Questions Your Pharmacist Never Wants to Hear Again But Will Anyway

Knowing what to ask your pharmacist isn’t hard: what’s this medicine? How do I take it? Will it make me bleed from my eyeballs? These questions are just common sense. But the questions you should NEVER ask the pharmacist – now that’s a different issue. They don’t, for example, like questions about the location of the toilet paper. I found that out the hard way. I always figured hey, the pharmacist works here – he must know where the TP is! But from the look on his face I gathered that the title “Doctor of Pharmacy” and the lowly bog roll were not compatible. Lots of questions that should be common sense NOT to ask are asked all the time, so to ensure that your next trip to the neighborhood pharmacy is a pleasant one, avoid the following. Your pharmacist will thank you (and also won’t report you)!

 ·         Are you sure about that? This question is posed by the customer who stares at the OTC bottle of medication she is unsure about, narrows her eyes suspiciously at the pharmacist and stares at the bottle again. This is AFTER a conscientious pharmacy tech has picked the product out especially for her, placed it in her hot little hand and then deferred to the pharmacist’s long and careful explanation of why it is the product of choice for her situation. “But the label says….” Yes, the label does say that, but as the pharmacist has already explained, there is an exception in your case. Whereupon the unbeliever turns on her heel and tosses the bottle next to the rawhide treats in the doggie aisle. Look – why did you bother to ask if you already knew? Don’t assume, unless you have a Pharm.D yourself, that you know more than the white-coat-wearing apothecary that stands before you. You don’t.

·         I don’t really need to take these, do I? This is the kind of question that will make your pharmacist’s mouth drop open the first time she hears it. No – of course you don’t need to take these. You’ve been to a doctor who told you your heart is working like a swimming pool pump full of mud, come across town to drop off your prescription, then come back a few hours later to claim your little bottle of life-preserving medication. But you absolutely, positively do not have to take it. You might, however, want to check if your will is up to date.

·         Can’t you just fill it? Now hear this: a pharmacist who is on the ball won’t fill a controlled medication even one day early. Ever. Physicians may call and “tell” the pharmacist to fill early but it will be refused. The reason? Pharmacy boards fine pharmacists for filling early. Your pharmacist’s license is on the line so he will check his state-controlled database of patient profiles if he doesn’t know or trust you. For him, this is a way of protecting his license. For the pharmacy board, it’s a way of protecting the public. If a pharmacist feels uncomfortable, he doesn’t have to fill. And he doesn’t have to explain to anyone, not even his CEO, why he feels uncomfortable. Your pharmacist is the licensed healthcare professional that keeps the pharmacy open – don’t screw with him.

·         That long? Yes, Virginia, it will be that long. You’ve already waited in line more than 15 minutes this week at the bank, at the restaurant and at the movie theatre. But obviously giving that pill jockey behind the counter time to get your life-saving prescriptions right isn’t worth your time. There’s a lot more going on back there than pill-counting. You see, your insurance company won’t pay for the brand name drug you need without prior authorization. That means your pharmacist must pull on his boots and slog through telephone hell to listen to automated responses, wait on hold and be transferred several times just to be disconnected. When he does reach an actual human he attempts to track down your doctor only to find she is busy with an emergency. The doc on call has apparently been called by someone else just now so you’re going to have to come back later. Retail pharmacists are realists – they rarely tell anyone it will only be 15 minutes wait time. They’ll tell you 30 minutes minimum and one hour if it’s busy. Which it always is. Calling for a refill? Two hours, non-negotiable. No whining or pleading. If you don’t like the wait time you can go somewhere else….and wait there.

·         How much Sudafed can I buy at once? Oh, brother. You’re what’s known as a “Sudafed Man” in pharmacist circles. You go from pharmacy to pharmacy looking for 12-hour pseudoephedrine, a very dangerous chemical, which you will take and mix with other dangerous chemicals to make methamphetamine, which you will sell to people to inject into their bloodstream to get high. You buy pseudoephedrine often and get away with it by 1.) always paying in cash (no paper trail) and 2.) presenting a fake driver’s license. That is, until your pharmacist notices that the laminate on your license is loose. Oops. Dirtbag alert. No Sudafed for you!

·         Are you the pharmacist? The white coat and name tag that reads, “Joseph C. Blow, Pharm.D” notwithstanding, your pharmacist politely answers, “Yes, I am. Can I help you?” But you look so young, say you! “Thanks for the compliment! Now what can I do for you?” I need a pharmacist with more experience, say you (this problem with your GoLytely is highly technical), can I speak to someone else? Well, I’m the only pharmacist on duty, fella. You can come back in a few years if you like.

·         Can I ring these up here? Oh, sure! Your pharmacist just loves it when you bring a truckload of foot powder and baby wipes back to ring up with your prescriptions! Listen, there’s a bunch of other registers out there in the store. You want it fast? Then let the pharmacy clear the line as fast as possible and take your cart to a cashier.

Oh, and another thing – when they say “45 minutes” it’s because at that very moment there is a 45 minute wait. No – not because you’re fat, or old, or remind them of their ex. It will take approximately 45 minutes to fill your prescription accurately. You see, it might really be closer to 30 minutes but then the phones go crazy, people jump in line with groceries and make-up, and John Q. Public wants to know where the jock itch is. After that the insurance company doesn’t want to cover and yes, your pharmacist knows this is not your problem. But be assured no one is in the back filing her nails or texting his girlfriend. The waiting room may look empty but there’s about 50 people waiting for their prescriptions to be filled in the next 20 minutes. This may look like a convenience store but it’s also a pharmacy – not the 7-11. If you really want it fast, next time call ahead. Otherwise, grab a magazine and sit down. Take a load off – there, now. Better?



Is a New Golden Age on the Horizon for Pharmacy?

I once heard a pharmacist remark that they are in a losing battle because the nature of business conflicts with the nature of the profession of pharmacy. The nature of business is making profits. In retail pharmacy profits are made by filling as many prescriptions as possible with as little help as possible. But the nature of the profession is health care. Health care practitioners promote health and well-being. Pharmacists make clinical decisions and judgment about medication therapy – which drugs are appropriate for an individual and which are not, how to take medication properly and how to recognize the side effects. In fact, the principal goal of pharmaceutical care is to achieve positive outcomes from the use of medication which improves patients’ quality of life. Ah, there’s the rub: the provision of conscientious clinical care and the business of retail pharmacy, in its current incarnation anyway, do not mix.

The complaints of retail pharmacists are fairly universal. After spending six years and thousands of dollars earning a doctorate in pharmacy, pharmacists use their extensive knowledge of pharmacology and their clinical training to stand on their feet twelve hours a day arguing with insurance companies on the phone. Oh, and directing customers to the cereal aisle. In between phone calls and customer interruptions they find the time to input, fill and check prescriptions, make sure techs aren’t making medication errors, giving patients the wrong information or escalating a situation with an irritated customer. Meanwhile, the market forces are closing in on them. Endless mergers mean that pharmacy chains are consolidating power within a short list of companies who decide how business is conducted. Mergers amongst pharmacy benefit managers and insurance companies give them an ever-growing influence over the direction of the profession. Pharmacists are nervous over the move towards automation, the increasing role of technicians, the mushrooming of pharmacy programs and the influx of foreign pharmacy grads flooding the market with hungry newcomers willing to work longer and harder for less. All in all, the picture for retail pharmacists is not a pretty one.

Some say the golden age of pharmacy is over. The squeeze is on for pharmacists to crank out the prescriptions, sacrifice quality to quantity, bend over for management and insurance companies and de-emphasize their skills as drug counselors and educators. But as blogger Pharmacy Mike wrote, “Maybe big box stores are not the best future for all of us highly educated drug experts.” Maybe not, indeed. Costco, Walgreen’s Wal-Mart and CVS will continue to push pharmacists out of the equation because increased use of automation and mail-order mean less labor and less labor equals higher profits. The hope for pharmacists is not to rail against the pressures of the retail business model but to expand their considerable skills and knowledge into a completely new direction.

Last week I wrote about the turf war that’s heating up between physicians and non-physician providers like nurse practitioners, physician assistants, dentists and chiropractors. Due to the state of our healthcare system there are millions of neglected or underserved people in need of care. The time is ripe for the development of new methods of healthcare delivery. We don’t lack competent providers who can step up and meet the need. We lack leaders who can face up to the arrogant posturing of medicine. Pharmacy must take its proper place within the medical community and demand the right to diagnose and prescribe. By deferring to the American Medical Association, pharmacy has given up its only true professional responsibility related to pharmacotherapy. Pharmacists can’t be first-rate drug therapists until they practice drug therapy. And the job of dispensing drugs in a retail drug store has almost nothing to do with pharmacotherapy.

There’s a lot written in the pharmacy blogs about the dreadful situation retail pharmacists find themselves in and many say they are “stuck on the sidelines” with neither the will or the power to do anything about it. But the winds are beginning to blow in a different direction. The Pharmacy Manpower Project’s 2009 National Pharmacist Workforce Survey indicates shifts in the pharmacy profession toward more patient care. Despite the economic situation, the study results show that pharmacists are in high demand and that the profession has the “capacity for contributing to the reforming healthcare system to meet patient care needs”. The survey surely reflects the fact that as the Affordable Care Act is phased in, some 33 million people will have expanded access to insurance coverage. That, along with an aging population and increased incidence of chronic illness, which is almost always treated with medication, suggests we’re going to continue to need pharmacists. Maybe those increasing numbers of pharmacy graduates will have something to do, after all.

Speaking of pharmacy schools, the need for pharmacists to increase their clinical opportunities and influence is not wasted on administrators. Some pharmacy schools have blended a PA program with the PharmD program, the perfect stepping-stone to pharmacists being able to prescribe in their own right. This is the only sensible future for pharmacy and educators know it.

As the market forces the profession on to a new tack, pharmacists may breathe a little easier. All is not lost. But as the current business model dies, countless pharmacists will be affected. States have individual pharmacy associations and the national organization, the American Pharmacists Association (APhA), is the largest association of pharmacists in the United States; the structures exist for pharmacists to come together and influence legislatures, both state and federal, to make changes. But out of about 269,000 pharmacists in the country, only 60,000 belong to the APhA. Pharmacists often say they are the introverted type – not joiners, and they’re notorious for not organizing. But consider the Tea Party. No matter how you feel about them or their backers, Tea Party activists literally commandeered the machinery of the Republican Party on the local level in order to elect their representatives and enact their agenda. Their influence on the system, for better or for worse, is obvious. Real change comes from the bottom and it would serve pharmacists to take over their associations in numbers. Many may not be convinced of the need to get active or of its potential but the time is coming when more will find themselves compelled to go to a meeting, write an email or make a phone call. Change is in the air but things will likely get worse for the profession before it gets better. And nothing motivates a person to action like an empty pocketbook.


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.

A Tiny Tale of Retail

The Pharmacy and Therapeutics Journal published a survey study of pharmacist job satisfaction in 2004. It found that pharmacists in chain stores reported “significantly lower job satisfaction than their professional peers in other settings.” It also reported that those differences in job satisfaction couldn’t be explained by demographics or other measured factors. Further research, they say, would be needed to understand “which aspects of jobs in different settings are more or less satisfying.” Never mind. You boys run along now and publish another study on the effects of Viagra on ground-dwelling herbivorous apes. I just have to check the industry blogs for the inside scoop on the state of retail pharmacy. “We went to school,” wrote the Angry Pharmacist, “to end up using our deep pharmacological knowledge so we can apply it via AARP covers Zocor and not Lipitor…Lyrica is only covered if Neurontin is failed and nobody covers f*#^ing Adipex-P or Xenical. We wait on hold to speak with some dillhole in India who speaks like a robot because the ID card has the wrong information or PCN printed on it. Take it and like it; you don’t have a f*#+ing choice anymore.”

Hmmm…… says CVS sucks. Pharmacist blogger Jim Plagakis says, “This profession sucks.” says the Costco pharmacy sucks. The declares, “Yes, retail pharmacy sucks.” The Angriest Pharmacist must surely think retail pharmacy sucks, ergo the blog name “The Angriest Pharmacist.” says all retail sucks, including pharmacy. The cafepharma message board states that retail pharmacies do indeed suck and as a result pharmacists also suck. Blogger Drugmonkey wrote a book entitled, “Why Your Prescription Takes So Long to Fill: A Foul-Mouthed, Liberal  Pharmacist Breaks the Curse of Christmas and Strikes Back Against the Ideological Forces That Threaten the Profession He Grudgingly Grew to Love.” Oh, yeah. Drugmonkey thinks retail pharmacy REALLY sucks.

Remember when you could get good service? When you could go to a hardware store and instead of some mouth-breathing high school dropout, a nice, middle-aged employee would greet you at the door? This was his CAREER. He could actually explain the benefits of a fiberglass- handled hammer over a wooden or steel-shafted one. I remember when an attendant pumped gas for you. I remember sitting down in a shoe store and yes, actually being fitted for shoes. I remember when my doctor took the time to have a discussion with me. And I remember the corner drug store where I could sit and have a soda while I waited for my prescription, get a recommendation for the best thing to use on a sunburn and then be told that since there would be a bit of a holdup on my pill refill, would I like it delivered to my house later today? Jeez. Those were the days. Where did they go?

American businesses are engaged in one big race to the bottom these days. The lowest price. The cheapest ingredients. The skinniest labor margin. Sure, everybody likes a bargain. But everybody also likes products that last. That are safe. Effective. Correct for the individual and the situation. In a race to the top kind of scenario, quality goods would be manufactured, sold and serviced by quality employees whose expertise and dedication to the clientele would be rewarded with a healthy paycheck and good benefits. Instead, we go to concrete warehouses to purchase cheap, plastic crap manufactured in foreign sweat shops sold to us by McEmployees who work for the same wage I got paid in 1979 and have no idea what the advantages of LCD over plasma may be. And don’t care. What that translates to at your local Walgreen’s or CVS store is some $4.00 prescriptions rung up by clueless pharmacy technicians overseen by disillusioned pharmacists. No compounding. No education. No counseling. No delivery. No service.

In the latest edition of Drug Topics, an e-zine for drug professionals, pharmacist Oluwole Williams comments that “public perception of the role of a pharmacist is somewhat distorted, especially when examined beside the pharmacist’s expectation of how he desires to be seen by patients.” No doubt. A dumbed-down public with low expectations and on the hunt for the next deal just wonders what the hold-up at the drive-thru is. How long can it take to get me that cream, anyway? Isn’t it already in the tube?

Pharmacists are drug experts. They went to school for a long time and have the loan payments to prove it. They may work the pharmacy counter at Costco, between the baby diaper aisle and the potato chips, but they are still the best resource you have when it comes to understanding the prescription drugs that can save your life. Or kill you. They should be seen as professionals – as providers of safe, affordable, effective medicines, counselors on the side effects, adverse events and possible interactions between the remedies we take, the source of supplements and safe medical appliances, contributors to public health issues, gatekeepers of prescriptions and poisons and overseers of the potentially hazardous mass-circulation of pharmaceutical drugs.

Retail pharmacies suck because retail corporations and insurance companies don’t care anymore about providing quality services and products. Like everybody else, I love to rag on the corporations – the Exxon’s and ATT’s of the world who wreck the environment, lobby Congress for sweet tax deals, pay their CEO’s 400 times what they pay their employees and export jobs to China for 25 cents an hour. And they deserve our criticism. But as the employees who work for them and customers who buy from them, we have to take some of the blame for what’s happened to service in this country. After all, we let them get away with it. Every day that we don’t complain to management, call our government representatives and professional organizations, or make another purchase at WalMart is a day corporations get away with providing cheap products, terrible service and rotten labor practices.

Come on, people. Your sense of outrage is slipping. Pull your pants up.

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

 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.

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.