Thoughts on the Long Island Pharmacy Shooting

While searching the internet for interesting pharmacy topics to post on Twitter, I wasn’t shocked to find that there had been another drugstore robbery until I noticed that this time there had been four people shot and killed. Execution style.

Sunday morning, June 17, a man wearing a baseball hat and sunglasses walked into Haven Drugs in Medford, Long Island armed with a handgun. He shot and killed everyone who was in the store at the time – the pharmacist, a teenaged employee and two very unlucky customers. Then
he took off on foot with prescription drugs, leaving the cash register untouched. Also unsurprising were the kind of drugs he stole: hydrocodone, the main ingredient in Vicodin – more than 11,000 pills worth. Along with that stash he stole “unspecified amounts” of two other medications, promethezine and cheratussin.

According to the New York Times, more than 1,800 pharmacy robberies have taken place in the US over the last three years. Most of the robbers have been young men addicted to opioid painkillers and looking for drugs to sell or feed their own addictions. The most popular drugs stolen are oxycodone, the main ingredient in OxyContin, hydrocodone and Xanax (popular for recreational use because of its mellowing effects, or for coming down off stimulants like methamphetamine.) I presume the Long Island robber grabbed promethezine and cheratussin so he could go home and relax with a nice glass of Purple Drank: mix prometh with the cheratussin (a purple cough syrup containing codeine), add Sprite or Mountain Dew, a couple pieces of Jolly Rancher candy (watermelon flavor is the best!), a little ice and enjoy! Or, as the hip-hoppers might say, “Take that S**T and put it in a cup with sprite, add a jolly rancher, sip it, spark a bleezy and you’ll be leanin’. Walk up in the club, high as hell cuz we full of drugs.”

The question now is how did we get here? Every pharmacist in the country is probably wondering, “Will I be next? “What can be done about this?” We tend to treat symptoms in America. When a problem comes up we don’t give too much thought to the cause. A suspect has already been arrested in the Long Island case and he will be dealt with. The current attitude toward crime and criminals is one of no tolerance. Quick justice. Stiff penalties. This guy killed four people and he ought to go to jail. No argument here. Yet if long sentences, more prisons and the death penalty were true deterrents to crime, we would surely be a crime-free society. The International Centre for Prison Studies at King’s College in London lists America as having the largest documented prison population in the world. We have about 2 million people behind bars, or 701 per 100,000. Only North Korea imprisons more of its citizens per capita than we do – an estimated 900 per 100,000. Terrific. The only country that locks up more of their own people than we do is a notorious, authoritarian state. Despite what you might think, crime here isn’t worse than other places. The US Department of Justice reports that rates of burglary, assault and car theft are actually higher in Britain – so what gives?

Government solutions to drug trafficking and abuse just aren’t working, no matter how much money we throw at the problems or how many jails we build. Sick and tired of violence and drug addicts, individuals look for solutions. Many pharmacists work behind bullet proof glass. Some carry handguns and use them, like at the Reliable Discount Pharmacy in Oklahoma City in 2009. We’ll see more of this – vigilante justice is very
trendy at the moment. Still others hire full time security guards. The move towards mail order pharmacy will speed up because it can be justified as a safer alternative to personal service. All of these reactions to violent crime are understandable in the context of the personal. If I were a pharmacist, a working stiff with a family, and I were worried that some punk, high on drugs, might come along with a gun and try to steal my wares, I might do the same things. But from a larger perspective, if more guns could prevent crime, America, again, would be crime-free. The World Health Organization reported a total of 29,771 firearm deaths in America in 2003, compared to 7,653 in 22 other high income countries like Australia, Canada, Norway and the UK. Our total population, by the way, was 290.8 million vs. 563.5 million combined in the other countries.

No doubt bullet proof glass and guns and mail order service could make the individual pharmacist safer. Yet pharmacists are seeking to expand their role as drug educators and counselors through Medical Therapy Management (MTM). MTM is conducted between patient and pharmacist, preferably in person and face-to-face in order to enhance trust and intimacy. But fear of violence in the workplace and the current ways of coping with it build a wall between pharmacists and patients which will, over the long haul, take a terrible toll on the profession.

Maybe the model for patient assessment and purchase of prescription drugs will have to change from the retail outlet to something else. But even that is not a long term solution. The root causes of drug addiction and crime are not completely understood or agreed upon. They’re not even part of our national conversation; we just want them to go away. Ever increasing poverty, mental illness, ignorance and disaffection are poisoning
American society; violence and addiction sicken and sadden and anger us but do not inspire us to any effective action. While we continue to voice our outrage and tighten the screws by isolating pharmacists and stiffening penalties, the criminals will go on about their business – ever more brazen and desperate.

 

The Panacea of Mail-Order Pharmacy – or Not

I noticed a little article in the New Mexico Senior Citizen News today. It’s all about the New Mexico VA Health Care System’s “faster, more efficient service – thanks to a new Refills by Mail program.” The article glows with praise about this system in which veterans will begin receiving their refills automatically. “Receiving refills by mail is so convenient when you think about the time some people would spend waiting in line at the pharmacy. Refills by mail is a win-win situation.”

The term “win-win” implies there will be benefits for all – both pharmacy staff and patients who use the pharmacy. “Currently, 40 percent of the work we do in our medical center pharmacy is refills. Our patients asked us to shorten wait times and we listened. This is one more example of our focus on veteran centered care.” At first glance, switching over to mail-order at the VA pharmacy sounds great. I mean, nobody wants to wait in line. And pharmacists would free up 40% of their time if the refills were handled by mail. Hey, I’m sold – and so are probably 90% of the seniors who pick up the News, and the author knows it. It’s imperative for any health care organization changing over to
mail-order pharmacy to sell it to its clients as a good thing. A time saver. A convenience. An improvement. When the author uses the words, “We listened” he wants you to hear the words, “We care.” But conflating mail-order pharmacy with a “focus on veteran centered care”? I wonder.

In pharmacies outside the VA system, mandated mail-order is becoming more and more common. Why? Because for the PBM’s (Pharmacy Benefit Managers) it’s extremely lucrative. PBM’s are middlemen that traditionally negotiate prices with pharmacies. They don’t necessarily pass discounts along to consumers. They take a piece of the action. In managing prescription drug programs for health insurance companies, PBM’s are always looking for ways to reduce costs and increase profits. One popular cost-saving strategy is mail-order. And they’ve taken it one step further: PBM’s are not only mandating the use of mail-order pharmacies, they’re mandating the use of mail-order pharmacies they own. David Kwasny, the president of Restat, a privately owned PBM, has said of this practice that “When we’re mandating a certain behavior and the person, the party mandating it owns that service, you’ve got to question that.”  Mr. Kwasny, I believe you’ve got a real talent for stating the obvious.

In February of this year, pharmacy lobbyists introduced legislation in New York to prohibit insurance companies from mandating the use of mail-order programs. They reason that the programs do away with the need to pay a pharmacist to counsel and administer the drugs. But Timothy C. Wentworth, senior executive at Medco Health Solutions, a PBM, says that mail-order patients can talk to a pharmacist over the phone, an optimal situation where they do not feel rushed or uncomfortable about asking questions, compared to the public atmosphere of retail pharmacy. And Mark Merritt, president and CEO of Pharmaceutical Care and Management Association, claims that mail-order pharmacies, run by computer systems, are guaranteed more accurate than a real, live pharmacist in checking for drug interactions and insuring proper dosages. Corporate CEO’s will no doubt continue to sing the praises of mail-order as long as profits continue to roll in but they cannot get away from one simple fact: mail-order pharmacy excludes patient-pharmacist interaction. Mail-order may save money but regular contact with a pharmacist can also save money, as well as increase quality of life. Pharmacists can, for instance, recommend programs for patients with chronic diseases. Let’s say a patient has multiple chronic, non-psychiatric conditions like Parkinson’s and cancer. He will have to take multiple drugs and will be at an elevated risk for depression. 25 or 30% of adult patients with depression commit suicide and the signs of depression are often contradictory, such as decreased energy with insomnia or anxiety along with disinterest in ordinary activities. He may also have vague, hard to interpret symptoms, such as aches and pains or changes in appetite. It’s crucial that this patient meet regularly with his pharmacist for assessment. Yet mail-order pharmacists often don’t have access to patient histories or prescribing physicians, so how can they build a solid foundation for consultation?

There’s lots of other problems with mail-order as well, like using the post office to distribute prescription drugs safely. The U.S. Postal Service concluded that a mere 8.4% of medication was distributed in temperature ranges recommended for safe storage of drugs. 65% are exposed to temperatures of 84-104 degrees. 25% are exposed to excessive temps over 104 degrees. 33%, shockingly, are exposed to temps over 170 degrees for as long as 21 days while being transported.

Like it or not, the health care industry in this country is run by corporations who are mandated, by law, to serve the interests of their shareholders. Devotion to the bottom line has led to the disturbing trend of cutting staff and personal service in order to preserve profits. But this approach is short-sighted. Western medicine seeks to find a cure once disease has set in, and our for-profit health care industry seeks to limit access to medical care and counsel to save money – a deadly combination. The average American citizen may be living longer than before, but he is also sicker. Illness is expensive. It seems a change in perspective is in order. It may never be written into law that a corporation must serve the general health and welfare of its customers, yet it stands to reason that preventive care and proper disease management would be simply cheaper than the way we do things now. If health care companies are motivated by neither concern nor compassion, pharmacists need to convince them that their expertise is just too expensive to waste.

Certainly, Sir. Would You Like Fries With That?

I went to my friendly neighborhood Walgreen’s the other day to pick up my prescriptions. I like this store because it has a drive-through. As I watched some schmo in the car ahead of me annoy the pharmacist from the safety of his front seat something occurred to me. No wonder pharmacists are complaining about getting no respect. Silly pharmacists – drive through’s are for hamburgers!

Think about it. McDonald’s: front counter, drive-through area, French fry station, hamburger station, set-up/prep station, etc. Maybe 1 or 2 people staff each station.

Your local chain pharmacy: front counter, drive-through window, data entry station, fill station, verification station, etc. Maybe 1 or 2 people staff the whole operation! But the schmo ahead of me is thinking: McDonald’s drive-through – fast food. Walgreen’s drive-through – fast pharmacy. He’s waving his arms wildly now and yelling at the pharmacist so he can be heard through the bullet-proof glass because those microphones in the clown’s mouth at the burger place never work. He just doesn’t get why he has to come back for his Simvastatin, Cialis, Norvasc, Xanax order. He doesn’t have to come back for a Big Mac!

What we have here is a bad case of fast food mentality. The boys in the front office created it. The schmo ahead of me caught it. And there’s no pill behind the glass that can cure it. You see, this guy probably came through and shoved four bottles into the drawer from a mail-order pharmacy. He wants to transfer his prescriptions to THIS pharmacy. He doesn’t want to wait. That’s why he came to the drive-through. Drive-through = fast food, or this case, fast pills.

OK.
First the pharmacist has to call the mail-order pharmacy. That’ll be 15 or 20 minutes, IF all goes well. In addition, the guy has new insurance. It’s three o’clock on a Friday afternoon and he’s going out of town this weekend. After 18 minutes of waiting on hold, the pharmacist is relieved to find that the mail-order scripts still have refills available. So he runs the first one with the new insurance…..it’s not covered. He explains to the guy that there are some generic refills available – maybe they will be covered. Schmo responds with much waving of arms and a sock to the steering wheel for emphasis. “Why can’t you call the doctor right now and get that prescription straightened out?” wonders Schmo. Sweat appears on the pharmacist’s brow. The phone is lit up. There’s a woman coughing discreetly at the counter. One tech is out sick. The other one wants his break. The pharmacist notices the other prescriptions are covered, but the co-pays are pretty high. He doesn’t have enough medication to fill the whole thing. Schmo blows a gasket over the prices. And so it goes…..

“Hey, Schmo,” I think to myself as I imagine the details of the drama unfolding ahead of me. “Get a grip!” That pharmacist behind the glass is NOT equal to the hamburger guy who slaps pickles on your bun at McDonald’s. He has at least a dozen other responsibilities and six other customers besides you and the health and well-being of all of you depends on the quality of his work. So can the attitude. And tell me something. Why on God’s green earth would you wait until three o’clock on Friday afternoon to fill prescriptions with NEW insurance when you’re leaving town in a couple of hours? And by the way, chewing out the pharmacist over prices is like harassing the waitress over the cost of your meal. Your prescriptions are expensive and he can’t write out new ones. If you want the cheap stuff, call your doctor. And here’s a clue: PICK UP THE PHONE
AND CALL AHEAD. If you had, your doctor could have been contacted and the right drugs could have been ordered.

Yeah, I know. It’s the staffing, stupid. If the suits at CVS and Rite-Aid and Walgreen’s want drive-through windows for those with fast-food mentalities, then they need to staff accordingly. They probably aren’t going to do that any time soon, but that’s a subject for another blog. In the meantime, when getting your prescriptions filled at your local pharmacy, use your head. Know your meds. Understand your insurance. This is your health, so take some responsibility for it. And dang it, Schmo, I know both guys behind the glass are wearing white coats, but applying condiments to your sandwich is simply not equal to double-checking your drug order for dangerous interactions. Those heavy-duty prescription medications you’re on have the potential of really messing you up if  your pharmacist doesn’t get it right. So think about it, Schmo. Do you really want it fast? Or do you want it good?