SUPERmarket PHARMACIST

A pharmacist's look at the supermarket and beyond

Month: March 2015

Garbage in, Garbage out

Most of us older pharmacists remember the good old days when all we had to worry about was trying to read doctors’ scrawls on prescriptions like this one:

Can you read all three?

Can you read all three?

Hint: It is not an order for Amibur, Leepu and Rispeel.
I often am called upon to decipher hand written Rxs in the pharmacy and as we move toward more computer generated scripts, the young pharmacists are getting less opportunity to hone that particular skill.

Occasionally a doc will make up a brand new drug, or just demonstrate a profound lack of spelling skills: IMG_0382

The growing trend toward e-prescribing continues to deliver a whole new set of errors. We often wonder if the prescriber even looks at what they have created before hitting the transmit button. Here is a favorite from our pharmacy:

What? What?

What? What?

That one was quite a monstrosity! More often we get nonsense information in fields other than the drug name.

200 inhalers!

200 inhalers!

What if we really dispensed this one with these instructions to the patient!

Eat 'em up!

Eat ’em up!


We thought it might have been an ICD-9 inserted in the wrong place, but that code is for GI cancer. Go figure.

Computer generated scripts are not always electronic. Here’s one that was printed at the hospital: pure
Of course this required some investigation. It turns out that we could find a company web-site for Pure Encapsulations but they purely encapsulated a wide variety of products. When we were finally able to track down the prescriber, we discovered that he was trying to order a pancreatic enzyme formulation that would not conflict with the child’s significant sensitivities. We got it done.

Of course our own pharmacy computer systems are not without fault. Our drug databases are often inconsistent, our pricing is often illogical, and we are constantly bombarded with irrelevant DUR warnings and pop-ups that only distract us from good data verification. This is one happens with many drugs that come in as e-Rxs and the description does not quite match the one in our database.

OMG  what is it?

OMG what is it?

Do I really need to be warned that Plavix 75mg tabs does not match Plavix 75mg tablets?
Or you may enjoy a handy, informative screen like this one:
It's verified dammit!

It’s verified dammit!


This is just one type of distraction that a busy pharmacist must overcome. A busy pharmacy with its cacophony of scanner beeps and boops, phones ringing, techs talking (maybe about a work issue, possibly a relationship issue – do you hear it all?), and the need to always be 100% accurate while meeting the ever more demanding metrics that your company has insisted is “industry standard,” is a workplace that is stressful environment. Knowing that, I can sympathize with physicians’ offices that are also being pressed to deliver high quality care at a rapid rate and with dwindling compensation.

If you are in a stressful job situation, maybe you should consider an Rx for Poozac! It’s for when you are down in the dumps and can’t even take a dump.

Poozac!

Poozac!

Pharmvolution

Pharmacy is always evolving. So many things are happening that I am almost thankful that I am approaching the final years of my career. On the other hand, it could be a very exciting time to be entering the field. There are many changes happening on may different fronts and I hope that my colleagues in all aspects of pharmacy will have their voices heard and their concerns dealt with in a positive manner.

Congress is still considering the tentative step of identifying pharmacists as health care providers, but only in under-served, rural areas. Really? I’m sure most of my patients consider me a health care provider and there is plenty of solid evidence that pharmacists contribute to positive health outcomes and cost-effective delivery of a variety of treatment plans. We are past time to codify the fact that pharmacists are health care providers. When this happens, and not just for rural areas, it will create a host of opportunities for pharmacists ready and willing to advance the profession.

While this positive development moves forward, other pharmacists are striking back against unfair labor practices by some of the nation’s largest employers. CVS recently settled an unpaid overtime class action suit to the tune of $2.8 million to be paid out to 627 Southern California CVS pharmacists. That’s about four and a half grand each or $1.29 after legal fees and taxes are paid. Just kidding! What is up with these companies like CVS, Walgreens, Wal-Mart and others that think labor laws do not apply to pharmacists? California law requires overtime be paid at a rate of one and one-half times the employee’s regular rate of pay for every hour worked beyond 8 hours in a single day or 40 hours in a single week. Same goes for the first eight hours worked on the seventh consecutive day of work in a workweek. Workers are to receive double their regular rate of pay for all hours worked above 12 hours in any workday and for all hours worked in excess of eight on the seventh consecutive day of work in a workweek. Wow! I wish we had that in Arizona! The sad part of all this is that pharmacists are working long, hard hours that meet these thresholds and are being considered exempt from these labor laws. I feel bad for my brothers and sisters that are exempt professionals and yet are expected to work 14 hours a day, or more, with barely time to empty their bladders. Kudos to companies that treat pharmacists fairly and allow breaks and foster reasonable schedules that provide adequate labor hours.

Another factor that will affect the profession is the abundance of pharmacy schools and programs available for the production of pharmacists. We now have over 130 programs up and running and although the rate of new school openings has slowed, there are still new schools being planned. We are currently adding over 60,000 pharmacists annually from these schools to the 300,000 of us already out there. This creates a troubling dynamic where older pharmacists are being nudged toward retirement. Many employers see great advantage in using young pharmacists that are at the starting end of the wage scale and are often more pliable to corporate demands. This creates an attitude, always denied, of course, that from a business point of view, it would be best if you old folks would just get out of the way. Many of the young pharmacists that I work with are quickly working towards burnout as they grab as much OT as possible trying to retire the crushing debt of student loans. Many of my contemporaries, we elder statesmen, have adopted an attitude of trying to toe the corporate line, keep our heads down to avoid both enemy and friendly fire, and just hang on until we are eligible for Medicare.

Of course, technology is changing pharmacy much like it is in other job sectors. Robotics and software like IBM’s Watson are changing healthcare with higher efficiency and the ability to consider huge amounts of empirical data. Will Watson ever a “gut feeling” or act on a “hunch?” Not without some sci-fi AI like our new friend, Chappie. Walgreens, a leader in the field has adopted new technologies at a rapid rate and has been fairly nimble at discarding the ones that don’t work. This turnover of technology will continue and even escalate as pharmacy practice expands into more direct patient care. There may eventually be a fracturing of the profession as we move away from the mechanical aspects of drug distribution to direct management of pharmaceutical therapies and other treatment modalities.

Today’s new pharmacists will have to straddle many worlds. I always tell students about to enter pharmacy that they should have a solid grasp of human physiology before starting any pharmacy program. As we approach the brave new world that is coming, these new practitioners must have many more tools in their toolboxes, including physiology, pharmacology, kinetics, psychology, and an understanding of various technologies. I hope that the pharmacists that care for me as I age, and my body and perhaps my mind begin to betray me, will have very sharp tools in their toolboxes, sharp minds to wield those tools, and most important of all, a sharp sense of compassion to temper their approach to care.

Take this pill and…

“Why does prescription medicine come with instructions saying the pills must be “taken by mouth?” How else would one take them? I shudder to think!” My cousin posted that on Facebook and a litany of reasons followed in response.

No sooner than that discussion began to explore the importance of being very specific with prescriptions, that I filled a prescription for diazepam 5mg to be used vaginally! It was not an error, the patient suffers from pelvic floor dysfunction. Sure enough, there is some evidence in the literature to support this off-label use. One small (n=21) study published in Urologic Nursing found that 62% of the participants were moderately or markedly improved. So there does seem to be some rationale for using diazepam to minimize pain during intercourse for women with urogenital pain or pelvic floor dysfunction.

Speaking of vaginas, did you see that University of Wisconsin student who made some homemade yogurt from the bacteria in her vagina? A healthy vagina should have a decent population of lactobacillus so it makes sense that she could get a starter culture from her vag (using a wooden spoon!) to add to milk. Heat, culture, serve. She ate at least a couple bowls of the stuff despite the warnings from FDA that “vaginal secretions are not considered ‘food’, and they may transmit human disease, a food product that contains vaginal secretions or other bodily fluids is considered adulterated.” I assume that she was fully aware of where her genitalia had been and who it had been hanging out or hooking up with, if anyone. One of my techs noted that people will willingly “eat” each other’s genitals, but will cringe and avoid eating a brown spot on a banana. People are fun!

I digress. The FDA recognizes over 100 routes of administration for medications. Many of these involve needles, where the drug is delivered to a precise target in the body (retrobulbar = behind the eyeball), to the more common injections such as into a vein (IV = intravenous), or into a muscle (IM = intramuscular), or under the skin (SQ or SC = subcutaneous).

Of course, any orifice is available for drug delivery and pharmaceutical scientists study the feasibility and pharmacokinetics of our various entrances and exits. The great variety of delivery sites coupled with the huge number of drug dosage forms gives medical science an expanding universe of dosing possibilities.

To be fair, let’s take a look at drugs used for erectile dysfunction (ED) so that we give equal time to the penis. If you’ve been following this blog, you already know that early ED remedies included rubbing a variety of spicy concoctions on the uncooperative member. Science progressed beyond those early and messy attempts at erectile achievement.

Prior to any FDA approved meds for ED, many men opted to have penile implants which involved surgery to insert flexible cylinders into the penis which could be filled with saline using a pump, often within the scrotum, to move saline from the reservoir, elsewhere in the groin, to the cylinders within the penis, mimicking an erection. A release valve on the pump would allow the saline to return to the reservoir. This gave a whole new meaning to the “I am here to pump you up!” skits on SNL.

Other drugs were tried before the advent of Viagra and its cousins, including MUSE, an urethral insert containing alprostadil, a prostaglandin (PGE-1). This drug can be absorbed thru the urethral lining, promoting increased blood flow and a viable erection. Take note that a small plastic delivery device is needed and a small urethral suppository is inserted into the penis. It’s been a while since I dispensed one of these but that applicator goes at least an inch into the penis and the suppository must be retained within the shaft and rolling the penis between a pair of hands will help release the drug. All told there is significant penile manipulation involved.

Another way to deliver alprostadil into the penis is by injection directly into the penis. Obviously not for the faint of heart, Caverject is injected directly into the corpus cavernosum. Fortunately, there is a corpus cavernosum on either side of the penis, allowing for alternating injection sites.

Of course the oral medications are the number one ED therapy and constitute most of the $4 billion US market. The next frontiers in sexual therapies involve female libido and premature ejaculation. More on that in a future blog post, suffice to say, science is tapping the huge market demand for unlimited sex with satisfaction guaranteed! Give me an O!

As we bask in the post-coital afterglow of all this activity, let me reiterate the need for very specific patient instructions to avoid the all too familiar tales of suppositories still wrapped in foil inserted into the rectum, or perhaps unwrapped and allowed to melt away between cheek and gum, or the young lady that thought she was supposed to take an OC pill “every time” and came in for a refill after a week, or the mom who put that pink amoxicillin into her child’s ears. It’s safe to say that a pharmacist should always be sure that the patient will administer the medication properly and the patient have no doubt in their mind regarding storage and use of the medications they are using. Remember that old maxim, never assume, or you could make an ass out of you and me.

I thought you might get a chuckle out of these images from my Safe Sex in the Future presentation at the Sixtieth Annual Pacific Coast College Health Association Conference, in November 1996 in Irvine, CA.

The Sex Files

That talk also featured this product prediction:
Sperm Ban gel