SUPERmarket PHARMACIST

A pharmacist's look at the supermarket and beyond

Crabs Up For Grabs

We have an Angry Crab restaurant down the street from our home. It’s loads of fun! You get great seafood and just throw all of it on the table and start cracking, slurping and sucking, with butter and juices running down your arms to your elbows and all over your face. We destroy these crabs! No wonder they are angry.

I discovered another angry crab recently. I came across an great article about harvesting, in this case bleeding, horseshoe crabs. Turns out that the blue blood of horseshoe crabs is the best way we have to detect dangerous gram negative bacteria. These bad germs could turn up in insulin, on medical devices like scalpels, IV sets, or even on your knee or hip replacement!

The magical substance that does the actual detecting is called LAL for short, or Limulus Amoebocyte Lysate. Limulus polyphemus for the species of horseshoe crab, Amebocytes are cells in the crab’s blood, and Lysate, as you may recall is the result of lysing or breaking the integrity of the cell. You can imagine that this stuff is not cheap. Estimates put the cost of this blue blood lysate at $15,000 per quart and a single LAL test kit costs about $1000.

To their credit, the six U.S.companies only take about one-third of the blood from each crab and return it to the ocean, where it is assumed they recover, much like we would after donating blood. We don’t donate 1/3 of our blood though! Of the 500,000 crabs that are bled each year, over 50,000 perish and there is also concern that fertility is diminished. Horseshoe crab populations are dwindling. As if marine species don’t have enough problems with rising temperatures, disappearing beaches, and floating plastic debris, this species is hunted for its blood. Horseshoe crabs are also eaten, well at least, the roe is. It’s quite a delicacy in Thailand, for instance.

There is hope on the horizon. Scientists reasoned that if the specific molecule that was responsible for detecting the gram negative toxins was isolated, and also identify the gene responsible for producing this molecule, we could mass produce an effective product without relying on crabs. A couple of scientists, Ding and Ho, did just that. Big Pharma was slow to adopt the new technique, however, and there are few companies that sell the recombinant Factor C kits. Factor C kits were approved in Europe in 2016 and Eli Lilly, one of the pioneers of recombinant DNA insulin, is lobbying hard for approval here in the U.S. Perhaps horseshoe crabs, a species that’s been around since dinosaurs walked the Earth, will survive another millennium or more!

I Hear Crickets

I was unable to find them in my marketplace, but crickets (and other insects) are on the way to the mainstream. At a recent Fancy Food Show there were at least three enterprises offering cricket-based, high-protein products. Although there are still some questions regarding labeling, preparation, and safety, with a potential billion dollar market predicted in the US alone, these will be resolved. Much like those who question almond “milk,” (where are the mammaries on an almond?), some take exception to the term “cricket flour,” saying that flour can only come from grain. Most of the commercial products that I have seen use the description, “cricket protein powder” and the word flour sometimes appears in parentheses. It’s already getting resolved.

Cricket farming, or ranching, does require plenty of preparation and some pretty precise housing requirements, including a nursery, if you want to keep regenerating a supply. The turnaround time is pretty quick. Crickets are usually harvested at 6 to 8 weeks. Much is being learned and many proprietary feeds and methods are being developed. Crickets are omnivores and crickets might do well on the grain leavings from large scale breweries and other wasted by-products. The protein profile is robust but with current prices somewhere in the area of $40 per pound, we have a ways to go to make cricket powder a family staple.

Crickets can be sun-dried, freeze-dried, dehydrated, or baked in an oven. If you’re willing you can add seasoning along the way during any of those processes or season them later. They’d be ready to eat as a crunchy snack at that point. Kind of hard to dip though! Most popular is to grind or mill the crickets to a fine powder that can be added to a variety of foods. The high quality stuff gets two or more millings, one rough grind from which legs, wings, and other bits which might get stuck in your teeth are removed. That would help!

All this makes me think back to summers in Maine when the family would drive to Lake St. George for a swim and a picnic. There was this little country store on the way that all kinds of things that we never saw in town. One of our favorites was a small box of foil-wrapped chocolates. Each bite-sized morsel contained different insects: grasshopper, cricket, bee, or ants. I think they were color coded and I recall the bees as being a favorite. I have no idea where they came from or how much they cost but for a couple preteen boys it was way cool to eat those suckers! But I digress.

Be prepared. The crickets are coming to your table. With low impact on the environment, cricket ranching is a growth industry. Even cricket poop is good shit. It’s dry, easy to handle, and ship. It has good amounts of Nitrogen, Phosphorus, and Potassium (i.e. good NPK values, for you farmers). The official term for cricket waste is frass, by the way, and I don’t know why. Frass goes for about $10 a pound. Don’t eat it, fertilize your garden.

Canada’s largest grocer already offers cricket powder under their President’s Choice private label. The supplier of the cricket powder is Entomo Farms of Ontario. Cricket farm co-founder Jarrod Goldin says,”The taste varies based on concentration. A small amount won’t add any flavor, otherwise it has a very lovely, earthy, nutty, mushroomy kind of flavor.”

Other bugs are out there too, waiting to jump onto your plate and provide a greener alternative to high environmental impact meats like beef, chicken and pork. Hmm. I’ll have top check and see if bugs are part of the Green New Deal!

I dare you. Eat a bug!

She So Horny

With props to 2 Live Crew.
On June 21, 2019, the FDA approved bremelanotide (Vyleesi) injection, indicated to increase sexual desire and libido in premenopausal women with Hypoactive Sexual Desire Disorder, or HSDD. Of course, I had to take a closer look. First I had Shay, pharmacy intern, write up the basics. Seems bremelanotide is an analog of naturally-occurring melanocyte stimulating hormone (MSH). Both the drug and the hormone are melanocortin receptor agonists, associated with skin pigmentation, weight regulation, and sexual responses. Note that the drug is not reported to enhance sexual response nor satisfaction, only desire, aka horniness.

The drug is injected under the skin at least 45 minutes before sexual activity, has a half-life of 2.7 hours, and is not to exceed 8 doses per month. The most common side effects (some you might guess) are hyperpigmentation of the face, gums, and breasts (incidence >50%!), flushing (about 20%), headache (about 10%), and nausea (up to 40%, but reportedly less with subsequent doses). Wow, doesn’t that sound sexy!?! The Vyleesi website cautions that “The duration of its effect after each dose is unknown.” Damn, they really studied the Hell out of this, huh? The hyperpigmentation is more common in patients with dark skin AND, so far, it does not seem to go away, even after the drug is stopped.

On the positive side, the web site also claims that Vyleesi will (oops, they use words like “could” and “may”) improve negative body image, relationship stress, and will improve self esteem. The super hip web site even uses text shorthand, saying “Low self-esteem: It can even impact your confidence. (ICYMI: you are great!)” In Case You Missed It.

Does it work? Well, there were two 24-week randomized, double-blind studies, and the FDA reports: “In these trials, about 25% of patients treated with Vyleesi had an increase of 1.2 or more in their sexual desire score (scored on a range of 1.2 to 6.0, with higher scores indicating greater sexual desire) compared to about 17% of those who took placebo.” So a bit better than placebo in 1 in 4 women that tried it. Not great, but maybe it could help some, although I have my doubts considering the side-effect profile.

Check this out: In 2012, the FDA identified female sexual dysfunction as one of 20 disease areas of high priority and focused attention. Take heart ladies, the FDA is focused on your sexual dysfunction! For the past seven years! Vyleesi may by only the beginning. More drugs are on the way. I’m sure many women would like to see an injectable drug (with a big needle!) for men that are assholes. We could have IAD, Inappropriate Asshole Disorder, and it would be treated with a drug with many side effects. But I digress.

HSDD was examined fairly well in a study published in Sexual Medicine. The drug will be launched in September 2019 and I was unable to find pricing information. Note that an increase in melanocortin leads to an increase in dopamine (which likely plays the key role in increasing desire), so perhaps you would be better off trying bupropion first!

Homeophobia

I’m waiting to see if the recent death of a 7-year old boy in Italy has any effect on how the FDA regards homeopathic products. The child was originally diagnosed with a common ear infection. Eschewing antibiotics, the parents opted to treat the boy with preparations provided by a homeopath. The boy eventually lapsed into a coma and died three days later. The Italian court sentence the parents to a three month sentence for aggravated manslaughter. We all know this is just the latest in a long list of therapeutic failures by homeopathy. This madness must end!

This so-called alternative medicine is simply quackery, nonsense, and vile bullshit born of greed and ignorance. I’ve been through this before, so please read Duck and Cover! for more information.

Now, I’d like to spend some time holding the FDA accountable. here is what the FDA says about homeopathic products. The most telling statement, to me, in that document is, “prescription and nonprescription drug products labeled as homeopathic have been manufactured and distributed without FDA approval under the enforcement policies in FDA’s Compliance Policy Guide (CPG) 400.400 since 1988.”

Here is what those brilliant scientists in Congress concluded about homeopathic products: “due to the unique nature of these drug products, some requirements of 21 CFR 211 are not applicable, as follows:

  1. Section 211.137 (Expiration dating) specifically exempts homeopathic drug products from expiration dating requirements.
  2. Section 211.165 (Testing and release for distribution): In the Federal Register of April 1, 1983 (48 FR 14003), the Agency proposed to amend 21 CFR 211.165 to exempt homeopathic drug products from the requirement for laboratory determination of identity and strength of each active ingredient prior to release for distribution.

So the FDA has been effectively neutered and lacks power to act. According to statistica.com sales of these products approached half a billion dollars in 2018. A part of that money is used to buy, oops sorry, lobby congress to keep the FDA and sanity from impeding profits. Yet another example of corporate greed influencing our so-called representatives. Vote ’em out!

To add insult to injury, notice that there are homeopathic prescription products. A recent student on rotation, Reggie Greenwood, easily identified over a dozen homeopathic Rx products. This was prompted by the arrival of a worker’s compensation prescription for Traumeel. Granted this is a small part of what is wrong with our health care system as only about 2% of American use homeopathic products, although that number is growing. I take heart in the fact that there are lawsuits pending against retailers like CVS and WalMart for deceiving customers by offering these products. Thank the Center for Inquiry for these lawsuits. They state, “CFI, an organization advancing reason and science, says the mega-retailer is deceiving consumers by making no meaningful distinction between real medicine and useless homeopathic treatments on its shelves and in its online store, misrepresenting homeopathy’s safety and efficacy.

Other retail outlets should beware. I have spent a fair amount of my time as a pharmacist dissuading patients from spending money on this crap and I won’t stop.

The American Institute of Homeopathy spent $100,000 lobbying Congress last year. That is just one of the groups that is involved, with friendly sounding names like the Integrative Health Policy Consortium, and the American Association of Homeopathic Pharmacists (WTF!!!???!!). I’m not going to bother linking to those websites.

Don’t let your friends or loved ones waste their money on this crap!

Emphasis used in quotes are my editorial prerogative.

If You Will Recall…

The continuing barrage of recalls of losartan and other ARBs is causing quite a bit of trouble in the pharmacy world, with millions of dollars in recalled products and untold man-hours dealing with the logistics of a Class One recall. Although the latest round of recalls have been “voluntary” recalls initiated by the manufacturers, each recall that I have seen is being treated as a Class One recall by pharmacies.

In addition to scaring the bejeezus out of patients with letters and phone calls, news alerts, and the inevitable spread of misinformation, which I guess we call “Fake News” now, the recalls continue to roll out. Anyway, I thought I should dig into this. Back when I was fat and ugly, I was on losartan for a time and although I don’t plan on being that fat or ugly again, I still want to know the facts.

The FDA recently unveiled new testing methods for the three nitrosamines of most concern, NMBA, NDEA, and NDMA. The FDA has “acceptable” limits for these three suspected carcinogens set at less than 100 nanograms per day. A nanogram is a billionth of a gram! The FDA states, “The acceptable intake is a daily exposure to a compound such as NDMA, NDEA, or NMBA that approximates a 1:100,000 cancer risk after 70 years exposure.” That’s one cancer for every 100,000 patients exposed for 70 years! Note that most carcinogens take decades to have apparent effect.

The thing is, these nitrosamines are not exclusive to pharmaceuticals. They are in our food, water and air too! For this discussion, I will try to focus on the three N-nitrosamines named above. These are notoriously found in cured meats, notably in super delicious crispy bacon (sigh), beer, (sigh), and even our water supply (double sigh). Before this gets too gloomy, here are some bright spots: Microwave cooking of bacon likely creates fewer nitrosamines, and most beer makers have adopted newer malt drying methods that reduce the amount of nitrosamines in their product.

NMDA has been studied most extensively of the three and has been demonstrated in factory discharges (constraints on which have recently been relaxed by the current administration), and detected in diesel exhaust. My point is that we have been and continue to be exposed to these chemicals. Even the FDA seems to acknowledge reality as it now “is temporarily not objecting to losartan with NMBA below 9.82 ppm remaining on the market,” which is considerably higher than the recall benchmark of 0.96 ppm.

With all that in mind, feel free to make your own decision based on this knowledge and after consulting your health care providers. Our current level of medical knowledge allows us to live longer. For many, that means cancer will appear eventually, if we live long enough. For others, it never appears at all. Until we unravel all the mysteries of life, death, and cancer, we are all left to make our own choices and live with the consequences.

Keep up with drug recalls here at this FDA page.

Sweet Nightmare

Diabetics are in the news as insulin prices soar to levels that many cannot afford. Patients are rationing themselves to the point of death. Still many in Congress have been brainwashed to believe that not only do we have the best healthcare system in the world, drugs companies are doing everything they can to lower prices on critical drugs like insulin.

Many of my pharmacy colleagues may not remember the names Banting and Best from the University of Toronto who had worked with dogs (under the forbearance of Professor John Macleod) to demonstrate that a pancreatic extract could alleviate morbidity and mortality in dogs without a pancreas. By 1922 they tried a purified version on a 14-year-old boy with a degree of success (the first injection resulted in minimal effect and a sterile abscess at the injection site). Further purification by a University of Toronto biochemist named Collip yielded a better product. Once word spread through the scientific community the improvements came fast and furious. Soon commercial products from beef and pork took over the market.

You can Google the details of further development as well as I so I’ll simply say that from that first bold trial until 1978 when the first recombinant DNA human insulin was produced by Genentech. Genentech signed an agreement with the Eli Lilly company to commercialize the product and in 1982 Humulin N and Humulin R hit the US market. These products and subsequent new types of rDNA insulins were paralleled with products from a Danish company Novo Nordisk. Normally this would be undiluted great news for diabetics, who suffered from a variety of side effects from the beef and pork products. But…

In 1923, Macleod and Banting won and shared the Nobel Prize with Best and Collip. They also obtained the patent for insulin which they sold for $1 each to the University of Toronto, saying that such a life-saving drug should be as widely available as possible, perhaps fearing what commercialization would do to the availability of their discovery. The University grant right to Lilly and other companies to produce insulin royalty free and to obtain new patents on any improvements they might develop. Insulin had left the realms of science, academia, and altruism and been naively cast into capitalism. And now, for the scientists, their worst nightmares have come true and are beyond anything they could have imagined.

BY 1941, Lilly, and 2 other insulin distributors were found in violation of the Sherman Antitrust Act for conspiring to arbitrarily fix insulin prices. They all took a plea of “no contest” and each company was fined $5,000 and each corporate officer $1,500. Today those old animal derived products are gone from the market (beef in 1998, pork in 2006). That sort of thing has gone dead silent as today’s insulin all seem to sport exorbitantly high prices within a few dollars of each other. Quite a coincidence!

I find it amazing that from the launch of rDNA insulin in 1982 to today that all we have managed to do is create more expensive insulin!

There are only three companies in the U.S. insulin market: Eli Lilly and Co., Novo Nordisk, and Sanofi (HQ in Paris).

For fiscal year 2018, the CEO of Lilly was compensated well over $15 million dollars. All told the CEO and leadership took home over $41 million. That’s for 6 individuals.

Things are different in Denmark: At Novo Nordisk, the most compensated executive makes $700,000, annually, and the lowest compensated makes $50,000.

Meanwhile , Sanofi sales took a hit and it’s CEO took a hit: The CEO’s pay package was slashed by 25% in 2018 to €7.28 million ($8.2 million).

To me, $700k seems a healthy income for anybody and keeps company income disparity at a more reasonable level of 14:1 versus Lilly’s 314:1.

This has been a long-winded way to get to my points.

  • Insulin must be affordable. If it takes Medicare for all or a reasonable national health plan, then I’m for it.
  • I feel that income disparity is as big a problem as inequitable taxation.
  • Healthcare should not be a commodity provided at exorbitant profit.
  • I realize that statesmanship is virtually dead. We must return civility and rationality to the national psyche and integrity to our government.
  • Learn. Speak. Vote.


Sedatussin, Ferengi, and Fragrances

I thought I would do a blast from the past for Pharmacists Month and take a look at a prescription from 1924 for a cough preparation called Sedatussin.

I picked this Rx from my collection because it it for a proprietary product. Most Rxs from 1924 are true Rxs or “recipes,” much like this one:
Sedatussin was marketed by Eli Lilly and Company beginning in 1909, advertised as free from alcohol and narcotics, which made it very different from many of the cough syrups on the market in the early twentieth century.
It contained cephaeline, a plant alkaloid more recently found in syrup of ipecac, which is used to induce vomiting. It was thought to be an expectorant back then. Today we use guaifenesin, which is of dubious effectiveness also, and even it did work would require doses approaching emesis inducing levels.
Another ingredient in Sedatussin is tincture Sanguinaria, from the bloodroot flowering plant. Used by Native Americans as an emetic, various tinctures appeared in the US Dispensary until the mid 1900’s. It is probably most notable for being listed by the FDA in 2010 as one of 187 “Fake cancer cures that consumers should avoid.” In fact, oral use of bloodroot preps have been linked to oral cancers.
As with many other cough syrups in the 1920’s, Syrup of Squill has many reported uses, from “heart tonic” to cough remedy, to an emetic, and even in some cultures as an abortifacient! We get squill from the bulb of the squill plantand has since been deemed unsafe for causing GI problems, rashes, cardiac dysrhythmias, and seizures. Syrup of Squill gained modest notoriety when it made an appearance on Star Trek:Deep Space Nine as a breakfast syrup valued by Klingons and price-manipulated by the Ferengi!
Sedatussin also had Syrup Tolu, derived from the sap of South American balsam trees. It still is in use today in some “natural” cough syrups, again as an expectorant, but it is valued in the perfume industry for its spicy, warm scent, likely due to the cinnamyl esters present.

I find exploring the evolution of pharmacy practice by taking a closer look at past products and ingredients quite a bit of fun since you never know where the journey will take you!

Rice and More

I am long overdue to get this blog out of the pharmacy for a while and out into the aisles.
While shopping recently, I noticed something interesting when looking for convenient rice. Good old Uncle Ben offered a variety of pouches that promised a variety of rice dishes that would be ready in 90 seconds. “Deal,” I thought.
Then I read the ingredients. The best bet is Whole Grain Brown Rice with ingredients listed as “water, whole grain parboiled brown rice, canola oil and/or sunflower.” Nice and simple and low sodium too. No wonder it claims to support a healthy heart.
It was pretty close between the Jasmine and Basmati versions, with 10mg and 15mg sodium respectively, and a few added vitamins.
Then things get pretty strange. With the flavored versions and “medleys” things like wheat gluten, corn starch, corn syrup, soy, milk products, xanthan gum and more. There is even pork gelatin in the cheddar broccoli variety!
The biggest disappointment was the Long Grain and Wild variety with “23 herbs and seasonings.” Uh oh. Not only is soy, corn, wheat and yeast protein added, we find salt and sea salt, bumping the sodium to a less friendly 590mg. I could not find 23 herbs and seasonings listed. There was sugar though.
Compared to other offerings in the “center store” aisles where processed foods reign supreme, most of these choices are not too bad if you are not concerned about surprise gluten in a rice product or hidden pork, for examples. It goes to show, though, how it pays to read the labels. I will give Uncle Ben credit for truly reflecting the differences in these products in their labeling, although stating that it is an excellent source of niacin, thiamine, and folate when these are added ingredients all but one of the varieties is pushing the envelope a little. If I was grading on a curve, I guess I would give this product line a B with an A for the simple whole grain brown rice option.
And they are from Mars!

Metrics? We Don’t Need Stinking Metrics!

We all know that retail pharmacy or health care in general can be a difficult and often thankless job. I received this letter in the mail and it made me happy!
grateful letter
The gratitude was well received by myself and staff. Eventually I began to think about metrics. Pharmacists and techs spend hours every day dealing with undecipherable prescriptions, impossible billing, and a wide assortment of barriers to good pharmacy care. As pharmacists we dole out free advice on a regular basis to patients that are usually appreciative. Patients will talk to us about anything.
On the same day that I received this letter, I had a man in his 40’s wondering why his doctor ordered Prozac for him when he was not depressed, just dissatisfied with the quality, quantity, and duration of his erections. He broached the subject and responded to one of my counseling questions by saying, “I think I’d be OK with a group of half naked cheerleaders.” That’s when the conversation moved to a more discreet level.
Later, a student pharmacist asked for my assistance counseling a young woman who wanted help selecting a prenatal vitamin. Turns out she was trying to get pregnant, and after explaining the benefits of a prenatal product and other healthy options, she took the conversation to a deeper level. After discussing underwear choices for her husband, she volunteered information about her tipped uterus and asked, “are there any positions that might compensate for that?” I was tempted to tell her the joke about positional gender selection, but my professionalism vetoed that idea. In case you are wondering, missionary and girl on top are the top two recommendations.

All three of these interactions are wonderful and meaningful experiences for the people involved. They do not, however, have an effect on our metrics, which, increasingly, is how our job performance is measured. We are constantly bombarded with data that is presented as helpful information to make the job easier as we gain effectiveness. Yet our “Percent Effective” measure looks only at the labor hours (and minutes) gained for the tasks that are required to fill prescriptions. The bottom line is that the biggest chunk of data demands that we fill a prescription using about 8 minutes of labor. And, there is time built into that to allow for counseling, regulatory compliance, inventory control etc., but at the end of the day it’s how many Rxs were filled with the labor permitted.

You can easily see that the scenario that Jay describes in the letter would have taken much more than 8 minutes to complete. Multiple people were involved and it required several faxes and two phone calls to the prescriber, calls to the patient, and multiple attempts to successfully bill the claim for the product. The forty-something with problems “down there” and I had a ten minute conversation exploring possible causes and solutions for his dilemma, which included the recommendation that he should keep his lust for cheerleaders as a fantasy. The young mother-to-be was another lengthy discussion that started out looking at vitamins and evolved into a frank discussion of the physiology of fertility.

All three of these examples had great outcomes and yet only one prescription was picked up by the patient, the testing strips for Jay. The other guy did not get the Prozac prescription, effectively making all the labor to fill it wasted, and created more labor to return it to stock. The soon-to-be-mom bought a prenatal supplement and left with several helpful ideas for conception strategies. In my judgement, all three of these were big wins for myself, my staff that were involved, and the student pharmacist that gained perspective on the delivery of very personal, even intimate counseling.

If we are lucky the patients will do one of those ubiquitous satisfaction surveys and we will get a second of recognition that way. Our metrics will suffer though, and that is a price that I am willing to pay. My patients know that they are not numbers to me. My whole team works hard to establish a solid rapport with each patient and from that grows the trust and mutual respect that lets our pharmacy thrive despite intense competition.

Metrics are a tool, a limited tool that will never be able to measure the kind of outcomes that health care providers work for every day. Labor hours should be added to the metrics algorithm that would allow us the time to treat all of our patients the way they deserve. Wouldn’t the loyalty and improved health and happiness of our patients be worth a couple hours of labor per week? After all we give ’em $25 just to transfer a prescription to us from a competitor. We should be playing the long game.

A Prescription Gone Wrong

The national media and social media exploded a local story of a pharmacist refusing to fill an prescription for misoprostol for a woman carrying a dead fetus. It’s difficult to get the exact details of the whole process, which took place over several days, but I think some of the events are evident and worth discussion.

Let’s first be clear that we should not have this opportunity to discuss this specific situation. It should have been a private process involving prescriber, patient and pharmacist, as we expect for each prescription filled. This patient, however, chose to put her uncomfortable and personal experience on social media, Facebook, and from there it migrated to more traditional local and national media. OK, that is your choice. So now anybody who cares to voice an opinion is free to do so and I will take my turn.

The OB/GYN ordered an effective drug that would terminate this nonviable pregnancy. A miscarriage was inevitable and the drug would allow the patient’s medical team to control the process. The prescription was taken to a Walgreens where the pharmacist would not fill the prescription for reasons of strong personal beliefs. The patient attempted to explain the medical reason behind the prescription and the pharmacist was unyielding. Apparently there was significant back and forth discussion between the two with that patient’s 7-year-old child, other pharmacy staff, and other people standing in line listening.

This is where things go careening off the tracks. First, the pharmacist should have recognized the very personal nature of this exchange and taken the patient to a discrete location for a private consultation. Most pharmacies have a consultation room and if not can find a private space. Retail pharmacies prominently display a large HIPAA sign that explain patient privacy protections. The dilemma for retail pharmacies is that the area where patients pick up their prescriptions is not private. Oh, we may have a little plastic divider shield, but if you look at most retail pharmacies there is little barrier between the pharmacist and patient at the counter and the patients waiting in line to be next or even in the waiting area. Do patients in this situation implicitly give up their privacy rights simply by being there willingly? To me, this particular situation was handled poorly by the pharmacist and the patient, but the pharmacist, as the professional, failed to act professionally in respect to patient privacy. Yes, the patient chose to discuss the details in this setting and then further on social media. At the pharmacy counter, however, the pharmacy staff should realize the obligation for discretion and act upon it. I have asked hundreds of patients to join me in our consultation room or another private space to discuss sensitive issues. Most pharmacists I know would do the same.

The moral objection to filling a prescription is supported in most pharmacy organizations and each of them that I have seen advise the pharmacist to provide another means for the patient to acquire the medication. This did eventually happen and there is some disagreement as to why it took from Thursday to Saturday for the Rx to be filled and picked up. One side claims that there were other pharmacists in the pharmacy the day the Rx was first presented and they were not asked if they would fill the prescription, while others say that the pharmacist did transfer the Rx to another Walgreens that would fill the Rx and it was the patient that delayed picking it up. Some of the latter have claimed that on Friday the patient was too busy giving interviews to TV news outlets and playing the victim card. Perhaps there is some truth to both sides. I will let the Arizona State Board Of Pharmacy complete their investigation and trust they will come closer to the truth better than any individual possibly might.

Pharmacists are presented with medical dilemmas every day. I have refused to fill many prescriptions. Some of those have been fraudulent, some have been presented by obvious drug seekers using multiple doctors or other schemes, and others were instances where I considered the health and safety of the patient in jeopardy. I personally believe that is the scope of our practice. We should fill all legitimate prescriptions unless the physical or mental health or safety of the patient would be put at risk. I do not believe that we should be making religious or moral judgements when assessing the appropriateness of a particular drug for a particular patient.

This particular drug had been identified in the pharmacist’s mind as a drug used for inducing an abortion and therefore would not dispense it. Any other use of the drug was apparently disregarded. I believe we are scientists, not priests. There are plenty of opportunities for pharmacists to apply religious or moral judgment on patients based on the prescriptions that they ask us to fill. Is this birth control Rx for a 16-year-old appropriate? Is that too young for sex? Is it better to provide contraception rather than risk a future abortion if she is sexually active? Oh wait, those questions are moot because the patient is taking the medication to control disfiguring acne, or to lessen her disabling dysmenorrhea. Do you refuse to fill HIV drugs because you consider HIV the “gay plague” and God intends gay people to suffer the consequences of their “choice?” Is it right for a pharmacist to work in an establishment that sells tobacco, liquor and sex toys? Each of us must decide our own morality, and we are free to express our opinions, but we have no right to impose them on others.

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