The Promise of the 15 Minute Prescription

(Note: We’re on vacation this week. The following is borrowed from Jim Plagakis – pharmacist blogger extraordinaire and the Philadelphia Inquirer.  See you in May!)

Don’t let speed determine your choice of pharmacy 

Take it from me. After focusing more than 35 years of my professional life on medication safety issues, and reviewing tens of thousands of medication error reports sent to our reporting program, speed should not be a primary factor when selecting a community pharmacy. But that’s exactly what people seem to want most from their pharmacy–to get in and get out fast.

If you get Consumer Reports, the May issue features a section on “Best Drugstores.” I was stunned to read that a primary determinant in rating community pharmacies was how fast you can get your prescription filled. While Consumer Reports actually called this factor “speed and accuracy,” it was defined as, “the factor most closely tied to satisfaction” and “reflects how long readers had to wait for service at the pharmacy counter and whether their medications were ready when promised.” There was no actual rating for accuracy, which, in fairness, would have required a scientific study, which was beyond the scope of the report. What a disservice Consumer Reports has committed when it comes to consumer safety!

There’s no question that speed is a desirable quality among consumers when choosing a pharmacy. The pharmacy chains cleverly use this knowledge to market their stores. For example, you may have seen a recent Rite Aid Pharmacy TV advertisement that promises customers a “15-Minute Prescription Guarantee” to dispense up to three new prescriptions within 15 minutes or less. If the pharmacy fails to meet the mark, the customer receives a $5 pharmacy gift card.

I don’t want to single out Rite Aid because we’ve seen similar campaigns by other pharmacy chains, with gifts ranging from cash coupons to free movie rentals, meals, and so on. One CVS billboard read, “Get in/Get out”—with nothing else except the CVS Pharmacy logo. If you read the fine print, the Rite Aid ad mentions that “prescriptions requiring ordering, prescriber contact, third party assistance, professional services, or prescriptions presented immediately before or during a Pharmacist lunch break” don’t count. Still, the message from pharmacy chains is clear. It’s all about speed. I get it; you don’t want to wait.

But please keep this in mind: speed reduces safety. You may recall, about 20 years ago Domino’s Pizza guaranteed that customers would receive their pizzas within 30 minutes of placing an order, or they would be free. The company later settled lawsuits brought by the family of a woman who’d been killed by a speeding Domino’s delivery driver and another suit brought by a woman who was injured when a speeding Domino’s delivery driver ran a red light and collided with her vehicle. The 30-minute guarantee was soon dropped.

Again and again, here at the Institute, we hear from consumers who tell us of medication errors that harmed them or a family member. What is a chief cause? Rushed pharmacists unable to take the time to thoroughly check their work. Here’s just one example of typical of reports we receive:

“Prescription volume was high. The pharmacist was rushed and constantly interrupted while filling my prescription. The wrong strength tablet (50 mcg) of the right drug (Levoxyl) was dispensed to me in a retail pharmacy (chain) setting. The correct strength was 75 mcg.

Sadly, we also hear from families or their advocates after fatal medication errors. I always wonder if the pharmacist who dispensed the wrong medication felt rushed and/or pressured to fill prescriptions within unrealistic timeframes that can lead to cutting corners and inevitably, medication errors.

If you talk to pharmacists themselves, they’ll tell you how much they hate 15-minute (or 10-minute, 19-minute, or any preset timeframe) “promise programs.” They hate being rushed and feeling forced to cut corners to meet their company’s unrealistic promise. Do a Google search on pharmacists and 15-minute promises, and you will see some of the chatter about it. They feel it jeopardizes public health by discouraging them from spending enough time to:

1) check the patient’s history and other medications that have been prescribed

2) verify that the prescribed dose and the directions for use are safe for the patient

3) check that the patient is not allergic to the prescribed drug

4) check to make sure the new prescription medication is safe to take with previously prescribed medications

5) make sure the patient has not been prescribed more than one medicine that serves the same purpose

6) call the prescribing physician’s office to discuss a safety concern or clarify a barely legible or incomplete prescription

7) thoroughly double check the medication and label after the prescription has been filled to be sure it is correct

educate the patient about the proper use of medications when picking up filled prescriptions

9) perform any other critical task that promotes safety.

Today’s prescriptions medications are much more sophisticated than those used a decade ago. Thus, a simple mistake could lead to serious harm. Given enough time to critically think about each prescription and employ high-tech computer software, your pharmacist can capture a mistake that your doctor has made when prescribing the medication and avoid making a mistake when filling the prescription. But a rushed pharmacist may never have a chance to do more than quickly find the drug on the pharmacy shelf, count out the number of doses to fill your prescription, print out a label and place it on the bottle, and put the bottle in a bag for pick-up. These rote tasks may take only 15 minutes or less to carry out, but working at this speed clearly leaves no room for the pharmacist to ensure accuracy.

You can contribute to your own safety by allowing your pharmacist the time necessary to complete each of the functions mentioned above—without distractions. Whenever possible, drop your prescriptions off in the morning and pick them up later in the day. Or, call the pharmacy a day ahead of time for refills. Use interactive telephone systems for renewals. Making sure your medicines are safe and effective takes time.

You can learn a lot more about what goes on behind the pharmacy counter in pharmacies that want you to make safety, not speed, the primary determinant when making a choice in where you have your prescriptions dispensed. I highly recommend clicking on the link above to read an article on this topic.

As an organization, the Institute will also be pursuing the state licensing boards of pharmacy to help limit unrealistic promises to consumers to fill prescriptions within timeframes too short to ensure safety.

For more on Institute for Safe Medication Pracrtices consumer website, go http://www.consumermedsafety.org.

 From Rite-Aid’s website:

Let us fill your prescription in 15 minutes. Guaranteed.

Bring your prescriptions in to Rite Aid today and we’ll fill them in 15 minutes guaranteed – or you get a $5 Rite Aid Gift Card.*

After all, we care about your health and wellness. Helping you achieve your goals is what we’re all about.

We also care about your time. Just bring your prescriptions in today and you can get well – Sooner.

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Isn’t There a Pill For That?

You know that feeling of satisfaction you get when you’ve solved one of life’s little mysteries? Like where black holes come from? Or why, when you drop your toast, it always falls on the buttered side? Well, I was listening to the radio this morning when I finally learned the secret behind the two bath tubs in the Cialis commercial! Two pharmacists wrote in to the show and explained it this way: a dose of Cialis lasts 36 hours, much longer than a dose of either of its rivals, Viagra or Levitra. So showing a couple relaxing in two bath tubs instead of one says, “No worries! We’ve got a couple of days to do the deed – and besides, she likes to soak in that stuff that smells like bubble gum.” And then there’s the company that makes Cialis – Eli Lilly – they’re a family company, you know. They don’t want anything of questionable taste in their commercials. Never mind that we’re talking about an erectile dysfunction drug….but oh, my – what a relief to finally know the truth!

But tell me, is there a pill I can take for annoying drug ads? You know, the ones that cause anxiety, depression – projectile vomiting? Like those Paxil commercials. GlaxoSmithKline sympathizes with us about those darn family picnics – so anxiety provoking. Usually I’d tell you to go and score a few more of those vodka Jell-O cubes from your cousin’s cooler, but heck, no! If the thought of the family reunion that’s coming up brings on another attack of “social anxiety disorder,” relax! There’s a pill for that!

Speaking of family reunions – there’s one commercial I can count on to send my significant other screaming from the room: the Mucinex Mucus family ads! I mean, really, where else but in America would you find a cold and cough medication called Mucinex? I mean, even the name is gaggy. And boy, when those greenish-yellow Mucus clan members gather for a reunion – there goes the neighborhood. But if you’re a fan of the little globules, check out the official Mucinex site where you can “Meet Mr. Mucus!” http://www.mucinex.com/html/  On the other hand, don’t let those pudgy droplets of goo charm you. Two of the articles on this morning’s Google search warn, “Mucinex makes me smell weird down there,” and “Mucinex makes man kill gay roommate.” ‘Nuff said!

Last week I confessed to you that I sometimes suffer from America’s newest disease – Restless Leg Syndrome, or RLS as it’s known in TV drug land. When it strikes I perform the arduous task of STRETCHING my legs to relieve the creepy-crawly sensation. Until I saw a Requip commercial. I just had to ask myself, “Self? Why do you insist on getting out of a nice, warm bed in the middle of the night to stretch your legs?” Such a bother! Relax! There’s a pill for that! Now, before I rush down to Walgreen’s at 3:00am, there’s just one little problem. Besides the usual side effects – drowsiness, nausea, dizziness, hallucinations, “Help me! The Mucus Family is drinking all the beer in my refrigerator!” – I might also suffer an “unusual urge to gamble or increased sexual urges and/or behaviors.” Man – I’ve got to tell the judge that the next time I get brought in for passing bad checks at the casino in nothing but my black boots and pasties!

Folks, America is a sick, sick country. Why else would we have all these new drugs and disorders? I’m thinking it’s just a matter of time before our friends at the drug companies come up with medications for all of life’s bothersome trials and tribulations. Like MUSICOSIS. Musicosis is my term for when those jingles from all the other commercials get stuck in my head: “Hot dogs! Armour hot dogs! What kind of kids eat Armour hot dogs?” One day I will no longer have to toss and turn, unable to sleep, while “Fat kids! Skinny kids! Kids who climb on rocks!” circles round and round my sleep-deprived brain. Relax! There’s a pill for that!

Or how about when you can’t remember where you put your keys? Oh, sure, you could call the beeper on your keychain from your cell phone – except you can’t find your cell phone, either! OK, no need to panic. You can locate the missing cell phone with the GPS app thingy on your iPad! Yay! You’ll just go out and get your iPad out of the car……..that is, as soon as you find your keys. Oh, the hell with it. Relax! There’s surely going to be a pill for that!

And I am fully confident that the drug makers will invent something for me to take when I just can’t seem to get to my happy place. You know, like when the neighbor’s cat comes and leaves little gifts in the new flower bed. Or when we finish giving our great, big bulldog a bath, finally remove the last of her hair and slobber off the bathroom walls and she goes out in the back yard and rolls in the dirt. Again. No doubt I’ll find out that misplacing one’s happy place is actually a symptom of a combination mood/thought disorder, or one of those schizoaffective, psychotic things that would cause me to drive myself, the dog, my spouse and the neighbor’s cat off a bridge, but nooooooo problem. Relax! You just know that one day soon there will be a pill for that!

Yes, dear readers, big pharma has us all safely in hand. One last thought – should you find yourself feeling anxious, depressed or offended by my little rant, it’s probably a sign that you have developed a severe case of Blogitis. But there’s no need to unsubscribe. Relax! A new drug is definitely on its way. (Results may vary. Use only as directed!)

America’s Real Priority: Us

Remember when you were a kid and your grandma or your Uncle Joe asked you, “What are you going to be when you grow up?” Do you remember what you said? How you felt? We try on lots of hats as kids, often literally. When I was a kid, our next door neighbor was a pilot in the Air Force. He flew a jet fighter and one day he gave me a plastic version of his own flight helmet – complete with Air Force insignias, visor and oxygen mask. I spent hours playing pilot at the living room window, flying my imaginary plane into the wild blue yonder of our front yard. Being a pilot was a prestigious job in 1960, whether military or civilian, and I loved the imagined excitement of flight and the status of the job. It didn’t matter a whit that women then weren’t allowed to become pilots in the Air Force – the whole world was open to a five year old kid. Maybe you wanted to be a fireman, or a doctor, or a teacher. Work has always provided us with a sense of identity and the pride that comes with service to our communities and families. Having a job means we’re somebody, and that we can take care of ourselves.

So now, at 55, I look around and see an America that feels foreign to me. During the recent battle in Wisconsin over collective bargaining rights I heard media pundits call state workers like nurses, teachers, fire fighters and police officers “bottom feeders” and “freeloaders.” Really? I can tell you stories in which my life has been touched by someone in every one of those professions and influenced for the better. These are people who have dedicated their lives to difficult, sometimes dangerous lines of work. Nobody gets rich being a teacher or a cop. They join these helping professions in order to serve. They deserve at least a decent standard of living, the tools to do their jobs, a safe working environment and perhaps most important – our respect. Because without it they lose the support they need to do the jobs they do for us and sadly, that’s seems to be the situation we’re now faced with.

Today President Obama delivered a speech about the budget in which he expressed his hope for the future of an American Dream which is not quite dead, but certainly on life support. That hope is based in “a belief that we are all connected; and that there are some things we can only do together, as a nation. Part of this American belief that we are all connected,” he goes on to say, “also expresses itself in a conviction that each one of us deserves some basic measure of security.  We recognize that no matter how responsibly we live our lives, hard times or bad luck, a crippling illness or a layoff, may strike any one of us. ‘There but for the grace of God go I,’ we say to ourselves, and so we contribute to programs like Medicare and Social Security, which guarantee us health care and a measure of basic income after a lifetime of hard work; unemployment insurance, which protects us against unexpected job loss; and Medicaid, which provides care for millions of seniors in nursing homes, poor children, and those with disabilities.  We are a better country because of these commitments.  I’ll go further – we would not be a great country without those commitments.”

He speaks to a mean-spiritedness that seems to have taken hold in America, one which says that there isn’t enough to go around because working people, the sick and elderly, children and the poor expect too much. Never mind what they do successfully in Sweden or Japan or Australia – we can’t afford to take up the slack for people who don’t pull their own weight; as Neil Peart once famously said: “Live for yourself, there’s no one else more worth living for, begging hands and bleeding hearts will only cry out for more…”  

In the America I grew up in one income could sustain a family. You could graduate from a four-year university without debt. You could retire without worry because you probably had a pension, Social Security and health care. Now working people are suffering home foreclosures, bankruptcies due to catastrophic illness, eroding worker safety regulations and declining wages. Pharmacists are not immune. In the 1960’s pharmacy began to reflect on its role in health care. In those days pharmacists just filled pill bottles as ordered by physicians and were not allowed to interfere in the doctor-patient relationship. As pharmacists questioned their limited role, a whole new horizon, the pharmacist as clinician, began to open up. Pharmacists were re-defined as participants in drug therapy decisions and regarded as drug experts and specialists. The profession gained new responsibilities and the kind of status and pay that come along with them. Today pharmacists work 12 hour days without lunch breaks. They double as the managers of technicians because the companies they work for don’t want to hire enough professionals to do the job. They’re on the phone all day sorting out 100 sets of rules with 100 different insurance providers. And the most counseling they get to do is directing customers to the toilet paper aisle.

Somewhere along the line our priorities have shifted. The billions we spend on the military, corporate subsidies and tax cuts for the wealthy tell me there’s still plenty of cash in this country; it’s just not being spent on the common citizens. Every dollar that’s picked from the working man’s pocket reinforces the idea that teachers, nurses, firemen, cops, physicians and pharmacists deserve less and that their contributions and sacrifices don’t hold much value. “For much of the last century,” the President said today, “our nation found a way to afford these investments and priorities with the taxes paid by its citizens.” If we did it then we certainly can do it now. We owe workers, and that means we owe ourselves, no less.

America and Pharmaceuticals – A Love Story

“Every educated physician knows that most diseases are not appreciably helped by medicine.” So says Richard C. Cabot, M.D. of Massachusetts General Hospital. Despite the many studies and medical professionals that support Dr. Cabot’s opinion, we persist in the use of toxic chemicals to treat disease. The Department of Health and Human Services says Americans take more prescription drugs now than ever before; at least half of us take one, and one in six of us take three or more medications. It’s unlikely that western medicine will undergo a major shift in philosophy anytime soon, but it certainly begs the question: why do Americans take so many prescription drugs?

In the 1980’s the Reagan Administration portrayed the Food and Drug Administration (FDA) as a bloated bureaucracy that was getting in the way of business by making it too difficult for new drugs to be approved. Admittedly, it was a slow process. It could take two years to get approval for a new drug and if you were part of the AIDS crisis that surfaced in those years, two years was too long. Reagan’s push to decrease government’s role in all businesses meant slashing the budgets of regulatory agencies like the FDA. A weaker FDA was seen as a good thing by drug companies who wanted to bring new AIDS drugs like Agenerase (amprenavir) to market. But lower funding meant the FDA was understaffed, so Congress came up with the Prescription Drug User Fee Act (PDUFA). The act stipulated that a fee be paid by pharmaceutical companies to the FDA for each new drug application, essentially allowing drug makers to pay staff salaries at the agency. The number of staff at the Center for Drug Evaluation and Research (CDER) doubled overnight. Today, the FDA receives about $260 million a year from these fees, blurring the boundary that had previously existed between the FDA and the drug industry. The boundaries are even fuzzier because FDA officials are allowed to move to jobs within the pharmaceutical industry; if someone doesn’t want to burn bridges with a drug company, they may be inclined to approve new drugs, whatever the findings may be. Finally, the FDA gets input from outside advisory panels made up of doctors who are experts in their fields. Most of these doctors receive payments as consultant fees, research grants and support for travel to conferences from drug companies. This doesn’t bode well for consumers looking for unbiased scrutiny of new drugs because “expert consensus guidelines” have a potent effect; doctors can be held liable if they do not adhere to accepted standards of care. As a result, while the number of people with disease is not growing, the number of adult Americans taking medication is increasing – half of us take prescription drugs every day.

It’s not surprising then, that in 1997 the FDA allowed direct-to-consumer advertising of pharmaceutical drugs on television. It also lifted the requirement for ads to list every possible side effect. In the next year TV ads increased retail sales of the most popular drug types by 12% and Americans began popping more and more anti-depressants, cholesterol-lowering drugs, antihistamines, heartburn remedies and nasal sprays. The Kaiser Foundation found that for every dollar spent on advertising, retail sales increased by $4.20. As of 2009, the U.S. and New Zealand were the only developed nations that allowed direct-to-consumer advertising of pharmaceuticals. The industry, however, is lobbying hard for the same rights in Canada and Europe.

Now that drug makers are sending us to our doctors for the drugs we see on TV, 54% of them will prescribe specific brands if we ask. And worse still, the companies seem to be finding new ailments we’ve never heard of and new drugs to treat them with. Ever heard of “restless leg syndrome”? I confess that I get it myself sometimes, and yes, it drives me crazy. So I get up and stretch. Problem solved. Chronic kidney patients may actually need a solution in the form of a prescription drug, but most of us don’t. The trend to medicalize conditions like menopause, irritable bowel syndrome, sexual dysfunction and osteoporosis amounts to drug-mongering. Often minor conditions are hyped into full-blown diseases which demand expensive, sometimes risky chemical intervention.  

I often remark that pharmacists know more about drugs than the physicians who prescribe them. With over 5000 medical journals and one million articles published each year, physicians can’t keep up. They depend on information provided by the pharmaceutical industry and on the reps that visit their offices. Drug makers hire academic physicians to give lectures – with company approved slides only. Drug companies also reward doctors who prescribe their drugs frequently with trips dinners and other gifts. Research studies show that, although doctors deny that the perks have any effect on their prescribing practices, there are changes in objective measures, like how often a doctor will try to have a drug from a particular company put on his hospital’s formulary.

 No matter how you slice it, America has a prescription drug problem. We spend twice as much on drugs as other countries and have worse health outcomes. In other words, we’re paying for drugs that don’t work . Sometimes the drugs we take are life-savers – antibiotics, for instance, or immune suppressant drugs that sustain transplants. But future advances in health will likely come more from changes in lifestyle, diet and exercise than from medications. Almost all of the chronic conditions for which pills are prescribed are preventable through such changes. Even conditions like cancer are partially preventable.

We Americans are in love with the idea that we can take a pill and have our problems go away. We want what we want and we want it now, so taking other actions to improve our health – diet, exercise, stress reduction, smoking cessation, and the like – just aren’t that appealing. Once we have developed a chronic condition or find ourselves in pain pharmaceuticals can make a world of difference but they ought to be our final, not first line of defense. And we’ve grown incredibly cynical. The idea of whole, unadulterated foods, clean air, activity and relaxation as preventive medicine has been derided as some sort of hippy-dippy, counter-culture nonsense. What’s being sold to us as the remedy for all ills, physical or emotional, is another drug. In the end it comes down to one question: how is that working for us?