A pharmacist's look at the supermarket and beyond

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Feed for Your Pet

New light is being shed on the pet food business, so here is some food for thought on feed for your pet.

Recently, a couple batches of dog and cat food were found to contain pentobarbital, sickening many dogs and cats with one verified dead dog. The product was labeled as containing beef but actually contained apparently euthanized horse. Of course, pet owners are righteously alarmed.

Pet owners speak out most effectively with their wallets, but, in truth, the $26 billion per year pet food market is mostly unregulated. One of the problems is that pet food is considered animal feed and so its labeling is not directly controlled by the FDA. The standards for animal feed, pet food included, are established by the Association of American Feed Control Officials (AAFCO). You can check that web site youself and see that their board of directors seems like a pretty appropriate bunch of folks, mostly from state agencies and academia. Where things get interesting is when you realize that AAFCO merely sets standards for animal feed. As it states: “AAFCO does not regulate, test, approve or certify pet foods in any way.” That leaves it up to pet food manufacturers to formulate products up to those minimum standards.

So who does regulate pet food, if anybody? Again quoting AAFCO: “It is the state feed control official’s responsibility in regulating pet food to ensure that the laws and rules established for the protection of companion animals and their custodians are complied with so that only unadulterated, correctly and uniformly labeled pet food products are distributed in the marketplace and a structure for orderly commerce.” In Arizona, our statutes for animal feed are in Title 3, Chapter 15 (3-2610 covers labeling and 3-2611 covers adulteration).

The problem is that many pet food manufacturers are simply not being held accountable and are essentially self-regulating. In my research I came across a website that takes issue with improper labeling and adulteration of some prominent pet foods, asking folks to contact their AZ representatives. Specifically the sample letter provided mentions: “Pedigree Dog Food, Hill’s Science Diet Crafted Pet Food, and FreshPet Pet Food show grilled meat or roasted meat on the label, however there is no grilled or roasted meat in the pet food.” The site also provides some great information on what to avoid and how to find good pet food.

There are many other issues too. Remember the AAFCO sets standards, minimum standards, and some nutrition may be inadequate for your dog or cat. I would also worry about adulteration, such as the pentobarbital case and concerns of previous reports of contamination such as the Chinese gluten debacle of 2007 (the wheat gluten contained melamine, an industrial chemical used in the making of plastics.) You may recall (get it?) that melamine has resulted in baby formula recalls also.

So far in 2017, there have been FDA recalls of pet foods containing pentobarbital, metal fragments, salmonella, listeria, high levels of thyroid hormone, excess copper, and my favorite, Cesar Filet Mignon dog food with plastic filler. Puppies usually get enough plastic in their diet by chewing up your personal belongings! Obviously, we have a lot of work to do. Considering the current administration’s love for lack of regulation the need to speak out is greater than ever. So check out the sample letter that was linked above and let your voice be heard.

In the meantime, it’s buyer beware. Always, buyer beware!

Some pics:
Notice that canned food is 78% “moisture” aka water!

Just one of the dog food aisles at Petsmart!

Jam Up and Jellyfish Tight

In 2008 the Nobel Prize in chemistry was awarded to Americans Martin Chalfie and Roger Tsien and Japan’s Osamu Shimomura for their discovery and isolation of Green Fluorescent Protein from jellyfish. Shimomura first isolated GFP from a jellyfish found off the west coast of the US in 1962 and demostrated that it glowed bright green under ultraviolet light. The Nobel Prize recognized the value of a luminescent protein in use as a “tag” or “marker” for tracking various physiological processes in the body. Shiomura collected the outer rings of Aequorea victoria and squeezed the juice out of them to get the bioluminescent protein. Roger Tsien was able to change out various amino acids in this complex protein to alter the color, intensity, and duration of the fluorescence. Marty Chalfie and others were able to insert the gene that coded for GFP and therefore use it as a marker to track production of various biologically active molecules. They were able to insert the GFP gene between the gene for the target protein and the “stop” codon, making a bioluminescent version of the target protein that could be easily monitored. Read more about that science here.

Notice that none of these scientists thought it would be a good idea to eat the stuff. The value of GFP is in its use as a biological tool for scientific study. The promoters and manufacturer of apoaequorin protein, the synthetic version of GFP, would have you believe that it improves memory function. Others have made even more fantastic claims such as holding Alzeiheimer’s at bay, battling delusions, and augmenting dream-awareness. Great. I happen to believe we have a huge placebo effect happening here. Oh, before I forget, Quincy Bioscience, the manufacturer, was able to grant Prevagen GRAS (Generally Recognized As Safe) status for itself, simply by gathering opinions and sending a letter off to the FDA. Prevagen does not have to be independently tested for safety nor efficacy because it is marketed as a “food.” A very expensive food at forty bucks for a bottle of 30 capsules.

Intersetingly, Prevagen is harvested from GMOs. Yep, genetically modified e. Coli are grown in vats, after have their genes tinkered with, and the apoaequorin is extracted from the fermentation broth. There is no valid, peer reviewed study to support the claims of improved memory or any of the other claims made on the packaging.

But here’s the rub. We are talking about a protein made of of about 80 amino acids. One of the main functions of our digestive tract is to digest proteins. You may recall some of this process: Chewing begins to break down the protein, physically creating more surface area, next stomach acid start to “unfold” these complex molecules exposing them to the action of the enzyme pepsin. By now the protein molecule has started to fall apart into “peptides.” As this acidic broth of peptides enters the small intestine, a bicarbonate buffer from the pancreas neutralizes the acid. The neutral environment of this portion of your gut encourages the activity of more protein-digesting enzymes, such as trypsin and chymotrypsin, originating from both your pancreas and the cells lining your small intestine. Essentially, this process results in individual amino acids that can then be absorbed and distributed throughout the body. So when you eat a Prevagen capsule, the wonderful jellyfish protein they love to brag about is DECONTRUCTED into amino acids! At best you are getting some very expensive amino acids. So although, this may be a unique protein for us humans, the amino acids that go into that e. Coli broth are not. I feel we are spending a lot of time and money feeding amino acid building blocks to pampered e. Coli, extracting, encapsulating, and packaging a product that we will simply digest back to the amino acids that we fed to the e. Coli.

So the only benefit from this stuff has to come from the amino acids, right? There is no need to spend $40 a month. If you are concerned that you are missing some nutrient that is harming your memory, improve your nutrition. I just suggested to our new vegan employee that she add some whey to her diet to ensure that she is getting the essential amino acids needed by the human body. I have written about whey before. The FDA and the FTC both have objected to the marketing practices for Prevagen and Quincy Bioscience has, so far, been able to stonewall any impact on their marketing.

Stop wasting your money !

Oh When I was pondering a title for this piece the old song “Jam Up and Jelly Tight” came to mind even though I hadn’t heard or thought about it for many years. I guess I do not need Prevagen either. Anyway, in 1968, this Tommy Roe song was too sexy for a lot of folks as it seemed to be pressuring a perfectly nice girl to say yes to sex. You can check it out for yourself. It is pretty tame by today’s standards. Hey, at least he asked:
“You’ve got a sweet disposition
So come on and give me permission”

Credit: Truth in

Va Va Land

There are some pretty nifty developments in the realm of women’s health. We have come a long way from the days when I had the rather unique opportunity to learn how to install an IUD. Not too many pharmacists get an opportunity like that! Over a decade ago, as Pharmacy Director at ASU Campus Health, our wonderful Ortho rep set up a training class on-site and I was invited to attend along with several doctors and nurse practitioners. We sat in front of life-sized pelvic models similar to one seen here and did not have benefit of ultrasound or other technology, so using just sight and touch, used a small device to carefully place the Paragard IUD. On our models, there was a little trap door in place of pubic hair that we could lift open to see if we had properly placed the IUD. A training session that I will never forget! Yes, I got right the first time! I still have my stunningly stylish Paragard tie tack!

Speaking of vaginas, I came across a bit of trivia. The Walt Disney company is credited with releasing the first film to use the word vagina! Apparently working with funding from Kotex, the animators got to work on explaining menstruation. A ten minute restoration of this animated classic can be seen here on YouTube. I do find it hard to believe that the scary STD films they showed to our boys heading off for WWII didn’t mention vaginas, but maybe not.

Fast forward to modern times and we find that researchers at Northwestern Medicine have developed a miniature, functioning version of the female reproductive system. It is a small cube that can fit on the palm of you hand. This 3-D model is made with human tissue and uses artificial “blood” to allow transport of hormones and other secretions throughout the system. This technology, EVATAR, will enable the testing of new drugs without risk to patients. Imagine having a drug tested on this model, made from YOUR tissue! Ultimately the long term goal is a “body on a chip” which would use your stem cells to create tiny models for testing of various treatments for highly personalized therapies. You can take a few minutes to learn more about EVATAR here on YouTube. Someday, your doctor will harvest some of your stem cells, grow out a heart, a lung, liver, or an ovary and then test dozens of drugs and doses to see which best would treat whatever ails you. Creating a pancreas via this process may someday lead to a cure for diabetes! There is a male version on the way called ADATAR and another focused on the testicles and prostate with the working name Dude Kube.

In the meantime, as we see more and more young people opting for more natural food and drink, it is no surprise that modern women are looking for alternatives to the mass-produced, artificial menstruation products. Many women rightfully worry about exposure to bleaches and pesticides. Several new products are being marketed with moderate success, from natural sea sponges to reusable fiber products like “Glad Rags” or Thinx panties. There are also menstrual cups like the Soft Cup or the Diva cup (these cups may be referred to as catamenia cups in some literature – from the Greek, cat (pussy) -menia (blood) sorry, just kidding, although catamenia is a real word). From what I have read they require a short learning curve as well as the ability to become more intimate with your monthly visitor as well as your vag. If you want to read about one woman’s journey of discovery as she “test drives” these products visit Rachel Krantz. Considering that one woman can have about 450 periods in a lifetime and may use 16,000 tampons, pads, liners and such, its obvious that this is a big market not to mention more “stuff” in our landfills. Having reusable options seems like a good idea to me.

In world news, in Italy, the parliament is debating a measure that would have employers offer “menstrual leave” of up to 3 days per month for women with painful periods. Italy would follow in the footsteps of countries like Japan and Indonesia already offering some form of menstrual time off. It seems like a sticky wicket to me.

More world news. In a response to Donald Trump’s pussy grabbing quote, the Russian girl Punk Band, Pussy Riot, released the English language version of “Straight Outta Vagina,” which reminds us, “Don’t play stupid, don’t play dumb, vagina’s where you’re really from.” These ladies spent 16 months in a Russian jail so they definitely have street cred as fearless feminists.

And now: If your vag feels or looks a little worn out, and needs a little rejuvenation, and you can afford the procedure, and several days off work, you might consider an “Aussie makeover.” It’s suggested for a well-used or stretched out vag, or if it doesn’t match up to partner’s penis size. You can even have your labial lips sculpted! I would never have known about this, but I have the tendency to read anything I can get my hands on, especially in a waiting room.

That’s all for now, my final word is, support Planned Parenthood!

Tour de Cure

I rode in my second Tour de Cure bicycle ride last week with over a thousand local riders, including many colleagues from pharmacy. I raised over $300 which might cover the cost of a box of insulin pens for one patient and that might last a month or more. Diabetes is an expensive disease. I signed up to ride 25 miles but the final course was just over 28 miles. That’s one mile for every million Americans with type two diabetes. Diabetes is a prevalent disease. The Tour de Cure raises money to aid diabetes research. We can only hope that we find a cure soon.

I fervently hope that a cure, when found, is not suppressed. It costs Americans, all of us, either directly or indirectly, about $200 billion per year to treat diabetes. You can bet the medical-industrial complex does not want to see that money dwindle away. I’ve been hearing rumors about this sort of thing ever since pharmacy school, so many years ago. Rumors of drugs that were so effective that they essentially fixed the problem, but the company owning the rights would manipulate the molecule so as to cripple its effect or limit its effectiveness, thereby requiring repeated dosing to hold the problem or condition at bay.
It’s our new business model, after all. We are encouraged, or forced, to “subscribe” to so many of our modern conveniences, lease our cars and gadgets, and constantly renew our prescriptions. Let’s not allow this to happen with diabetes or any other of the diseases or conditions that we all walk for, run for, bike for, or otherwise donate our time, energy and money. I dream that part of our ideal national health care policy is to be sure that basic research, funded by tax dollars or donations, reveals all results to we the people. I know, naive and I didn’t really intend to stray down that path of negativity.

As I pedaled those miles, I took time to ponder some other facets of diabetes, beyond the staggering cost of treatment. There is lost productivity, as well, of course, but it seems that few of the players devote serious energies to managing type two diabetes without coming to me for drugs. Take a pill! If my corporate overlords allowed it, I could spend more time with these patients. Being in a supermarket presents a tremendous opportunity to do some coaching on buying habits and encourage smarter choices. We would spend most of outr time going around the perimeter of the market, limiting exposure to the center which is mostly stocked with processed foods. It does not have to be myself or even one of my staff pharmacists, I’d love to see an appointment system set up to have our at risk patients go shopping with an expert in nutrition. Unfortunately, without a significant charge to the patient, there is no return on investment. In fact, if some of these folks got healthier, we might fill fewer prescriptions. Ye gods, NO!

The baby step here is for patients and their loved ones to start small, by adding some fresh produce to every day’s menu, eliminating soda, whether sugary or artificially sweetened, and slowly sneaking in some exercise. It could happen. It might start with a friendly nudge.

To learn more about diabetes, you must start at the American Diabetes Association! Check it out! I invite you to ride with me next year.

Here is part of our pharmacy fridge. Probably close to $50 grand in there at the moment and that replenishes about once a week.

My Tour de Cure 2017:

My Tour de Cure

Health Care Extremism

The latest attempt to repeal and replace “Obamacare” has failed, despite a Republican controlled Congress and a president that ran as a Republican, but is demonstrably a party of one. The Ryan plan, dubbed the American Health Care Plan, remained too socialist and liberal for the conservatives, too generous to the wealthy for the Democrats, and too weak to be a meaningful replacement for the more robust ACA. I’m glad it failed. It was an extreme and poorly crafted alternative. This is the best they could come up with in seven friggin’ years??!! And then they were willing to bend over for the “Freedom” Caucus and demolish women’s health care. Spineless tools.

Not that I am all that happy with the ACA. Most folks agree that certain aspects of Obamacare are winners,the pre-existing condition requirement, the age 26 coverage as a dependent, and the expansion of Medicaid, seem to be the top three. Major mis-steps are the pricing structure that allows healthy individuals to forego coverage unless they pay a penalty, and the mandated coverage of certain items that are not universally needed. Either way, a person starting out in the workforce has a new expense that will delay many desirable milestones as a contributing citizen. It makes it more difficult to buy that first home, start a family or own a business, and erodes any attempt to plan for the future. Insurers were left offering policies with unneeded coverage line items that inflated premiums and made plans unattractive to potential buyers. That whole pricing/minimum coverage strategy coupled with tax implications are the biggest flaws of the ACA.

My question is: Why must we repeal and replace the entire Act? That’s extreme! Shouldn’t we be gathering our experts and stakeholders to work with Congress and find a workable solution? Congress should be representing the best interests of its constituencies, not special interests such as Big Pharma, behemoth insurance companies and their CEOs, or other members of the oligarchy.

Medicare has worked relatively well for decades. This despite the government “borrowing” all of the money that we have paid into the trust fund itself. The funding strategy is not as convoluted as the ACA and with proper changes in design, intelligent limits on coverage, and aggressive fraud deterrence, a national health care plan is possible. We should cover every American with a basic level of coverage starting with first breath. A balanced fee structure could be designed using a person’s age and income (ability to pay) to determine a reasonable premium. Note that I said basic coverage, you can read that as catastrophic coverage if you like. The main point is to provide federal coverage for all. Once we agree on that we can start to discuss incentives for healthy behavior and limits to care for self-inflicted conditions. We can balance payments according to age and ability to pay. We could even consider levels of coverage above the basic as people entered the workforce while creating incentives for people to seek gainful employment. States could take action to help those at greater risk and lower abilities. I’d still like to see everyone contribute to match their abilities.

This would not mean the end of more robust plans, which could be offered by employers as part of an attractive benefit package. HSAs could easily survive.Once the baseline coverage foundation is established, building on it in the marketplace, either through private purchase or as part of a group (be it employer or other groups), can fulfill that burning Republican desire for capitalism in health care. Although we need to be very careful how this is crafted.

I wonder if we see this extreme behavior to completely destroy Obamacare as a reactionary dislike for our first Black president simply because he is Black. I’ve told my Senators and Representatives that I want the ACA made better, not destroyed. That is how we made America great, by building on our successes and revising and improving on ideas that didn’t meet expectations. Not by the extreme politics that we are seeing now.

And while we are at it: One of the components of the ACA was to limit health insurance executives to $500,000 in tax deductions. HHS Secretary, Tom Price stated that it is unAmerican to single out these individuals.
I agree! Why not have that $500,000 limit on everyone? We could exclude charitable donations to true charities (NOT PACs!). No one is singled out. Problem solved!
Who the Hell needs more than half a million in tax deductions??? Yeah, I can think of one guy too.

Finally, no matter what we do, the end result should be something that can be easily understood by the average Joe. No more of the coverage gap, you pay this % we pay that %, Big Pharma gives you a discount (wink, wink), spend this much, we match, check out of pocket, cover this today, not tomorrow, authoritarian health rules. I must be able to explain coverage to my patients! Preferably in two sentences! That would be Great!

Suggested Executive Orders for DJT

I thought I should expand on a brief note that I have sent to the White House and posted on Facebook. Maybe, though, rather than expand it, I would be better off trying to get it down to tweet size! (Added text in italics)

President Trump,
I am not a lobbyist. I am a practicing pharmacist with a few suggestions for my professional arena that I think will help make America greater.
1. Immediately make all pharmaceutical manufacturer’s discount cards eligible to be used by patients with Medicare. This exclusion is just a lobbyist-fueled, mean-spirited obstacle for those patients most in need of our help with exorbitant drug costs. This is an apparent attempt to avoid violating the Medicare Anti Kickback statute. Congress enacted the Anti Kickback Statute as Amendments to the Social Security Act in 1972. It was more recently revised in 2010 as part of ACA. In pharmacy, one notable case involved Walgreens in a 2012 settlement of $7.9 million. Walgreens, of course, denied any fault. They had simply offered gift cards Medicare and Medicaid beneficiaries in exchange for transferring their prescriptions to Walgreens. I suppose this is similar in concept to a drug company offering to reduce a copay for a Medicare patient’s brand name med. The difference is that patients are given an Rx for a specific drug. It’s not like they can simply go across the street to a competitor. Too often, a patient struggles, trying to decide where the money will come from to pay for their fancy post-op blood thinner or the latest and greatest diabetes med that may lower their A1C by half a point. It’s OK if you are privately insured though! This distinction helps to contribute to the high cost of brand name medications and should be modified as soon as possible. Easily remedied with an executive order! Notice these cards not only exempt Medicare patients but also our veterans covered by TriCare or other DOD plans!

2. Create a third category of pharmaceuticals that could be ordered by pharmacists for the benefit of their patients. Drugs to be included in this category can be selected by a small pro-tem committee of a practicing pharmacist, an academic pharmacist, a physician, a representative of PHRMA, and a consumer. This idea has been in various stages of discussion for as long as I can remember. There seems to be a concerted among powerful lobbying groups to prevent it from ever happening. As always, the reason is money. I’m sure the AMA sees it as an attack on their rice bowl as does the insurance industry. As a colleague of mine pointed out (thanks, Andrea!) Big Pharma should be with us on this after seeing what pharmacy has done to increase sales of immunizations. Easily remedied with an executive order!

3. Immediately grant pharmacists provider status. Congress has dithered with this long enough. Make it so. The latest iteration is a proposed statute granting provider status in rural, under-served areas ONLY. That’s a bunch of crap. The value of pharmacists in the delivery of health care and the resulting improvement in outcomes and cost and been well documented many times. Easily remedied with an executive order!

I tried to keep this message brief and would be happy to discuss or answer any questions that you may have.

Let’s make pharmacy greater!

Who Wants to Live Forever?

I was looking over my Social Security statement today and noticed a few things. Most obvious was the impact of my professional education. My annual income increased ten-fold in my graduation year. Granted that compares a student’s wages (working full time during summers and other breaks, with some part time work during school), against six months as a pharmacist. Suddenly, I had money and I learned to spend it, usually unwisely, but that’s another story.
I also calculated that the amounts paid in by myself and my employers would fund my retirement for ten years, even if that money did not earn any interest or other dividends. With only modest compounded interest, it is obvious that my retirement could and should be well funded, even beyond my death. My employers and I have paid a mere $81,000 into Medicare, however. That could buy a health insurance policy for about $350 per monthly premium for ten years. How much does health insurance cost? I checked:
Average monthly premiums for individual plans by age group were: (The figures are from eHealth’s Health Insurance Price Index Report for 2016)
$152 for people under age 18
$177 for people age 18-24
$239 for people age 25-34
$303 for people age 35-44
$400 for people age 45-54
$580 for people age 55-64
So if I were in my forties, I might be OK, but really I could last about 12 years, again assuming no earnings on my contributions.

With careful planning and a frugal lifestyle, I could probably make it to 90 without either of these government programs, assuming I invested similar amounts. Fortunately, I have made additional investments for my future, as well as my children, so I’m good to go indefinitely! Unless immortality is very expensive, of course. Kidding. I am lucky to have made it this far!

One of the proposed suggestions for revising American health care is Medicare for all. It is apparent to me that after paying into Medicare for over 40 years that I could barely take care of my own health needs, and I’m pretty damned healthy. There are millions that have exhausted any funding that they may have personally contributed and are now dependent on folks like me. If we are to keep Medicare solvent and/or cover everyone then we face some huge financial hurdles. Like any other type of insurance, we will have to make sure that the money coming in is sufficient to pay the claims to be paid. Right now, we do not have that balanced equation and that must change.

First of all, we cannot pay for everything. I’ve blogged about incredibly expensive, yet hardly effective treatments, and those must be forsaken. End of life planning is essential and you may call them death panels hoping to scare people away but the costs of an unplanned, undignified death are simply unreasonable. Our efforts to eliminate fraud have met with modest success and our payment system must be rigorously reviewed and strengthened. If everyone had the same baseline coverage, the incentive to have a cohesive system would be strong and we would all be invested in seeing it succeed.

My employers and I have each paid 1.45% of my wages into Medicare. If self-employed you pay 2.9% of your net earnings. That may not be enough to sustain Medicare for all. Do we raise this contribution? Now that Citizens United has declared corporations to be people, perhaps they should start paying into Medicare and Social Security too. How should we fund the new health care model? What we will find is that our entire taxation model has been corrupted and will require overhaul also. I’d be a lot more comfortable with taxes that are encumbered for specific uses, elimination of loopholes and subsidies that are essentially corporate welfare, elimination of unnecessary redundancy in our government agencies, and finally, most importantly, a balanced budget. We must have fairness, truth and justice. When the accumulation of wealth depends on the immoral strategies of deception, corruption, conspired laws, and outright cheating, there must be a reckoning.

Get out there and make a difference!

Contact your elected representatives!


Oh Those Golden Grahams!

My supermarket had the Valentine’s Day candy out on the shelves before the Christmas clearance had been fully marked down. I always recall the son of one of my ASU technicians whom I met while he would visit us back in the time he was taking classes. He is now married with kids, but back then he was very single. I used to tease him that he always got confused this time of year because he couldn’t tell the difference between Valentine’s Day and Palm Sunday. Perhaps he should have been eating more graham crackers.

Minister Sylvester Graham, a married man and a member of the Pennsylvania Temperance Society in the early 1800s, who became a big believer in abstinence and vegetarianism, is usually credited with the invention of the graham cracker. He was ahead of his time in his recommendation for the use of whole wheat in bread-making and his disdain for branless, additive-laden white flour. He even published a Treatise on Bread and Bread-Making and during a cholera outbreak in the 1830 began lecturing on whole foods and healthy habits. These healthy habits most certainly did NOT include masturbation. In fact, his rigorous plan included cold baths, loose clothing (but not loose women), and a meatless diet in order to keep the libido in check. It’s not clear if he or one of his acolytes developed the Graham cracker which was touted as an essential part of the diet for those wishing to avoid masturbation or excess sexual activity.

His lectures targeted at young men spoke of the evils of spices and hot food. His ideas were not all crazy. He may have liked talking about sexuality, which was a part of his lectures. In my home state of Maine, one of his lectures was aborted by a mob of citizens too shocked to allow him to discuss sex in front of a mixed audience.

Remember, this was the early 19th century, when society was becoming more urban (and urbane?) and religions still tended toward severe chastity and restraint, proclaiming sex was only for procreation. I imagine many people found the crackers helpful if only as a placebo to curb their lustful urges and activities. Of course, combining graham crackers with chocolate and marshmallow and heating it up over a fire is far different than the pastor’s intention. Some might even say that s’mores are an aphrodisiac. Maybe Sylvester was on to something after all.

Almost a hundred years later, Nabisco, mass produced graham crackers with a different formula and even highlighted the “graham” taste with the addition of honey. You can see here that today’s honey grahams contain a mixed of enriched white flour and whole grain (graham) flour.
Sylvester Graham would not approve.

Today we have a multitude of graham crackers on our shelves and I don’t think any of them would meet Pastor Graham’s standards.

(Somehow I cut off the last couple paragraphs and pics in the first upload. Sorry)

End of Year Hijinks

The end of the year is always an interesting time in the pharmacy. Some patients are trying to hold off until the next calendar year when they will be out of the coverage gap while others are trying to squeeze in every refill possible because they are beyond the gap or their insurance is changing or co-pays are going up next year.The ones that are trying to hold off are a particular challenge because they often put their health at risk by skipping doses or even entire weeks of medication. We strive to find solutions for these folks, but I fear that much of this behavior flies under the radar and we simply don’t know it is happening. We use partial fills when possible and try to find manufacturers’ discount cards for the more expensive brand name drugs. (see several previous blog posts) Unfortunately, our tool of a Congress has made it illegal to offer these discounts to people that are Medicare eligible. Not even enrolled patients, mind you, “eligible” patients. So even if you opted out of coverage you still cannot take advantage of these discounts! Our Senators and Representatives have no such restrictions, of course, enjoying the best health care coverage possible, on our dime.

So, yes, we have found some of our patients reducing their insulin dosage or simply doing without. Scary. Others forego blood pressure drugs, or even heart meds. It is quite common for people to use a variety of ill-conceived strategies to stretch their supply of medication. Their interactions with their insurance companies must be quite interesting.

One of our patients was recently approved for Enbrel and since he was past the coverage gap and into “catastrophic” coverage his co-pay was only $200. This persuasive and persistent patient was able to convince his Medicare part D plan that he was going on vacation in early January and got approved for a “vacation override” for another 4 weeks of Enbrel. Score! Most patients are not so lucky, each claim that we try to squeeze in before the end of the year is often rejected with a “refill too soon” message that indicates the date it may be filled. There is no easy way around this.

Another patient, with a Health Savings Account (HSA) thought it would be clever to refill all his inhalers, nasal sprays, and anything dispensed in its original container so that he could charge it to his HSA and then return them all for cash. Dude, that’s genius! Luckily, he asked about our return policy before actually proceeding with this scam. Federal law does not allow returns of medication, regardless of packaging, nor would we participate in this attempt at fraud. Dude, you’re busted!

Most of our chronic pain patients understand our guidelines and will not even ask about early fills. We did get a few however who questioned our calendar math, trying to get a fresh supply of oxycodone before the New Year. We are merciless and will not fill schedule 2 Rxs until there is 90% utilization of the previous Rx from the date picked up (not date filled, that may differ). We only had a handful that tried to push the issue. Being closed on Christmas and New Year’s day we often had to point out that even if Christmas was day 27 of 30 (90%), on the day after they should still have 2 days of medication remaining. Patients that continue press this issue end up with us taking a closer look at their utilization over a longer span of time than one month. We cannot be too careful when close to 100 people per day are dying from opioid overdose! Patient education and counseling becomes critical in these situations.

There are also a number of patients that have prescriptions that can be filled before the end of the year that will wait in our “ready” bins until the new year because the patients do not have the funds to pay their co-pays. This gives them about two weeks to come and pick up their meds.

I write this on New Year’s eve and I will tell you that next week will be even more fun as we deal with huge (or is that “yuge” now?) numbers of our patients having new insurance coverage and a fair number of them with no new insurance card, or changes in coverage and co-pays that they did not expect. It is one of the most challenging weeks in a retail pharmacy. Believe me!

Here is a chart from Kaiser that illustrates 2017 Medicare part D coverage:

Mind Games

Here’s a little mental exercise to play with:

We do a huge part of our prescription business in mental health medications. Some of these brand name meds are quite expensive and I would like to focus on aripiprazole, aka Abilify, for this thought experiment. Abilify is indicated as an adjunct or “add-on” therapy in the treatment of depression. There are a couple studies showing that it is more effective than placebo when added to existing SSRI, such as Zoloft or Paxil) or other therapies such as bupropion. Patients report both success stories and miserable failures when taking Abilify. Half of the package insert is a discussion of side effects and adverse reactions. In my opinion this is a drug of some moderate usefulness, high cost, and very significant risks.

One of the state behavioral health plans covers Abilify, and interestingly insists on brand name. I can only assume that some sort of rebate to the plan is in place. Otherwise, why spend more of the taxpayers’ money than is necessary? The monthly cost of Abilify is about $1,000 per month. Abilify is often used to boost the therapy of a depressed patient. So I postulate: If we have a depressed patient, being treated with moderate success with one or two generic agents, and we are considering adding Abilify, why wouldn’t we consider another choice? I would suggest that the taxpayers could be well-served by simply giving the patient $500 cash each month! If I were moderately depressed and on a state welfare plan, $500 per month might be a huge factor in changing my life and lifting my depression. An extra $500, with continued counseling, could change my life in ways far beyond the power of a pill like Abilify. I doubt the plan is getting a 50% rebate, so $500 likely saves the taxpayers plenty of money. Even if the stipend was $300, there would be a noticeable and positive on that patient’s life and lowered taxpayer cost.

I, for one, would rather see my cost reduced and my taxes dollars be used in more insightful and innovative ways. Obviously this is just the nugget of an idea and needs refinement but don’t be afraid to consider this kind of out of the box thinking when it comes to recreating health care.

Think about it.

the wall

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