluded that chemotherapy contributes just over 2 percent to improved survival in cancer patients.
Currently, doctors are paid by a simple formula: the average sales price of the drug, plus 6 percent. Pretty generous for a drug that might coast ten grand , right? But what if the drug is sold to the doctor for $5,000, and is paid by Medicare at the full $10,000. In that case, which is apparently a likely example, the doctor not only gets the 6% ($600), the doctor also pockets the extra five thosand dollars paid by Medicare, i.e. YOU and I! Changes in this scenario are being offered by the Obama administration but are being vehemently opposed by BIG Pharma, physicians groups, and “fake” patient organizations which are funded by BIG Pharma.
And you wonder why chemo is so readily offered. Check this out on

I’ve discussed the opioid problem before and some of the weird ways that we pay for these drugs. This PDF from the American Society of Addiction Medicine has most of the latest numbers. Drug overdose is the leading cause of accidental death in the United States. Here is a great article from the American Journal of Public Health that describes, in depth, the depths of Purdue’s marketing of Oxycontin, including the free giveaways like the music CD, “Get in the Swing With OxyContin” and cute little stuffed animals oxy teddy bear and nifty fishing hats: oxy-hat If you don’t think highly educated doctors can be influenced by these trinkets, the free dinners, and the island “educational” get-a-ways, you should come and spend some time in my pharmacy.

Maybe the $3 billion offered by Mark Zuckerberg and Priscilla Chan will help to change things also. Interestingly they said, “The first disease to be wiped off the face of the earth must be ignorance. The health care industry has impeded progress because it has failed miserably in the effective use of available data. It has been the poster boy of ignorance.” Yes, the health industry has failed miserably, in large part intentionally.

Email this to someoneShare on FacebookTweet about this on TwitterShare on LinkedInPrint this page

Cholesterol: the Good, the Bad, and the Sexy

Billions are spent in this country to lower cholesterol blood levels. The two newest agents would cost $14,000 per year, FOR THE REST OF YOUR LIFE! Or at least until something better comes along. It’s a safe bet that the something new will NOT be cheap!

I have been thinking more about things that we have labeled as bad for us in such extreme ways that we may have overreacted and caused ourselves more harm than if we had just tried a little moderation and try to “act naturally,” meaning use our bodies as they are designed. As I discussed, some sunlight is essential for our bodies, particularly for synthesizing Vitamin D. It occurred to me that many of our issues regarding high cholesterol are a result of our modern lifestyle and nutrition. In order to see how we arrived at the point where over 70 million of us in the United States have high cholesterol (actually high LDL, AKA “bad cholesterol”), we must first have some idea what roles cholesterol has in the healthy body.

Cholesterol is an interesting molecule, on one end a -OH (hydroxyl), making it an alcohol and slightly water soluble, then four hydrocarbon rings, the hallmark of a steroid, and finally a hydrocarbon “tail” which is the oil soluble portion of the molecule. These characteristics give cholesterol its unique qualities. Cholesterol is transported around the body via the blood by lipoproteins. That is where the infamous LDLs and the happy HDLs come into the story. The cholesterol carried by these proteins is the same, only the proteins are different.

Cholesterol is a part of virtually every cell in your body, maintaining cell wall structure, integrity, and function. It is the key starting material for the sex hormones for both genders, for the corticosteroids, and bile salts, which are essential for digestion. Cholesterol is sexy beyond its conversion to testosterone, estrogen and progestins. Cholesterol and related sterols are part of sperm production, transport, and even seem to play a role in capacitation of the sperm after ejaculation. When sperm come in contact with various sterol-binding biochemicals produced by the uterus the sperm is “turned on” and now able to fertilize the egg. Changes in cholesterol levels have been linked to changes in vaginal lubrication, pH, and possibly other factors affecting female fertility. Every sexual act requires cholesterol, with climax and ejaculation consuming some cholesterol each time. To some degree, sex (yes, even by yourself) directly lowers cholesterol, not to mention the other healthful benefits for mind and body.

Cholesterol is converted to vitamin D as discussed previously in this blog. It is also critical for serotonin receptors and other neurotransmitter receptors. It protects our nerve fibers and plays many roles in the brain, many yet to be clearly defined.

Obviously, dietary sources of saturated fats plays a role in the soaring incidence of high cholesterol. However, when seeing all the important functions of cholesterol in the body, I cannot help but wonder if our modern way of life, beyond nutrition, also plays a role in our dysfunctional lipid profiles. I already discussed how we have been taught to shun the sun. Could this avoidance of a normal biological process that uses cholesterol be a factor in higher cholesterol? I recently read that millennials are having less sex than previous generations (mine included!). Could this reduction in sexual frequency also contribute to higher cholesterol? There are some studies looking for a link between SSRIs and other psych drugs and high LDL cholesterol. Are we monkeying with normal biological pathways that require cholesterol for proper function and thus raising cholesterol levels? Are we denying our bodies the fun and frolic that keep us healthy?

Human physiology is amazing and its complexity continues to hold many secrets. Our biochemistry is a wonderful dance of chemical reactions, all trying to reach equilibrium and all part of a great feedback system that strives to keep us going. All those chemical reactions will only reach final equilibrium when we are dead. We have learned that when you tinker with one part of a biological process with drugs or other exogenous material that we can get unexpected results or “side effects” such as the dry cough from the buildup of bradykinins due to ACE inhibitor drugs.

It is clear that we function best when we eat mostly unprocessed foods low in saturated fats, and live an active lifestyle with regular exercise and sexual activity. Get outside, move around, make love, laugh, eat healthy, and you may find high cholesterol does not come knocking on your door. When I pay attention to what I eat, get outside and walk or ride my bicycle, and have some time to frolic, I not only feel better, my lab work shows numbers like this:
Cholesterol: 136
HDL: 48
LDL: 68
Those are my last lab results.
They took 3 blood pressure readings:
Blood Pressure Reading 1: 120/70
Blood Pressure Reading 2: 130/80
Blood Pressure Reading 3: 122/80

I report all this to show that even a man in his sixties can make lifestyle choices that lead to good health without pharmaceutical assistance. Somewhere around 25 million people take a statin drug to lower cholesterol. What if we didn’t just look for an easy answer like taking a pill and embraced cholesterol as a vital part of us that can be harnessed and utilized for good physical and mental health?

I believe that it is possible. Live and love!

Email this to someoneShare on FacebookTweet about this on TwitterShare on LinkedInPrint this page

D3D2: Into the Light

Vitamin D2, 50,000 units, is a fast mover in our pharmacy. This baffles me, because we have known for quite some time that vitamin D3 is a far superior form of vitamin D. The cool thing about D3 is that our bodies can manufacture D3 from cholesterol and exposure to sunlight, specifically, UVB light. I’m not going to go through the hard science here, but I do think it is fascinating and worth your time if you are so inclined. Vitamin D is important for your bones, your muscles, and your mental health!

I’ve been doing a lot of walking lately, getting ready for the Susan G. Komen 3-Day walk. I was about 3 miles into a morning walk when a fellow motioned to me that he wanted to talk to me. I turned off my headset and he proceeded to tell me that this was not the best time of day to get my vitamin D and started talking about “solar noon” which he described as from after 10AM till 2PM. I had taken my shirt off to get some sun and he must have assumed that I was on a mission to get some vitamin D. I do indeed like getting my vitamin D naturally and I also like not looking like a beached white whale when I visit Hawaii or the Caribbean. Hawaii But, please take note! I try very hard to limit my sun exposure, paying close attention to the length of time and the time of day that I walk around without a shirt on. I’m pretty white. To tan, I must expose myself very gradually to the sun, which works out great for vitamin D production. The usual recommendation is about half the time it takes for the skin to turn pink. For my skin, that’s about 20 to 30 minutes depending on time of day.

Living in Arizona, this whole “solar noon” thing intrigued me. Walking at high noon in Arizona, in August, is just plain crazy. It’s friggin’ hot! I told the guy that the amount of UV radiation reaching us during the day is somewhat of a bell curve so I was still getting my vitamin D even though it wasn’t even 9AM yet. That’s what my logical, scientific mind thought, anyway, and later I decided to see if I could verify that theory. I discovered the WillyWeather website that has the UV index for the Phoenix area, day by day, hour by hour. Lo and behold, it’s a bell curve!

My science served me well in this case, at least as far as the bell curve theory. But am I getting any vitamin D synthesized? Most sources that I checked suggested a balance between exposure and protection. It appears that a UV index around 3 is what will yield good vitamin D synthesis while minimizing the risk of skin damage and the formation of those dangerous radicals that could lead to skin cancer. I am pretty happy to discover all that. During these training walks we often start at 5AM. I will often take my shirt off around 7 to 7:30, if in an appropriate environment, and get covered back up by 9AM. This seemed intuitive to me and I feel more comfortable doing this now that I have done the research. The UV index in the Phoenix area hits 3 between 8AM and 9AM. Again, I trust in that bell curve and feel that even when the index is 2, I am synthesizing some vitamin D. Plus it feels good to have the morning breeze on my skin! We all live under the same sun and as long as we respect its power, we can all benefit from it.

Getting back to those bottles of 50,000 IU vitamin D2 on my shelf.. How long will it take for prescribers to catch up with the science and start ordering D3 for their patients? Both forms are very low cost and well tolerated. For some great guidance and solid information, visit the Vitamin D Council website. I encourage my pharmacist friends to spread the word so that we can get D3 onto that shelf where we have the D2 stacked now. To my physician and other prescriber friends, what are you waiting for?

Email this to someoneShare on FacebookTweet about this on TwitterShare on LinkedInPrint this page

Boob News

I’m in the middle of training for the Susan G. Komen 3-Day Walk for breast cancer. I’ll be joining my wife and her team to walk 60 miles in 3 days in the Twin Cities (August 19-21). I’ve helped out the team in the past 8 years by running errands, fetching jackets, taking jackets away, bringing ice cold Diet Cokes or G2 and ferrying the team from day’s end to the hotel and back again in the morning. In that role I’ve been called “team bitch,” “walker stalker,” and last year a lady gave me my personal favorite, “underwire.”
You have to realize that there are hundreds of teams and thousands of walkers for these events and their team names often eschew normal political correctness with team names proudly flaunted, using every variation of slang for breasts from ta-ta’s to tits (including itty bitty titties), boobs and boobies, of course, hooters, second base, cupcakes, and many more. So pardon any lack of decorum on my part.

It’s no wonder then, that I am attuned to breasts and stories about breasts when I see them. Who am I kidding? I’ve been tuned into breasts since my first ex utero meal. Here are couple developments that I recently noticed:

I caught this headline in USA Today: “Why Millennials are Going Braless” and I just had to see what was going on (or coming off!). It seems that this generation of young women are opting for lighter, wireless “bralettes” of simply doing without. As a teenager in the 60’s, I recall stories of women burning their bras as a statement of liberation for women. For young men like myself, our solidarity in that cause may have been somewhat tainted by the desire to see nearly naked boobies parading around our neighborhoods. Right on, sister!
This new phenomenon of minimal breast support is even having an impact of sales at places like Victoria’s Secret, where bra sales are are sagging and its stock price is down 30% this year. With about 1/3 of their revenue traditionally coming from bra sales, that is no surprise. The Wonder Bra is on the way out in favor of the more natural style preferred by Millennials. Victoria’s Secret now offers bralettes that are very light, offering little support or padding but are stylish and meant to be exposed. Maybe sales will bounce back. Celebrities are leading the way as they do in most areas of fashion. It looks like my underwire nickname may be in jeopardy. Also, according to Plastic Surgery News there were 279,000 breast augmentations in 2015 and that is down 2% from the previous. For the record, I like ’em natural.

About half of US states have breast density notification laws. Now before you guys start running around hefting the boobs in your lives, this is actually medically important because high breast density is a risk factor for developing breast cancer. The problem is that there is huge variation in how mammogram density results are interpreted and/or obtained. The human reading the results is the primary cause of variation as different providers must be subjective in their finding. There are no clearly measurable results that can be shared in a uniform manner. Even different brands of mammography equipment will show differing degrees of tissue density. Of course, BMI, race and ethnicity are also factors. Finally, the amount of compression used on the breast during the procedure can result in a different appearance. Talk about having your tit caught in a wringer! Roughly 2 out of 5 women have dense breasts and would be considered for additional tests such as MRI or ultrasound. There is hope that computer models will bring some objectivity to the measurement of breast density. Until that happens keep doing your self exams and always discuss your options with your trusted doctor.

Support a 3-Day walker!

Email this to someoneShare on FacebookTweet about this on TwitterShare on LinkedInPrint this page

Medical Food Gets Served

We do not dispense much medical food in the pharmacy where I work. It’s been limited in the past to products like Axona and we may have ordered in some Pulmocare too. Some folks might even consider products like Ultrase (pancreatic enzymes) to be a medical food. Others would add those special folate products like Cerefolin and Folgard to the list. Most of these have been covered by prescription insurance but I wonder if that will continue considering a recent FDA action: the final guidance reiterates FDA’s original premise that medical foods cannot bear the term “Rx only” because that term can only be used in the labeling of prescription drugs, and that medical foods should not bear an NDC number, which could cause the product’s labeling to be misleading. Of course, if these products are not prescription products, I expect many prescription plans will not cover them and if they bear no NDC number, pharmacies will have no easy way to bill them through normal Rx billing methods. The NDC is universally used as a drug identifier on pharmacy claims. Note that the recent FDA guidance is the final one, so now these specifications will become fully enforceable.

To be fair, I never understood why something like Folgard was Rx, other than to generate sales via insurance coverage. Here is what is in Folgard: 2000 IU vitamin D3, 800 mcg folic acid, 12 mg vitamin B6, 120 mcg vitamin B12. You can see that there is nothing there that makes you jump ump and say “Wow! That stuff should be prescription only!”

The FDA guidance says that Inborn Errors of Metabolism (IEM) could be managed by a medical food, so long as the specific IEM cannot be managed with modification of the normal diet alone. An example used is phenylketonuria, the impaired metabolism of phenylalanine. Interestingly, Lofenalac, an infant formula created by Mead Johnson, is considered the first commercially developed medical food brought and was brought to market in the late 1960s. Conversely,the FDA reasons that the galactosemia (an IEM of impaired galactose metabolism) is commonly managed by limiting intake of lactose and galactose.

All this is relatively new and will take some time to all shake out. My guess is that we will see fewer and fewer of these products covered by Rx insurance, whether Medicare or private. The sad part is that many patients could benefit from good medical foods that in many cases are superior to drug therapy or are, in fact, the only option to manage their IEM.

You can find an FAQ on the latest guidance on the FDA web site.

Email this to someoneShare on FacebookTweet about this on TwitterShare on LinkedInPrint this page

My DNA Makes Me Wonder

A while back I send some spit into for a DNA analysis that would show my general genetic origins. Having heard speculation that we had some American Indian blood in our family tree, I was quite anxious to see if this was true. I have also researched my family tree using the resources on and other web sources, tracing my patriarchal line back to some of the earlier colonizers of Quebec. I was able to identify when some of my ancestors came from France to the areas around Quebec and Montreal. Much of this research is quite murky and found me brushing up on my French skills as I tried to decipher scans of birth, death, and wedding records that were written over 400 years ago in various styles of cursive and in French. Challenging to say the least!

Anyhow, with information like what I found about some of my possible ancestors leading me to discover many liaisons with native Americans which gave rise to a mixed race dubbed “Metis,” I fully expected my DNA to show some native genetic trace. Here is an example of the stories that led me to that conclusion:

647 December 3: (I)-Medard Chouart Des Groseillier (1618-1696?) married Helene Martin, in Fort Quebec and settled down in Trois Rivieres; being the first wedding in several years (this is not true). Helene is the daughter of a river pilot, Abraham Martin, whose land would become known as the Plains of Abraham. Medard’s second marriage after the death of his first wife, is to (II)-Marguerite Hayet dit Radisson,a half sister of (II)-Pierre Esprit Radisson, Metis, (1632-1710). Pierre Radisson, at age 15, while out on a duck shoot, is captured by the Mohawks and taken to Lake Champlain. He is adopted by the tribe and became an Indian. He and a Algonquin escaped but were soon captured. The Algonquian is killed and (II)-Pierre Esprit Radisson, Metis (1632-1710) is tortured but rescued by his adoptive family. He later escaped to the Dutch Fort Orange near Albany, New York, worked as an interpreter for the Dutch, and then made his way back to Trois Rivieres- all before turning 21 years old. (see Radisson 1631)

1649 January 19: A female of age 15 or 16 is hung at Quebek (Quebec) for theft and Monsieur (I)-Abraham Martin, dit I’ecossois (1589-1664) a Scotsman is accused of violating (raping) her. Some suggest a sixteen year-old girl in Quebec, sentenced to death for theft, escaped death by acting as her own executioner. Still others suggest the executioner is a pardoned criminal and the girl is hung.

1649 February 15: Kebec, (I)-Abraham Martin dit L’Ecossais (1589-1664) is imprisoned on a scandalous charge concerning a girl 15-16 years old who was executed this year for theft. It is said this old pig Abraham had debauched the girl. This could be the reason the birth and marriage records are not retained, the Jesuits likely cleared the files?

from New France: Quebec Cultural Roots by D. Garneau

Apparently the Jesuits were some of the few people reading and writing and thus controlled what records were kept and there was a bit of sanitizing going on. Also plenty of shenanigans!

Here too is a record of showing the mingling of New World and Old World DNA:

1638 May 22: Kebec, marriage (I)-Etienne Racine, b-1607 to (II)-Marguerite Martin, Metis (1624-1679) daughter (I)-Abraham Martin dit L’Ecossais (1589-1664) and Huron savagesse and/or Marguerite Langlois, Metis b-1611?, see 1624: It was on May 22, 1638 that, Father Nicolas Adam fulfilled his parish duties at Quebec. He blessed the union of (I)-Etienne Racine and (II)-Marguerite Martin, Metis, b-1624, now fourteen years old. Olivier Tardif/LeTardif and Guillaume Couillard were present. Promise of marriage was made November 16, 1637.

And then I get my DNA results back and it shows 100% European ancestry! Here’s what it shows:
Europe 100%
Ireland 28%
Europe West 19%
Italy/Greece 17%
Iberian Peninsula 15%
Scandinavia 12%
Great Britain 8%
Trace Regions 1%

Everything that I learned first-hand from my family elders and everything that I learned from my research on-line makes me doubt the accuracy of these results. Everybody that I met in the family had very strong French roots. So now I wonder if a different agency might use different technology for their DNA testing and I am tempted to spend a few bucks to get a second opinion.

Email this to someoneShare on FacebookTweet about this on TwitterShare on LinkedInPrint this page

Hygeia Acceptance Speech (annotated)

Just one day before starting vacation I was honored to receive the Bowl of Hygeia Award for Arizona. I knew I would give a little speech so here is what I wrote. I’m not much for reading from a script, as anyone who has been to one of my talks knows. So I’ll try to give you some of the ad-libs as I remember them (in parentheses) and some mental background (italics).

Hello Arizona pharmacy! I’ll be brief. Action speaks louder than words. (This went a little wordier as I commented on my wife’s comprehensive introduction and recount of my service and good deeds) (After hearing her speech, I was taken by how many of my endeavors involved sports and the Susan G Komen 3-Day. I almost commented that “wow, after hearing Kathy talk about me, you must think I’m all about balls and boobs!” but I held my tongue)

This is truly an honor and I am humbled to join the ranks of so many wonderful pharmacists, many of whom are here today. I have to give thanks, starting with my family, especially my wonderful wife Kathy, who is already a Hygeian. (I was paraphrasing by this point and I don’t think I used the term Hygeian to describe Kathy) I love you always, babe. To the many pharmacists and technicians that have been a part of my career, names like Savage, Wastchak, and Kristal that many of you may recall fondly. To my Fry’s family (Paul says we now have 8 Hygeia winners), to ASU, (kept out the part where I was going to say that my stint at ASU was like a 12 year rotation with a focus on sex, drugs, and rock & roll because I didn’t want to make the other schools jealous.) UConn ( I gave a nod to Jim and Maria, fellow alum), and the AZPA ( gave a plug here to encourage everyone to find a new member!). To the U of A and Midwestern for letting me precept their students, keeping my brain agile and alert. To my amazing mother, whose values and unconditional love started it all and kept me going through thick and thin. (Got a little emotional here and rambled something about living on rice and veggies while working my way through school) (that may have been a little cheesy, but true, and it got me back on track).

Being a part of the Mesa Leadership program was a terrific opportunity to learn about my community from the inside out, giving me a chance to meet our leaders and learn where I could make a difference. This diverse (I told them awkwardly just how diverse) group had many sessions where we worked out solutions to problems through respectful debate and a desire to do some good. In this election year, I will demand the same attitude from my elected leaders.

I would encourage more pharmacists to take part in these types of civic programs which are a great way to broaden your horizons beyond pharmacy and have an impact on your community. (paraphrased, then I glanced down to get this next part right…)

Our national political environment has developed into a shallow spectacle, where demagoguery is acceptable (and unfortunately, effective), corporations are people, and money is free speech. Don’t let yourself be drowned out. Participate beyond voting. We elect people to represent us and to work together for the common good. Insist on that. (I added that I would like to throw them all in a room and lock them in until solutions were found) (My first draft was harsher and contained the phrase “the bastards” so I was pretty smart to edit it to something more appropriate to the occasion)

Thank you all for being a part of this grand adventure and keep pushing the envelope. Get out there and do more good! Thank you all! (or something pretty close to that)

Email this to someoneShare on FacebookTweet about this on TwitterShare on LinkedInPrint this page

Community Pharmacy

I’ve been giving some thought to the future of community pharmacy. There are around 180,000 pharmacists and 260,000 pharmacy technicians working in community (retail) pharmacies in this country. That is a lot of manpower, and so, significant potential power. Here in Arizona the numbers are about 6,000 and 9,000, respectively, according to the US Bureau of Labor Statistics as of May 2015. Imagine the powerful impact on the practice of pharmacy, healthcare and our communities if there was a concerted effort to bring positive changes to our workplaces, our best practices, and in our patients’ lives.

Many pharmacists expect change to happen through action of their state associations, yet participation in these organizations is almost universally dismal. In states where membership is not mandatory, the percentage of member pharmacists barely reaches double digits and technician enrollment is usually less than 10%. Our state association has evolved over the years, combining the original health system pharmacists’ organization with the more general pharmacy association. The Arizona Pharmacy Association has a mission to serve and represent all pharmacy professionals in all practice settings. One of the challenges facing pharmacy is how to leverage our collective power to effect positive change. Is it through our professional association, our elected representatives (changing regulations), a pharmacy union (as some suggest), or do we just grab our paychecks and look forward to our next vacation?

I believe that no matter what steps our association, and its sub-committees (or “academies” in Arizona) take to promote change there must be an ongoing drive to grow membership and participation.
The active members currently involved should be taking a close look at issues that directly affect their work environment. Membership and participation will grow when there is evidence of specific support for changes that improve our daily lives. Some of the things to consider are already ripe for change, while others are approaching as technology and market forces drive the evolution of our practice.

Work Environment
Many community pharmacists that I talk to feel that although they are well compensated monetarily, they are not treated as professionals. Many cite the lack of breaks and meal times, long hours, and dehumanizing metrics. Chain drug stores like CVS, Wal-Mart, and Walgreens have been sued and settled a variety of lawsuits from unhappy pharmacists, whether for unpaid overtime, lack of breaks, age discrimination via metrics, racial discrimination, and other issues regarding personal beliefs. Clearly, pharmacists deserve to be treated like professionals, with decent work hours, appropriate compensation for overtime using labor laws as a guide, reasonable work breaks, proper appreciation and utilization of more seasoned (older) pharmacists, and reasonable metrics that are used as tools for improvement (as promised) and not cudgels to drive profits. I believe broad based representation of retail pharmacists and pharmacy technicians within the state association could allow meaningful discussions resulting in useful ideas to improve the workplace environment.

Automation is inevitable in retail pharmacies. Many already have dispensing robots, counting machines, and other time-saving devices. How this balances against the duties and responsibilities of pharmacists and technicians is a process that we must be involved with if we expect results that do not further diminish the importance of the human roles in the practice of pharmacy.

New educational standards for pharmacy technician training programs were put forth by ASHP and APCE effective January 1, 2016. These new standards include requirements for a minimum of 600 clock hours of health-related education and training, extending over a period of 15 weeks or longer. Those 600 hours must include 160 hours of didactic learning, 80 hours of simulated activity, and 160 experiential hours. As new technicians are asked to achieve this new standard, their expectations will rise accordingly as will wage pressure. Again, state associations should be developing objective transition models that consider existing conditions and new demands.

The pharmacy that I manage generates roughly 40 cubic feet and waste every day, most of it paper and plastic. With over 67,000 pharmacies in the U.S., there is a huge opportunity here. There are only a handful of retail pharmacies attempting a recycling program. Sure, there are challenges, but by recycling empty stock bottles pharmacy waste could be reduced by 50% or more. These folks have taken a good look at the problem and offer some germane ideas. Many rigid plastics take over 450 years to break down in the environment. Let’s get busy and do our part to save the planet.

We have some incredibly intelligent and talented people in our field, many are passionate in their zeal to improve our profession, our patients’ lives, and our world. I submit that state pharmacy associations are the ideal place to bring these people together and create the future. You have to be involved to make it happen.

Email this to someoneShare on FacebookTweet about this on TwitterShare on LinkedInPrint this page

Questionable Drug Coverage

Something smells foul in this situation. Why does a prescription drug plan prefer a brand name drug (Nucynta) that costs over four times as much as a generic (oxycodone with acetaminophen)? We are talking over $400 versus about $100 respectively. You can be pretty sure it’s not therapeutics!
My cancer patient was once again besieged by his insurance company. He had just been enrolled in a new Medicare Part D plan and it seemed that every facet of his medication therapy was being challenged. This is a patient whose health care team has worked diligently to not only keep him alive but provide a decent quality of life. Now his anxiety level was being ratcheted up by long letters from his new drug plan that threatened the successful management of his disease.
Of course, the first hurdle was getting new “prior authorization” for meds like the tincture of opium that he needs to reduce his number of bowel movements to less than 15 per day from the 30-something he experiences without treatment. Fortunately, we were able to anticipate this hurdle and good communication with the doctor, his community pharmacy, his specialty pharmacy, and the plan, allowed us to get the prior authorization in time for his next prescription.
The latest letter (four pages!) from his plan stated that his Rx for oxycodone with acetaminophen would only be covered one time for a 30 day supply and then he would have to switch to the formulary drug, Nucynta. The reason given is that although the oxycodone product is on formulary, “you must first try other drug(s), specifically NUCYNTA IR, as part of what we call a step therapy program.” This patient has been battling colon cancer for five years! He has been through every possible “step” to manage his pain that you can imagine! So now his health care team is again forced to spend time convincing the health plan to cover the drug that works best for this patient.
Trying to determine why this step therapy was required led me to look into the Medicare Part D money trail. Although I cannot say that this patient’s plan is involved in any of the practices that I uncovered, the fact still remains that a higher priced drug is being “pushed” on plan patients.
Some of the strategies that may lead to a decision like this have been exposed in the past. For instance, pharmaceutical manufacturers settled suits where they were shown to have given “concealed discounts” to pharmacy benefit plans in the form of interest-free loans, “data processing fees,” and “risk share” rebates tied to growth in an insurer’s outlays for the drug companies’ products. There have also been instances of “price bundling” where one or more products in the manufacturer’s catalog is steeply discounted to be put on a plan’s formulary, while other, expensive brand name drugs also get added to the formulary as part of the “bundle.”
Prescription benefit plans also have a financial interest in getting discounts from manufacturers, especially for drugs sold during the patient’s pre-donut hole spending. During this part of coverage the plan gets a direct subsidy from Medicare. This is a fixed subsidy, unaffected by any discounts that the plan may have negotiated with manufacturers. Once the patient is past the donut hole, the subsidy is based on actual drug cost. Apparently we can thank Congress for that little gift to insurers.
That is how we have the paradox of a $400 drug which may or may not benefit my patient being preferred over the low cost generic that has worked well for him over several years. I have no idea why this drug plan prefers Nucynta over generic Percocet. I am certain, however, that is more about money than therapeutics.

Email this to someoneShare on FacebookTweet about this on TwitterShare on LinkedInPrint this page

Dust to Dust

I am allergic to amoxicillin. Reconstituting hundreds of amoxicillin suspensions through my early years as a community pharmacist is how I feel that I sensitized myself. That was back in the days of Trimox, Wymox, and Amoxil. I remember the great deals we used to get buying these products directly from the manufacturer, with prices way below AWP, and getting six months to pay. Some companies would even give free gifts, from teddy bears to TVs!
Back to that pesky allergy. I had some dental work done and the dentist ordered some amoxicillin for me and shortly after the first dose, I developed a bight red, very itchy rash over most of my body. I had no prior problems with any of the penicillin family of antibiotics, taken years earlier. We found an alternative and time and Benadryl cleared up the rash. I thought back to mixing all those pediatric suspensions when the water was added and a little pink cloud of powder rose out of the bottle like smoke from a chimney. Occasionally, I could even taste or smell it, so I know it was getting into my body. A certified technician is now my preferred method of reconstituting any of the penicillins. Either that or I hold my breath!
Much more recently, I have had the “opportunity” to do much more product dispensing (counting and pouring) than usual and another concern became apparent. No, not the lack of technician staffing. I addressed that 2 or 3 blog posts ago.
Moving from the pharmacist work station to the dispensing counter, I often inherited an incredibly dusty counting tray and spatula. I think this is a pretty common situation in most retail pharmacies and perhaps in other types of practice sites as well. How much of this drug-laden dust are we passing on to the next patient?
I’ve always been pretty meticulous about using a clean tray, wiping it down frequently with a paper towel damp with alcohol. Obviously, others are not so rigorous. The tray in the picture may be an extreme example of a dusty tray, but it is something I find from time to time at a variety of practice sites. counting trayAre we increasing the incidence of drug allergies within our patient population by not frequently cleaning the apparatus we use to move the “pills from the big bottle to the little bottle,” as Jerry Seinfeld has described community pharmacy practice? I think it is entirely possible. Exposure to these minute amounts of drug may not only lead to new allergies that could potentially cause harm or confound future treatment plans, there may be other biological consequences to this low level exposure. Just look at the changes to our animals friends that are caused by drug contamination of the environment.
In our busy workdays, we rarely have the time to contemplate issues such as this, which may seem inconsequential, but are actually overlooked problems with easy solutions.

Email this to someoneShare on FacebookTweet about this on TwitterShare on LinkedInPrint this page
« Older posts