SUPERmarket PHARMACIST

A pharmacist's look at the supermarket and beyond

Month: June 2014 (page 1 of 2)

Do Docs Still Write Prescriptions?

Judging by many of the new prescriptions (Rxs) I see every day, I believe doctors and other prescribers do not write many of the prescriptions that get to the pharmacy. If you are a patient, I hope this encourages a little sympathy and patience.

We get Rxs delivered by hand, sent electronically, faxed, and phoned. Quite often these orders are a mess of malarkey. Much of the problem stems from the use of computers in medicine. Government reimbursement for medical services is higher for those offices using electronic records and ordering, so thousands of doctors across the country are trying rapidly learn new, complex software. Often they must learn more than one, in their own office, at one or more hospitals they see patients at, as well as variations of navigation depending on what device is being used.

Photo by Greg Mursko

Photo by Greg Mursko

The most egregious errors we see are in drug selection. Most medical software have one of those little bars with a triangle at the end which “drops down” and list from the first few letters typed or when the little triangle is clicked. Another click selects the drug that will appear in the Rx. Too many times, every day, there is a mis-click and we get the line above or below the intended target, or the entire description is not read and the first easy target is selected. Another type of error seems to occur when the doctor gives a verbal order to an office personnel and they make an (ahem) educated guess.
I saw this today as I was processing four electronic Rxs (e-Rx) that included 2 antibiotics, omeprazole, and bismuth subgallate. Now here the 2 antibiotics plus generic Prilosec gets me thinking h. Pylori therapy for an ulcer or GERD. The standard regimen calls for Pepto Bismol (aka a suspension of bismuth subsalicylate) NOT bismuth subgallate. Bismuth subgallate is give given to ostomy patients to reduce odor in the collection bag. A phone call corrected the problem fairly quickly in this case. I was not told if it was a mis-click, an incomplete reading of the description, or a mis-selection by an inadequately trained personnel.

Another troublesome time-suck comes from poorly trained staff calling in verbal Rxs and leaving them on voice mail because they “can’t wait on hold.” So they opt into voice mail, speak as fast as a coked up carnival huckster, mispronounce names of people and drugs and omit required information. My wife had a young lady leave an order for Alpha Zolam today. Of course, my wife had to then call the doctor’s office, wait on hold, and try to get clarification, only to have a snotty response that it was an order for Alprazolam. I once talked to a person who insisted the order was for Mr. Clean. Finally has to get her to spell it to learn it was for Mysteclin and my fault for not understanding in the first place. Hurry, hurry, hurry and somehow respect and common courtesy evaporate.

We also love the eRxs that come for bizarre quantities, multiple sets of instructions (sigs), cryptic messages in the notes field, and just plain non-existent products.

Oh sure, we still get plenty of indecipherable hand written ones too!

I am hopeful that this will all get better. Of course, I’ll be spending my days on a beach by then.

Today’s SCOTUS Ruling – My Take

The contraceptives at issue before the court were the emergency contraceptives Plan B and Ella (Emergency Contraceptive Pills ), and two IUDs.

NIH, FDA, and ACOG all define pregnancy as beginning with implantation
Takes about 6 days for a fertilized egg to begin to implant
Intervention within 72 hours cannot result in abortion
ECPs are not effective if a woman is already pregnant

However, Justice Samuel Alito wrote in his majority opinion that forcing companies to pay for methods of women’s contraception to which they object violates the 1993 Religious Freedom Restoration Act. He said the ruling is limited and there are ways for the administration to ensure women get the birth control they want. He went on to write that this only affects “closely held” companies whose owners “have religious objections to abortion, and according to their religious beliefs the four contraceptive methods at issue are abortifacients.”

Notice the quotes and notice the contradictory use of the terms contraceptive and abortifacients in the same sentence. Proof positive that these justices did not gain an understanding of the science involved here. The whole situation illustrates the fact that much of our population would rather cling to the folklore of the past than to try to understand scientific and medical knowledge.

“The common belief that the major mechanism of action of IUDs in women is through destruction of embryos in the uterus (i.e., abortion) is not supported by the available evidence.” – NIH

Widespread use of emergency contraception could prevent an estimated 1.7 million unintended pregnancies and 800,000 abortions each year.
(Glasier & Baird, 1998)

Peace, Love, Freedom

Going Bananas!

2 bananas

2 bananas

I enjoy bananas. I enjoy ripe ones far more than the firm yellow ones usually offered in the market. That’s OK, I just let them ripen at home until they get those brown dots on them. I find a riper banana is tastier than an all yellow pretty boy.

These spotted bananas are mostly better for you. Yes, as the fruit ripens more of its starch is converted to simpler sugars that give you a quicker blood glucose increase, although that is somewhat mitigated by the good fiber content of the banana. The sugar increase is somewhere around an extra 2 grams, from about 14 to 16 grams. There is also some evidence that browning bananas yield a cytokine called Tumor Necrosis Factor alpha (TNF) which helps your body destroy abnormal cells that might become cancerous. I’m still not quite sold on the validity of this claim or whether it is actually a significant effect. I do like the spotted bananas better, though.

The average banana, say about 7 or 8 inches from one end to the other provides about 105 calories, is very low in fat, no cholesterol, high in fiber, virtually no sodium, and only about a gram of protein. A pretty good healthy snack that satisfies my hunger for a good length of time. Oh, the average banana yields about 1 milliequivalent of potassium per inch for those of you looking for good natural sources of this critical electrolyte.

The riper banana also smells stronger to me, which means more isoamyl acetate is present. I recall that we synthesized this ester in organic chem lab. There is some anecdotal support that just smelling bananas helps control weight. This may have some credence as the aroma of ripe bananas seems to cause an increase in dopamine in the brain and this could result in diminished appetite and a pleasant feeling or satisfaction. I won’t comment here about the pleasure derived by seeing suggestive oral maneuvers performed on a banana by a member of the opposite sex. Oops, too late.

On a side note, a bit of isoamyl acetate is released from a bee’s stinger when it stings you. This is a chemical marker that encourages other nearby bees to also zip over and sting you too! Hopefully, you are not eating a banana at the time!

Sit, IBU, Sit!

Part One

I started off the day with a question about using ibuprofen and its affects on the kidneys. I have to admit that all that I could instantly recall was that there were kidney related problems associated with long term ibuprofen use. The same is true of the whole class of NonSteroidal Anti-Inflammatory Drugs (NSAIDs), some more so than others. My answer satisfied my patient.

I figured there must be some hint in references so, of course, I quickly asked a student to give me a list of ibuprofen contraindications, thinking I would find the answer. Turns out we had to take a closer look at the pharmacology. Oh boy!

NSAIDs work by limiting the manufacture (synthesis) of these fat-like molecules called prostaglandins. These molecules are involved in inflammation, pain, and fever responses. Stay with me, now. NSAIDs do this by inhibiting enzymes called cyclooxygenases, COX, for short. There are at least two types of COX enzymes, dubbed COX-1 and COX-2. Blocking COX-2 results in fewer prostagladins and so less swelling, pain, and fever. But wait, there’s more!

Most NSAIDs are non-specific, meaning they inhibit both COX enzymes. COX-1 is always present in various body tissue, doing its thing. In the stomach, COX-1 generates prostaglandins that protect the gastric lining. In the urinary tract it produces produces prostaglandins that help relax the blood vessels nurturing the kidneys, and on platelets it interferes with thromboxame production so that platelets don’t stick to each other very well. These functions are the downside of NSAIDs, less protection for the stomach lining added to not-so-sticky platelets results in an increased risk of bleeding, while long term constriction of blood vessels to the kidney results in diminished kidney function.

Unlike COX-1 which is a normal part of our physiology, COX-2 is inducible or triggered by some insult to the body. Something like, “You’re as fat as your mother!” Um, no, actually some sort of physical or chemical trauma that brings on the alerting/assisting responses of swelling, pain, and fever.

OK, enough pharmacology. I tried to keep it simple. If you can sketch out arachidonic acid metabolism, please return to your lab bench right away.

Part Two

If you’ve been reading this blog, or know me just a little bit, you know I’m going to toss some history your way.

In 1974 I was working as an intern at LaVerdiere’s Drug store in Maine and was approaching my final year in pharmacy school. That was the year of the biggest, most anticipated new drug launch I’ve ever seen. Motrin was coming! The word was getting out that this new drug, Motrin (ibuprofen) was a miraculous new treatment for painful conditions like arthritis. The demand was incredible even in small town, New England. We actually had a waiting list! We had thousands of doses ordered but we were told that initial orders might be reduced due to demand outstripping early supplies. True that!

The Boots Group had been selling Ibuprofen as Brufen in the UK since 1966 and in 1974 it was licensed to the Upjohn company in the US. It was a blockbuster, quickly becoming the number 5 Rx drug in sales at over $250 million per year. A decade later it was approved in a 200mg dose for over-the counter (OTC) sales and has blossomed into a $2 billion market darling. We’ve got Motrin, Advil, Nuprin and many more.

The Upjohn story has cool beginnings. Way back in the late 1800s most meds were sold either in liquid form as extracts or elixirs or hard, compressed tablets. The liquids were inexact and unstable and most of the tablets were so tightly packed that they did not dissolve, passing unchanged into the commode or chamber pot. Dr. William Upjohn came up with a process of making a more effective tablet. He was happy to demonstrate the superiority of his tablets by showing the old rock-like pill being driven into a board with a hammer, while he pressed his tablet to crumbs with his thumb. Interestingly, Upjohn also was first to market Pheno-Lax, the first candy-laxative! Pheno-Lax Wafers were so popular they almost cracked the million dollar milestone in 1924. That’s a shit load of laxative!

William was a fervent gardener, wrote a book on peonies, and gave his workers a seven hour workday during the summer so they could have time to water their lawns and tend their gardens. He was one of the first to offer his employees group life insurance. William Upjohn passed in 1932. The Upjohn company is now a global concern with subsidiaries in over two dozen countries.

Sweet!

How long has your favorite candy been around?

Candy is a very profitable category for supermarkets. Next time you go for groceries in a traditional supermarket notice how many candy displays there are scattered throughout the store. It’s like there are these giant piles of sugar in almost every aisle and, of course, next to every cash register.

America’s love of candy began over a century ago with the introduction of the first box of Whitman’s chocolates, a “sampler” of the varieties previously sold separately. That was in 1854, the true sampler was not coined until 1912 when the needlepoint artwork was added to the box, as well as the highly prized diagram that illustrated where your favorite was lurking. Later, during WWII, ladies making the samplers being sent overseas to our men in the military would add little notes to the soldiers and apparently contact info as it was reported that many lasting relationships developed from these sweet surprises.

In the meantime, this Milton Hershey guy, around 1900, started marketing a straight up chocolate bar. Six years later, the famous foil-wrapped kisses made their debut.

In 1920 the Baby Ruth candy bar appeared and many folks assumed it was named after slugger Babe Ruth, but was in fact a nod to President Cleveland’s baby daughter. Also not baseball related, Mounds, with two bars in one package, debuted in 1923. With their milky white coconut filling, perhaps they were named after some other popular mounds.

Frank Mars had childhood polio and spent plenty of time at home in the kitchen with his mom. Later he dabbled with various iterations of candies, including nougats, the Mar-o-Bar, and other confections. His breakthrough product came with the brainstorm to take advantage of the popularity of soda shop malteds and he finally came up with the Milky Way in 1923. This was advertised as a chocolate malted milk in a candy bar and sales took off from there. Snickers followed in1930 and the success of the company was guaranteed. I don’t think it was advertised that Snickers was named after a horse. In 1932, the 3 Musketeers bar sold for a nickel and added to the strength of the companies portfolio of hugely popular candy bars. The original 3 Musketeer featured 3 different nougats, vanilla, chocolate and strawberry. The chocolate eventually won out and we have had the current version since 1945.

You can guess that summer temperatures were tough on these chocolate candies. Trying to keep chocolate sales steady during the summer months, Forrest Mars, son of Frank, came up with the brilliant candy-coated M&Ms that “melts in your mouth, not in your hand.”

Lady Green M&M

Lady Green M&M

Skipping to the present, we have unlimited variety of candy to choose from, with line extensions that take advantage of prestige brands like Snickers that create a multitude of sugary offerings. There is a National Confectioners Association that says there are over 70,000 candy making jobs in the USA. Yay! Jobs for America! However, the NCA also provides some other data on their website, most notably, for 2010, nearly $30 billion in sales, representing 2.44 billion pounds of sugar and 1.47 billion pounds of corn syrup. Yay! Diabetes for America!

Draw your own conclusions, though, I’m giving you a perspective from the pharmacy where millions of people are getting prescription drugs, some of which might be unnecessary if better nutritional choices were made and we enjoyed a sweet fruit as much as a candy bar. The cost of treating diabetes in this country is somewhere around $170 billion per year.

I’m Off to See the Wizard!

Amazing NEW Weight Loss pill! Developed by a pharmacist! All Natural! No drugs or chemicals! Lose weight and eliminate toxins!

This amazing product eliminates hunger and removes toxins from your GI tract. It also helps decrease absorption of fats! Just follow the directions and the suggested exercise program and you are guaranteed to see the pounds melt away. In fact that’s the name of this amazing breakthrough product: Poundzaway!

This may all sound too good to be true. In fact, it’s just a brainstorm of mine and I want to get it on record before somebody else takes it. I’m going to put diatomaceous earth and sawdust in a capsule and call it Poundzaway! I’ll need some venture capital and a spot on Dr. Oz, of course. I think it would be safe and effective. Better than most of the crap pitched by Dr. Oz, anyway. Let me know know if you want to provide the seed money. Maybe I’ll take it to Shark Tank. Surely Mr. Wonderful could throw $100,000 my way. Anybody with me?

Legumes Forever

A study reported in the Archives of Internal Medicine examined the role of legumes (e.g. peas, beans, peanuts) in reducing the risk of coronary heart disease (CHD).  With a cohort of 9,632 men and women, studied over an average of 19 years, the study supported what Mom knew all along.  Results showed that patients that ate legumes at least four times per week had a 22% lower risk of CHD and an 11% lower risk of cardiovascular disease (CVD).  So, EAT YOUR PEAS!

It’s Like Butter!

The latest issue of Time magazine features butter on the cover and has a pretty decent article on the new way of thinking about butter in our diets. It started me thinking about fats and the good, the bad, and the ugly. There are plenty of good sources to explain the differences between good fats like mono or polyunsaturated fats, and evil stuff like trans fats and saturated fats. I do not intend to provide an in depth study here, just illustrate a few observations.

I sent my pharmacy students out to check some labels. They came back with a gazillion pictures. Like most departments in a modern supermarket, there are way too many choices here.
Check this out:

Butter

Butter


Pretty simple, huh? Sweet cream and salt. Notice that serving size is one tablespoonful. That’s consistent throughout these products. 11 grams of fat, mostly saturated. As the Time article informs us, the old thinking was that saturated fats are the bad guys. Numerous studies fail to support that notion.

A popular butter alternative is Country Crock, with these nutrition facts:

Country Crock

Country Crock


So, yeah way better on the fats, but way longer list of ingredients with some good oils, some vitamins, chemicals and more. Obviously an engineered edible.
In case you want even fewer calories and fat there is Crock Light:
crock light

crock light


Lighten it up by adding more water! In fact, almost every “light” butter
light butter

light butter

or alternative simply added more water, listing it as the number one ingredient! No wonder your toast seems soggy!

Despite the notorious reputation, trans fats still lurk in the buttery display case, such as in these Fleischman’s sticks.

Fleischman's

Fleischman’s

It takes about 21 pints of whole milk to make a pound of butter. Butter dates back to those years we refer to as BC and is referenced in King Tut’s tomb. Margarine goes back to the late 1800s. That margarine was usually made with beef fat. We switched over to oils during the depression and World War II eras. Butter is lactose-free. My wife’s grandfather had a breakfast of bacon, eggs, and butter almost every day and lived well into his 90’s. Of course, he worked his ass off, managing acres of farmland and a herd of beef critters. The one movie theater in town actually used real butter on their popcorn! Delicious! My point is that butter is not evil. It can be part of a healthy, balanced diet. Moderation, brothers and sisters!

Remember, when it comes to fats, the MonoUnsaturated Fatty Acids (MUFA) and PolyUnsaturated Fatty Acids (PUFA) are likely the ones that should be a large portion of your total fat intake. MUFA and PUFA, easy for you to remember, right?

A bit of butter is better. I like to use olive oil whenever possible!

Simply Crackers

Had to get back to the market after being away for over a week. I had my list and my camera. I did a pretty good job of filling my cart with fresh fruit and vegetables as well as lean meats. I’m trying hard to make smart choices for the family.

I am a big fan of Triscuits, lately buying the “Hint of Salt” variety to lower our sodium a little. Considering my efforts to simplify my shopping choices by selecting “single entity” items, I thought I would compare a few crackers.

Luckily, my triscuits came up pretty well in the competition for fewest ingredients:

Hint of Salt

Hint of Salt

Then I checked Keebler’s Club crackers:

Club Crackers

Club Crackers

Not too bad, at first, I see some added vitamins (not sure why), I can even let slide the phosphates, but then, there it is: High Fructose Corn Syrup (!) and even non-super-powered Corn Syrup. It’s like HFCS is some kind of crack. The cracker is probably OK without the syrups, but add them and your body just wants MORE. Cracker crack.

Surely, I will do better with good old Saltines. That’s a simple cracker, isn’t it?

Saltines

Saltines

Pretty good. Again the enriched flour. (we’ve been adding iron and these four B vitamins to our flour since 1942, but that’s another story) At least everything here is readily identifiable and I don’t have to recall my chemistry courses. The cottonseed oil is partially hydrogenated so it should be almost 95% saturated fatty acids.

Let’s check something a little more exotic, like these Cheez-It Zingz! That sounds highly processed!

Zingz

Zingz

Whoa there Nellie! That looks like a bunch of stuff! Plenty of dried plants for sure, some natural colors, and pretty light on straight up chemicals, but still highly processed. I can just see the food lab with whole food coming in, then dried, powdered, separated, and recombined with Frakenstein-like glee! Why Zingz gotta be so complicated? 🙂

Read your labels, simple is better.

Drugs in the Water

I am back from a vacation! One place I was in was Colorado, the Rocky Mountain National Park, where we crossed the continental divide. You’ll recall that water that falls west of the divide reaches the Pacific and water that fall on the east side flows to the Atlantic. As I urinated at 13,000 feet, I thought about all the drugs that I dispense and that most of them are excreted in the urine. What happens then?

If you are in a civilized setting you probably have a water treatment facility nearby that processes waste water for further use, most often agriculture or watering golf courses and such. So if a drug is reaching our water supply it is not directly going into the water that we drink. It is, however, going into the environment.

The EPA places drugs in a category called Pharmaceuticals and Personal Care Products (PPCPs). Here is a cool and complicated PDF, life cycle of pharmaceuticals in the environment. You can see that drugs and cosmetics eventually get into everything.

Thankfully the exposure to humans is still very low, but as we continue to dump these products into our waters, we may reach a tipping point where demonstrable effects are more common.

EPA studies of water from various treatment facilities found many drugs. I found it interesting that Diovan, a blood pressure medication, was most often the highest concentration found. Even then a person would need to dink this reclaimed water at a rate of 2 liters per day for 2 or 3 years to get near a single day’s dose. Blood pressure meds are some of the most commonly found drugs in treated waste water, with things like Xanax, hydrocodone, antidepressants like Prozac, ibuprofen, and a host of others showing up consistently. Many are in a metabolized form that may have lower activity than the original drug.

Most likely, you are not drinking water that contains drugs. However, they are reaching our ground water and are therefore being ingested by all kinds of critters. The long term effects are unknown, but when you couple this with things like triclosan, BPA, nano-particles, fracking chemicals, industrial spills and on and on, it’s a wonder we haven’t already spawned a real Godzilla.

It will not be easy to stem this tide. I urge you to support environmental causes, shop mindfully, vote wisely, and demand integrity from government and industry.

Older posts