A pharmacist's look at the supermarket and beyond

Month: September 2014

Pain is Inevitable

“Pain is inevitable, suffering is optional.” A large number of the prescriptions that I fill every day are for the treatment of some type of pain, chronic or acute, localized or general. Pain helps keep my profession in business.

Pain does not come cheaply. The Institute of Medicine puts the direct health care cost at close to $300 billion and the indirect costs of diminished work capacity at just over $300 billion. This $600 billion amounts to $2,000 per person per year for each and every citizen in the U.S. That’s a hidden pain tax!

Twice as many Americans are being treated for chronic pain as those with diabetes and cancer combined. Of course there is overlap. Many patients with diabetes, cancer and other morbidities also have pain. Coincidental to chronic pain are issues with sleep, depression, anxiety, obesity, cognition deficits, and a significant disruption of general well-being. Anhedonia, a term I learned early in pharmacy courses, the inability to experience joy, is a common symptom for chronic pain sufferers. Chronic pain ruins lives.

It’s hard to find a pain study not funded by a pharmaceutical company, but I came across this survey from the American Pain Foundation that had some staggering results:

    Almost two-thirds (59%) reported an impact on their overall enjoyment of life.
    More than three quarters of patients (77%) reported feeling depressed.
    70% said they have trouble concentrating.
    74% said their energy level is impacted by their pain.
    86% reported an inability to sleep well.

Looking at that study, funded by Endo (makers of Percocet!), led me to even more incredible discoveries.

The American Pain Foundation (APF) closed down of May 3, 2012. The web site still exists and the cover letter explains a lack of financing and other resources, hopes to transfer content to other organizations, and asks for a public outcry against the government that is blocking access to these wonderful drugs. What a crock of crap!

The APF got 90% of its funding from Big Pharma and Big Medical. When a US Senate committee started to investigate the distribution and marketing of narcotic analgesics one avenue of investigation led to APF. Seems that materials distributed to patients and providers were essentially commercials for their sponsors drugs, explaining and exaggerating the wonderful therapeutic effects of these narcotics while minimizing the risks.

As a practicing pharmacist, I have seen the good, the bad, and the ugly sides of pain management. What has happened, is happening, is once again, the corruption of health care by the forces of greed. We see it in so many aspects of the new American capitalism that I do not need to point out the disparities in big business that are destroying the middle class and wrecking the idealistic principles that are the foundation of our democracy. Pain meds are marketed commodities and their manufacturers are doing everything they can to maximize profits. The APF was just another puppet organization that scurried into the shadows when exposed to light.

This whole process has made pharmacists take a bigger role in law enforcement to help prevent diversion of prescription narcotics. I recently attended a DEA Diversion Conference where the discussion focused on the pharmacist as the primary gatekeeper for the distribution of legal narcotics. Yes, we saw undercover footage of bad doctors prescribing oxycodone, alprazolam, and carisoprodol as thought they were candy. Mostly, these docs hardly looked at the patient, let alone doing any kind of assessment. There is much cash to be made and unscrupulous prescribers and pharmacists tend to reach into the honey pot with both hands. Until they are caught. The problem is how to separate the good from the bad. What is best for the legitimate patient is balanced against drug abuse and profiteering. Its not all on the manufacturers, of course, certain people will abuse drugs. Mankind has been experimenting with altered mental states for as long as humans have been thinking and there is no reason to imagine we will suddenly give up that quest for blissful nirvana.

In our pharmacy, we have strict guidelines for filling controlled substance prescriptions. We try our best, but I often wonder if we are enabling some abusers while sometimes denying medication to legitimate patients. We are not perfect and each order is a judgement call. We make use of our state controlled substance monitoring database, which helps identify some bad apples, but is only an effective tool some of the time. I believe in science and expect that as we learn more about pain and addiction we will become better at pain management. In the meantime, however, we have a huge problem with prescription drug abuse and it is up to all of us, not just pharmacists, to do what we can to improve the situation. This might mean taking the time to listen to a patient in pain, dealing with pain in novel ways, funding stronger enforcement, re-educating prescribers, and providing good guidelines for health care providers as well as alternative resources for patients.

Most folks are often left on their own to self treat pain, choosing from the assortment of pain relievers seen on most supermarket and drugstore shelves. Although there appear to be a multitude of choices, only four non prescription pain meds are offered. These three medications, aspirin, ibuprofen, naproxen, and acetaminophen. Acetaminophen acts as an analgesic and antipyretic, helping with pain and fever. The other three are Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and also help with pain and fever and also reduce inflammation. Those are your choices. They may be combined with caffeine, diphenhydramine, or even one another, delivered in tablets, capsules, caplets, liquids, and more, but these are really all there is to choose from. Other modalities exist on drug store shelves, such as TENS (Trans-dermal Electrical Nerve Stimulation) devices, TENStopical preparations, and heating and cooling appliances. Each has advantages and drawbacks and as always, I encourage everyone to read the labels and talk to your pharmacist.

Others have taken the lesson of the opening quote and applied it to their own situation, focusing on the manipulation of suffering rather than the pain itself. Yoga, mediation, prayer, acupuncture, mind-fullness, hypnosis, massage, music therapy, and other spiritual or metaphysical strategies have all been attempted and recommended as ways of limiting suffering. Most accept the pain and choose to limit the suffering as a matter of perspective. Many emotional factors can affect physical pain and a support system is essential to managing chronic pain. Having others around that care for and about you will lessen suffering. Love and comfort ease the pain, loneliness makes any pain more painful. State of mind determines your reaction to pain.

Pain is complicated. I’ve experienced a variety of pain from the minor sting of a flu shot or a minor burn, to sweet pain during sex, to sudden, violent trauma that brought me to my knees. Guys are told to “suck it up.” I have had extensive dental work, even once coming awake during dental implant surgery, but I am fortunate not to have significant chronic pain. I’m on my feet at work all day so I have an aching back quite often and the older I get the longer it takes to recover from muscle pain from unusual physical exertion. No pain, no gain isn’t as appealing as it used to be. Having somebody to love and to care for helps to let the pain go away.

Pain is inevitable, suffering is optional.

Maybe we need fewer pain killers and more hurt blockers.

Food from a Neighbor

There are many good reasons to buy local produce whenever possible. When you buy local you are supporting your neighbors and their families, not some giant conglomerate that squeezes every penny of profit from the mass production of the goods that we buy. There are many other reasons to buy local produce.

Although locally grown produce may not always be as pretty to eyes that have been taught to accept the standardization of food, local produce almost always tastes better. If you have never tried a ripe tomato right off the vine, then you may find the clone-like abominations that we are routinely offered to be acceptable. But if you are willing to taste produce that may have some variation in shape and color and perhaps a blemish or two, the you are in for a treat. I won’t even mention the loss of nutrients during that long trip from a foreign land, nor the carbon footprint left by moving that tonnage all those miles.

Buying local produce also helps fight the battle against Genetically Modified Organisms. Local farmers on small farms celebrate genetic diversity and often grow varieties that have been “in the family” for generations. They are growing for goodness, not what grows fastest, cheapest, and retains its color and shape longest. Much distant produce is picked “green” and then gassed with ethylene which causes an unnatural “ripening” of the treated produce. These hybrids that are mass produced and gassed are as bad as the GMO crops in that they have lost the naturalness that makes for a nutritious food.

So much of the food found in grocery stores is grown using pesticides, hormones, antibiotics and other drugs. Some is irradiated, waxed or otherwise manipulated to appear “pretty.” What do you think is the cumulative effect on the humans that consume these crops?

Many local farms offer up their lands for visits. Pick your own! Take part in a harvest festival! Learn how farming can be difficult and satisfying. Don’t be afraid to get your hands dirty. Don’t be afraid to meet a bug or two.

Local farms support the environment by providing habitats for wildlife while being good stewards of the land, practicing proper crop rotation and management. Being on family-owned land, these farmers tend to take a long term view of things. Where a giant conglomerate farm might simply use GMO techniques and dump more and more chemical into the soil, local farmers know how to keep the same soil rich with nutrients over long periods of time. These methods are not always the cheapest, but they are tried and true and faithful to the planet.

Everkrisp Vegetables is a local farm that supplies grocers here in the Phoenix area. This is a third-generation family farm enterprise that is striving to provide quality produce in a planet-friendly manner. I would encourage you to visit their web-site. Their story is very similar to those you will find if your explore local farming in your community. These farmers deserve our support.

Local Farmers

Local Farmers

I have no financial interest in any of these farming enterprises.

In the Cosmetics Aisle

The earliest evidence of cosmetics were found in Egypt and dated back to 5,000 BC.

Brushes are seen in European cave paintings dated about 2.5 million years ago.

Alfred C. Fuller of Nova Scotia started the Fuller Brush Co. in 1906 working out of the basement in his sister’s home. Fuller Brushes were sold door-to-door. Today the factory is in Great Bend, Kansas where they continue to make brushes and other cleaning products. They are partnered with Stanley Home products, who are often credited with the “party plan” of selling, where friends gather to explore products, socialize, and buy. This method of selling continues with popular companies like Mary Kay and Pampered Chef.

Nail polish has been traced back to ancient (circa 3,000 BC) China. It was made with gum arabic, egg whites, gelatin and bees wax. Ancient Egyptians likely used henna to tint nails and other body parts. Modern nail polish shares an ingredient with dynamite, yet another nitrate, in this case cellulose nitrate (aka gun cotton). You may recall cellulose as plant fiber, and the nitrate is flammable and can even be explosive, as it is in dynamite. In nail polish, the tiny fibers are what make the film that covers the nail. Various colors, volatile solvents, and flexible agents may also be added. Tiny chips of mica or even fish scales may also be added. Making nail polish is risky business that must be closely monitored.

Vaseline petroleum jelly was patented on May 14, 1878. It is purified white petrolatum that was originally found on oil rigs and has since found a multitude of uses in the home, on the farm, and all around the town. Petroleum jelly will glow a nice shade of blue under UV light, making it a fun addition to Halloween parties where black lights are used.

Max Factor was born in Lodz, Poland and at the age of eight was placed in an apprenticeship with a dentist-pharmacist. He spent many years mixing potions and poultices at the direction of this early healthcare provider. Max eventually opened his own shop near Moscow where he soon was appointed official cosmetic expert by the Russian royal family and the Russian Grand Opera. Max and his family came to America in 1904 where he became the make-up darling of the movie industry. In 1920 he introduced his “make-up” to the general public saying, “Every girl can look like a movie star by using Max Factor make-up.” Thus began the march toward what I think are unrealistic expectations of beauty and body form.

A Polish-American named Leo Gerstenzang invented cotton swabs, aka Q-Tips, in 1920. They were originally called “Baby Gays!” The Q-Tip company was acquired by Chesebrough-Ponds in 1962 who then moved manufacturing to Puerto Rico in 1974. Chesebrough-Ponds is now a part of Unilever, which began as Lever Brothers. This story not only features an early example of off-shoring but also the food chain effect of industry where big fish swallow smaller fish.

French chemist Eugene Schueller invented the first synthetic hair dye in 1907. The new dye was dubbed “Aureole” and led to the company known as L’Oreal. He is also credited with inventing the first sunscreen in 1936.

In 1944, a pharmacist in Florida, Ben Green, created a suntan cream in his kitchen. It debuted as “Coppertone Suntan Cream.” Ben was next spotted on a beach where his dog was pulling down his bathing suit to expose his pale white buttocks. Kidding.

Does Your Company Have Multiple Personality Disorder?

The company that I work for is a benevolent behemoth, an uncaring bureaucracy, a force for good health, a greedy American corporation, a soulless hierarchy, a nurturing matriarch, a faceless dictator, a greed machine, and so much more. Like many American companies, this company does much that is good. I’m a part of it. I have the opportunity to have a positive impact on people’s lives every day that I show up and suit up. Yet I can get so frustrated by the multiple levels of corporate management that very often give mixed messages or more often, illogical ones. I’m betting your company shares some of these traits. Plenty of feel-good benefits for employees and plenty of community giving, balanced against the drive to dominate the market and maximize profits.

Imagine this in today’s climate of perceived job shortages: my company recently announced that they would be adding 20,000 jobs! Here in the trenches, however, the reality is that we are and have been severely understaffed for some time. My latest schedule contained over 50 unfilled technician hours, with over 250 hours with nobody to work them in the entire market. I have dedicated people that realize what it takes to deliver the quality of care that we provide. These people step up, for the benefit of our patients, to the benefit of our store and ultimately for the benefit of our entire company. We keep the place open and running and the profits pouring into the corporate coffers.

At one level, ground level, patients and fellow staff members appreciate how hard we are working. Those of us in primary management have to skillfully tread through the swamp of misguided messages from the upper levels of the company. With hundreds of hours of unfilled shifts, the place suffers and it starts to show in things like poorly stocked shelves, a little dustier than usual, we get a little behind on all the mandatory tracking forms, training modules, new initiatives, and whatever the latest key metric is this week. In the midst of all this we are told that we must not allow any overtime! So, I wonder, do we want employees that step up and work a little extra to support the mission or do we want employees that don’t give a shit, punch in, punch out, and go home? I can say for pharmacy, my crew, and pharmacists and techs that I know, that our biggest reward is helping people with their health needs. Other messages from management implore engagement with the customer, take the time to make a connection, stay a little late for that patient with the ER scripts that shows up 5 minutes before closing. That OT is OK. But keep the OT down! And keep those numbers up! Meet your metrics! OT would shrink away to virtually zero with proper staffing. Using their own metrics, my pharmacy often performs at over 110% effective. For us, that means we have done the job required (providing Rx care along with filling thousands of scripts) using 40 or more fewer labor hours than the company metrics would and should provide. This is the recipe for burnout. Let’s get those 20,000 folks hired! I only need 2 or 3. If only the task was in my hands.

“Please complete our survey and tell us how we are doing!” Almost every retail establishment now has a survey on their receipt. Great importance is given to the data from these surveys and often will determine if employees receive a bonus. I believe that the data from these surveys is flawed. I know that I rarely complete a survey unless something extremely good or terribly bad happened during my transaction. I am more likely to vent about a shortcoming. Mostly, I am simply not likely to take the time to do a survey at all. Our patients bring baked goods, thank you cards, and hugs.

Companies look at these surveys and want results somewhere in the neighborhood of over 80% of respondents being “highly satisfied!” We get daily (Daily!) email updates showing just about every division running at about 70% highly satisfied and the number rarely changes. I have to see that frigging email every day. Delete. The thing is, if you look at the data, 97% of our customers are satisfied or highly satisfied. That’s awesome in my book! Not everybody that comes to our market is going to have a little orgasm and then run home to tell us about it on the internet. No, wait, a little orgasm would be “satisfied,” we want sweaty, muscle-clenching, screaming halleluiah experiences! Every day we get pounded with the negative message that only 70% of our customers had that kind of experience. Bad lover, bad! But boss, 97% of the time our customers roll over smiling and can’t wait for next time.

If you are a regular customer somewhere and you have a chance to do one of these surveys, I encourage you to be kind and give highest marks. It’s good to name names too, that often will directly enrich that employee with some small token and acknowledgement of a job well done. Consider that your service may have been poor because of under staffing.

Companies also survey their own employees. They want employees to love the company and will spend beaucoup bucks trying to enure high marks. Slick, colorful mailers singing the praises of the company with glowing testimonials from employees (just like you!) come in the mail during the weeks preceding the survey. Free food at meetings becomes more plentiful and includes all employees! Hey, it’s associates’ week! Feel free to “dress down” and wear your jeans! In years past a common message was very close to “you should love this company, you are lucky to even have a job.” The survey itself is filled with leading questions and slanted perspectives that make it hard to convey a specific negative observation or comment. Love us, damn it!

Why does it take so long for a large company to make a change that would benefit employee job performance? I have numerous instances, not just in my current position, where a large corporation will have hundreds, if not thousands, of pharmacists and techs be forced to do the same repetitive tasks over and over, day in and day out, when a solution has been identified that would only need a programmer to make a small change in the operating code for our software. I hear this happens in many fields, the corporate ship is rarely nimble in these matters. When changes are made, they must first prove a Return On Investment or ROI. What that usually translates to for us in the trenches is a reduction in our labor allocation. So when great ideas are submitted that would make our jobs easier or more effective, some bean-counter sees it as an opportunity to cut labor costs, not as a way to improve outcomes and job satisfaction. Too often the bean-counters win.

I realize that there are economies is having these large corporations that keep coalescing into larger and larger entities but every time we focus on metrics or numbers rather than people we take another step toward the dehumanization of the workplace. We have various departments that create directives seemingly in a vacuum. There seems to be little effort to coordinate with other departments, often resulting in a shower of demands that only add to workplace stress. Poor planning on the part of upper management can often result in short deadlines for employees, again increasing stress. Little consideration is given to how much work time is sucked away by this constant barrage of emails, reports, pleas, FYIs, newsletters, and technical problems with hardware or utilities. I have no doubt that others face similar, perhaps worse, situations in their workplace.

Perhaps I’m an idealist and naive, but I define progress as improving the lives of all of us. I do not define it as greater corporate profits from increasing productivity to the point of burnout, rapidly cycling planned obsolescence (ready for that next iPhone?), drone-like workers paid only enough to be good consumers of more shit wrapped in cellophane, a population that knows more about the Kardashians than our system of government and our elected officials, and people that are paid hundreds of times more to play a game than to teach our children, defend our country, or protect us in our communities.

Prid, GRASE, DESI, and I

The history of drug safety and effectiveness in the US really began in 1906 with the passage of the Pure Food and Drug Act which followed closely on the heels of the Meat Inspection Act. It was a time in our history when so-called muckraking journalists were exposing all sorts of shenanigans in the burgeoning industrial age. Upton Sinclair’s The Jungle came out in 1906 also. Coca-Cola, which evolved from a wine and cocaine beverage which in turn ran into the constraints of prohibition of alcohol before the problems with cocaine became apparent. Coca-Cola, with a bit less than 4% cocaine, hit the market in 1886 and was reformulated in 1903 without the cocaine. Reportedly, they still use coca leaves, although the cocaine is removed and sold to the pharmaceutical industry by a separate company.

I guess you could consider the third part of an Old Drug Product trilogy, along with the saltpeter post and the alum post. I still had ichthammol ointment on my mind, after selling a product called Prid to a customer looking for a “drawing salve.” I have usually recommended ichthammol ointment, but now it is considered by the FDA to be an unproven product and unavailable. That means, really, it has been around so long that it has never been subjected to current regulatory standards.

The Federal Food, Drug, and Cosmetic Act came in 1938 and required manufacturers to prove product safety. The 1906 Act was more concerned with adulterants and contaminants and the stated strength or concentration on the label. A 1962 amendment to the 1938 FFDCA was the first time consideration was given to both safety and effectiveness and asked for reevaluation of drugs brought to market in the intervening years between the original Act and the amendment. This is where the term DESI drugs, which many of us pharmacists have heard much about, came into being. DESI is Drug Efficacy Study Implementation, the process of reevaluating the drugs that came on the market between 1938 and 1962. It includes drugs that are Identical, Related, or Similar (IRS drugs). There are thousands of DESI drugs. Just to add to the confusion, there is a category of Generally Recognized As Safe and Effective (GRASE) drugs! Many manufacturers would delay the expensive DESI studies by claiming GRASE status for their products. Since making the cut to be GRASE requires consensus agreement among experts and solid scientific literature there are no prescription products that are GRASE. In 2006 FDA launched a new initiative to get unapproved drugs off the market. Targets included carbinoxamine, previously found in Rondec a popular Rx cough and cold remedy for infants and children, but suspected in at least 21 infant fatalities; Trimethobenzamide (Tigan) had no good demonstration of effectiveness; all forms of timed-release of guaifensin other than the one approved product, Mucinex; hydrocodone products due to labeling issues with safety in general and dosing in children.

Prid is on the market as a homeopathic product and so dodges much FDA scrutiny. It still contains ichthammol as well as phenol (aka carbolic acid). There are only a small number of GRASE items for topical use: Allantoin, cocoa butter, cod liver oil, dimethicone, glycerin, hard fat, lanolin, mineral oil, petrolatum, white petrolatum, aluminum hydroxide gel, calamine, kaolin, zinc acetate, zinc carbonate, zinc oxide, Colloidal oatmeal, and mineral oil. You’ll notice that Prid has a National Drug Code (NDC) number, so I think it is only a matter of time before the FDA notices this product and it disappears or is reformulated. Hyland also markets a leg cramp homeopathic product, which, up until recently, contained small (I say sub-therapeutic) amounts of quinine. That was noticed and now the product has been reformulated without the quinine. There is still tonic water with its 83mg/liter of quinine. We used to sell 300mg capsules of quinine without a prescription so you’d have to drink about five liters of tonic water to get a similar dose. You may not get nighttime leg cramps but you’d be up often to empty your bladder!

On the other side of the coin, I have had patients that love these products and claim they really work well. I’m not a homeopathy fan. I am a believer in the placebo effect and I think that is a large part of the success of Hyland’s Leg Cramp relief. I have used ichthammol personally with good success. I have not used Prid, although I just sold some to a former pharmacy tech for use by a relative with a splinter and he came back to tell me that a “small metal shaving” was drawn out of her skin after about three days of Prid application. Others have claimed good results in shrinking a boil or dealing with an ingrown hair.

Ichthammol, by the way is a petroleum-derived substance. Ichthammol 20% ointment is a black, tarry, smelly, goop. IMG_2130You can see that Prid looks similar, although not as black as the old stuff. Ichthammol is derived from shale oil and I can just imagine some scientist assigned to study this stuff, saying, “this looks and smells like fish shit,” and turning to his Latin naming guide, came up with Ichthy salve, or Ichthammol. The fish shit assessment persisted in the common lore and in my early days of pharmacy practice had more than one customer come looking for “that fish shit stuff.”

I know that some of you are thinking that I’m old enough to have lived through all of this history. For you I give a nice, loud and wet razzberry! I do love to read about lots of cool things and sometimes I just go down the rabbit hole, opening door after door, and finding how connected so many things are. Then again, I have practiced pharmacy for four decades. Yikes!

Don’t Salt my Peter!

I had a call yesterday from a gentleman seeking saltpeter. My young staff pharmacist was unfamiliar with this simple chemical which I know as potassium nitrate. I was familiar with it from my many hours with my chemistry lab in the basement, cooking up a variety of experiments. This included trying to see if plants and insects could survive in an ammonia atmosphere, trying to make a gelatin form of gunpowder, and creating rotten egg “bombs” for deployment at school. The first two were unsuccessful and the latter was successfully deployed on more than one occasion. The rotten egg bomb was simply a test tube filled with wax and sulfur. The tube was capped and carried easily to school where it could be uncapped and placed behind a nice warm radiator. The smell of rotten eggs was quickly noticed. Eventually, I was ratted out and that ended those escapades. Nuns do not tolerate such things. But I digress…

The caller was interested in saltpeter to control his libido, he said, not to make explosives. I explained to him that using potassium nitrate to suppress libido or decrease frequency of “spontaneous erections” (his words) was “hogwash” (my word). He persisted, telling of its great success by the military, including George Washington’s troops, and other institutions with exclusively male populations, like prisons. This is hogwash, a myth, a lie repeated repeatedly until it gathers believers (much like politics). He still wanted to order some and since I could get a 4 ounce bottle for under $5, I went ahead and ordered it for him. He said he wanted to take it to his doctor so he could get a proper dosage, since I was unable to provide dosing instructions. Don’t people listen?!? I suggested he ask his doctor about a nice SSRI that would be a better choice to help control his bothersome boners and impertinent impulses. I could almost hear that advice bouncing off his brick head and coming back through the phone. Sigh. IMG_2120I’m not going to go into detail about saltpeter, the label says it is for household and farm use. Try Google. Or Bing.

There are real lessons to be learned here. What will the boomer generation do when they come seeking this arcane knowledge of products and chemicals, some useful, some harmful, and some just stupid. I have an assortment of products in the pharmacy that I have introduced to my young pharmacists and they have seen some utility in these “old-time” remedies. Many, of course, are simple disappearing from the marketplace. We used to carry ichthammol ointment as a drawing salve but apparently this can no longer be sold. The FDA, I would imagine. We also keep zinc oxide ointment, capsaicin cream, assorted bottles of generic drugs that are grossly overpriced in our “front end,” as well as an old-fashioned rubber water bottle/douche/enema kit, styptic pencils, and more. Major pharmacy chains are anxious to get rid of older, higher paid pharmacists, with plenty of vacation time, in favor of younger, cheaper pharmacists willing to work longer and more inflexible schedules. Time is running out for these youngsters to gain some of the ancient wisdom we gray-hairs can offer. I am amazed when patients come to our pharmacy with a script for magic mouthwash or Questran ointment that the kids at Walgreens or CVS or one of our own sister stores refused to mix. One of my techs suggested it wasn’t that they could not mix it, it was because they did not know how to get the thing added to the computer database. Sweet Mother of God! Many patients end up going to a compounding pharmacy where they are eager to fill such orders and more. Bless ’em!

Another lesson is that patients do use the internet to gather information about their health problems. Unfortunately many of them, like my saltpeter guy, only learn what they want to learn. I am also amazed at the number of people who seek the advice of a pharmacist and then completely disregard it. I suppose that as long as we continue to give free advice, some patients will continue to give that advice zero value. The future is yours youngsters, change the world!

I try to make my students think. My favorite was a student that was assigned to identify and discuss excipients in various Rx tabs or caps. The process was to read the chemical and then look it up on their phone or iPad until I put a stop to that. Really? You are looking up ferric oxide? Stop! Think!
“What is ferric?”
“um, um, iron?”
“and oxide means…?”
“ahhh, oxygen?”
“so what is ferric oxide?”
“think way back to inorganic chemistry…”
“oh! iron and oxygen, oh! oxidized iron!”
“and that is more commonly known as…?”
“oh yeah!”
“so why would rust be in this tablet?”
Blank Stare
“what color is rust?”
“kinda orange”
“and what color is this tablet?”
“kinda orange”
Slowly a shaft of white light shines down on the student’s head and you can hear angels singing Halleluiah!
“OMG it’s there for color!”
I rest my case.
These young pharmacist are filled with years of knowledge and yet many do not know how to access and compile what they have learned and act on it. I stress foundational learning for the many students seeking my recommendation for pharmacy school. Pay attention and understand the sciences that you are taught leading up to the pharmaceutical sciences. If you can grok physiology, chemistry, biology etc., then you will be ready to add pharmacy science to that fundamental understanding and will be prepared to answer questions and offer advice without reaching for a smart phone or iPad. That is not to say we ever stop learning and using our research tools. When you can connect the dots and see the big picture you are truly an asset.

Jala Neti

The neti pot is a specially shaped container, most often purchased with saline packets, that is recommended to cleanse nasal passages to improve sinus-related ailments. The shape of the container makes it easy for users to deliver a saline solution into nasal passages, creating a “nasal irrigation” for sinus sufferers. There are also versions that a simply plastic squeeze bottles which can also be used for this process of nasal douching, although most experienced neti users advise against using more force than what is provided by natural gravity during a neti rinse. Simple neti

The neti pot has its roots in Ayurvedic medicine where it is called jala neti, Sanskrit for nasal cleansing. In India and other countries, it is as common and routine as brushing one’s teeth. However, because it is a new technique over here, many users are a bit intimidated their first time.

Basically, the neti pot allows a user to pour 8 to 16 ounces of warm saline into one nostril while letting the solution pour out the other nostril after making the transit through the nasal passages. The nose is the first filter for the air that we breathe. Little hairs and sticky mucus membranes trap particles and pollen before they can get to our lungs. Nose breathing is good! If you have seen the dust motes floating prettily in a shaft of sunlight coming through the window, you have a good idea of what is being filtered out: Tiny bits of fabric or lint, dead skin cells, mite poop, dirt, various pollutants from vehicles or industry, and anything else that got stirred up into the air.

Typically, in a neti kit, the packets contain 700mg of sodium bicarbonate and 2300mg of sodium chloride; however, a level teaspoonful of plain salt can suffice if your pot does not come with saline packets. Simply empty the packets into the neti pot and add warm water, give a little stir and you are ready to go. The kit will have a diagram showing you the correct position for proper irrigation. Any stinging or excessive dryness after neti use is likely due to a salt concentration that is not quite right. The goal is to have the salinity slightly higher than “normal” body salinity, which for sodium chloride is 0.9%. Adjust your mix according to your comfort, attaining proper salinity and temperature.

The most important element to remember is to continue to breathe regularly, through an open mouth. It is a natural reaction to hold your breath when feeling water in your nose but if you hold your breath, you will not allow the solution to make its way through the nasal passage and out the other side. When you are finished, blow gently into a tissue and squeeze your nose as if you had a cold. This should clear most of the water and some remaining mucus along with some air pollutants.

The authors of a randomized trial published in the Journal of Family Practice concluded “Daily hypertonic saline nasal irrigation improves sinus-related quality of life, decreases symptoms, and decreases medication use in patients with frequent sinusitis.” If you have allergies, regular sinus problems, or just do not want all that crap in your nose, the neti pot is a good tool for a cleaner nose.

Alum: From Pickles to Prostitutes

alumAlum has been used by ancient Romans, cooks, tanners, alchemists and whores for hundreds of years. Potassium aluminum sulfate is the alum that you find in the supermarket, although its utility in cooking, industry, and health care is unknown or forgotten by modern shoppers. Mostly, supermarkets sell it for pickling although newer recipes depend more on lime or Pickle Crisp, which is calcium chloride, a firming agent.

In my practice, I added styptic pencils to the stock of the pharmacy, since they were no longer part of the contemporary offerings of our shaving section. As an astringent vasoconstrictor, alum is a quick and easy way to stop a small shaving bleed. It does provide a bit of a sting, but that just means it’s working!

Ancient Romans, Egyptians, Indians and others knew of the water-purifying power of alum. IMG_0174Alum added to turbid water causes suspended solids to come together into larger clumps or “flocks” which sink to the bottom of the container. water plant This flocculation, using alum, is one of the first steps used in modern waster water treatment plants, including one I visited here in Mesa, AZ. Alum is also known to long-trail hikers, Grand Canyon river rafters and other outdoors folks as a good way to un-cloud cloudy water.

Alum was used to shrink what was called “proud” flesh, that is, tissue that was swollen with blood and fluids, usually as the result of an injury or infection. The astringent action of alum would tighten that proud flesh as it constricted blood vessels and drew water from the tissue. It is this same astringent property that was made use of by knowledgeable women that wished to keep their packages tight.

There’s an early mention of this use in the Muslim text, The Perfumed Garden, from the 1500s:
“Know, O Vizir (God be good to you!), that bad exhalations from the vulva and from the armpits are, as is also a wide vagina, the greatest of evils.
If a woman intends to contract her vagina, she has only to dissolve alum in water, and wash her sexual parts with the solution.”
Click the link and read a few chapters to see where some of our sexual hangups, myths, and misconceptions come from.

In 19th and early 20th century Arizona, the wild wild West, it is known that some of the busier prostitutes kept a cloth soaking in a bowl of alum solution within reach so it could be used between customers to “freshen up,” if you will. This also tended to keep the customers coming at a quicker rate, which was good for business.

In the mid to late 18th century alum was used internally as a way to quiet whooping cough (pertussis), help heal bleeding ulcers, counter hyperhydrosis, and was added to many snake oil-type remedies as a way to prevent wrinkles.

Anecdotally, I have heard many reports of very effective treatment of hemorrhoids using an alum paste or mixing some alum in Vaseline and apply to the hemorrhoids. I have recommended this and been told it works, and most patients were happy to share that they went from the painful burning of hemorrhoids to an almost pleasant cold stinging from the alum. Since a hemorrhoid is really just more “proud flesh” it all makes sense.

You’ll see large fist-sized blocks of alum sold as an antiperspirant and that works too if you don’t mind rubbing a rock in your armpit every day (I don’t think you want to sit on a rock if you have hemorrhoids). For best results, don’t apply after a shower, apply at bedtime when your pits will be at their driest for a long time. Aluminum salts are the most commonly used ingredient in antiperspirants.

Alum is also found in hair removal waxes or applied after waxing.
In the old days alum was used in the laundry to help maintain clothing colors. Our superior dyes make that unnecessary.
Alum is used in leather tanning, taxidermy and is used as a flame retardant. Egyptians were using alum as a flame retardant hundreds of years BC.
If you were in a marching band you may be aware of the old trick of putting alum on somebody’s mouthpiece so that they were so puckered up they could only blow little squeals.

Finally, I should talk about aluminum salts found in vaccines. There is some controversy here that feeds into the irrational fear of vaccination. Aluminum salts, including alum, are used as adjuvants in several types of vaccine. Adjuvants are used to increase the stimulation of the immune response, and/or improve solubility of the antigen or other components, and/or decrease the toxicity of the antigen. I say “and/or” because it may be any one, two, or all three reasons for an adjuvant to be used.
Here in the US, aluminum adjuvants are found in DTP, DTaP, Hib, pneumococcal, Hepatitis A, Hepatitis B, HPV, Anthrax and Rabies vaccines. FDA updated their info on aluminum in vaccines in January 2012 here.

Aluminum is the most common metal found in the Earth’s crust.

Here's where to find alum in the seasoning section of the market!

Here’s where to find alum in the seasoning section of the market!