Holy opioids.
That's one thing I have to say about the new place of employment - some docs are not afraid to prescribe opioids for pain. Granted, I am serving a different population and many of my new customers have cancer pain.
Today, I dispensed 360 OxyContin 80mg tablets, 360 Percocet 10/325mg tablets, 240 carisoprodol 350mg tablets, and 90 diazepam 10mg tablets to THE SAME PATIENT. It's amazing to me that he's even walking around.
It really reinforces what they told us in pharmacy school: there is no ceiling dose for morphine. It's all about tolerance.
This is not our only patient on crazy high doses of pain meds, he is one of many. All of the prescriptions are legal and the patients were titrated up to doses that high, but it still really blows my mind. I'm used to dispensing 60 OxyContin 10mg or 20mg tablets at a time - I am not sure I had EVER dispensed the 80mg tabs until I worked here.
Tuesday, May 13, 2008
Wednesday, May 7, 2008
You have the power
If any of you out there are retail pharmacists working for a corporation and hating it, here is a word of advice.
LEAVE
You have the power. There is a pharmacist shortage. Quit letting them boss you around, micromanage your vacation time, and undermine your every decision. You are professionals. You deserve to be treated like one.
There is a regional manager working for a corporation in my area who recently quit. Why? His wife had a baby very prematurely. The baby was in the NICU and he wanted to be there with his wife. The corporation told him that he couldn't have any time off, so he quit. He has the right idea - he can go get a new job anywhere, but they cannot find a replacement regional manager so easily. (By the way, regional pharmacy manager has the be THE WORST job of the all time. Can you imagine? Dealing with customer complaints, penny pushing, etc).
My new job is awesome, lots of compouding. I feel like I'm using my brain again. The only downside I can see is potential unwanted hair growth and hormone imbalances from all the progesterone, estriol, liothyronine, testosterone, DHEA dust that I'm inhaling. Maybe I should start wearing a mask....
LEAVE
You have the power. There is a pharmacist shortage. Quit letting them boss you around, micromanage your vacation time, and undermine your every decision. You are professionals. You deserve to be treated like one.
There is a regional manager working for a corporation in my area who recently quit. Why? His wife had a baby very prematurely. The baby was in the NICU and he wanted to be there with his wife. The corporation told him that he couldn't have any time off, so he quit. He has the right idea - he can go get a new job anywhere, but they cannot find a replacement regional manager so easily. (By the way, regional pharmacy manager has the be THE WORST job of the all time. Can you imagine? Dealing with customer complaints, penny pushing, etc).
My new job is awesome, lots of compouding. I feel like I'm using my brain again. The only downside I can see is potential unwanted hair growth and hormone imbalances from all the progesterone, estriol, liothyronine, testosterone, DHEA dust that I'm inhaling. Maybe I should start wearing a mask....
Tuesday, April 29, 2008
New Job
Because of my recent....transition.... in employment status, I have a new job.
I love it.
I am working at an independent compounding pharmacy. It's a perfect mix for me: challenging but laid back. My boss crusies on match.com for a while, then makes a geometric dilution for a triiodothyronine aliquot.
Today, the tech made Mustargen ointment.
Seriously.
(I am still afraid of touching chemo agents, but maybe I'm a chicken.)
We do a lot of bioidentical hormone replacement therapy: estriol, estradiol, DHEA, testosterone, progesterone, pregnenolone.... in every combination and in every dosage form imaginable. Tablet triturates, troches, mini troches, creams, gels, ointments, suppositories, capsules.
I made a nasal spray today in which I put budesonide in a bottle of Astelin. Some drug company needs to market THAT.
My favorite things about my new job are the people and the hours. I work with PEOPLE; another pharmacist and 3 techs. After working such long hours at my last job alone most of the time, it's fun to get to have relationships with coworkers again. And I no longer have to work nights, weekends, holidays.
I get to eat lunch. It's like a pharmacy dream.
I love it.
I am working at an independent compounding pharmacy. It's a perfect mix for me: challenging but laid back. My boss crusies on match.com for a while, then makes a geometric dilution for a triiodothyronine aliquot.
Today, the tech made Mustargen ointment.
Seriously.
(I am still afraid of touching chemo agents, but maybe I'm a chicken.)
We do a lot of bioidentical hormone replacement therapy: estriol, estradiol, DHEA, testosterone, progesterone, pregnenolone.... in every combination and in every dosage form imaginable. Tablet triturates, troches, mini troches, creams, gels, ointments, suppositories, capsules.
I made a nasal spray today in which I put budesonide in a bottle of Astelin. Some drug company needs to market THAT.
My favorite things about my new job are the people and the hours. I work with PEOPLE; another pharmacist and 3 techs. After working such long hours at my last job alone most of the time, it's fun to get to have relationships with coworkers again. And I no longer have to work nights, weekends, holidays.
I get to eat lunch. It's like a pharmacy dream.
Flat Co-pays and the Public's Inability to Understand Them
(This is the last of my old posts, republished. Anything published from here on out will be new material. Enjoy!)
A man comes to pick up a prescription today. It was a refill that we had faxed his doctor on, for Avodart. The doctor only approved #15 capsules because the patient had not had an appointment in over a year. His insurance company charges a flat $60 copay for this non-formulary medication for a montly supply, and #15 capsules cost $56.99 because they just charged him the cash-Rx price instead of the $60 copay.
He yelled at me, saying that me and my company were screwing him. He hardly let me get a word in edgewise. He kept asking “What about the other 15 capules?” He claimed that my company was overcharging him and no other pharmacies did this and he was calling the Better Business Bureau and whatnot.
I had to tell him that there were no other 15 capsules, his doctor had only authorized 15 and that is all I could fill. I didn’t set his copays, I billed claims to his insurance and they tell me what to charge. He thought that 1/2 prescription should have 1/2 copay (or $30) no matter how many times I told him it didn’t work like that. I told him he was welcome to call his insurance company and ask them about it.
After he left, I sat here fuming, wishing I would have said this:
“Listen up, if anyone is at fault for this high copay on only 15 capsules it is not the pharmacy. Let me tell you the three entities you should be blaming.
Number one: YOURSELF. Last month your doctor’s office told you that you need an appointment, that it had been more than a year. You ignored them. Now, when they only authorize 15, you have only yourself to blame. If you had made an appointment, they would have authorized a month or more.
Number two: your doctor’s office. Most doctor’s offices know that there are flat copays on brand name drugs, and that you will have to pay the same copay no matter how many you get. Even if you haven’t had an appointment in more than a year, they should still authorize 30. Unless it’s a controlled substance.
Number three: your insurance company. They are the ones that you should call and bitch about copays to, because I have absolutely NO CONTROL over them. You might as well bitch at yourself because you’re the one that picked the plan. Oh, and your doctor, too, because he’s the one that prescribed that non-formulary medication for you.
I, on the other hand, was nice enough to fax your doctor three times for the refill on this prescription. As you can now see, me and my pharmacy had nothing to do with this situation, and if you still can’t understand why there is nothing more I can do for you.”
Thanks, I feel better now.
A man comes to pick up a prescription today. It was a refill that we had faxed his doctor on, for Avodart. The doctor only approved #15 capsules because the patient had not had an appointment in over a year. His insurance company charges a flat $60 copay for this non-formulary medication for a montly supply, and #15 capsules cost $56.99 because they just charged him the cash-Rx price instead of the $60 copay.
He yelled at me, saying that me and my company were screwing him. He hardly let me get a word in edgewise. He kept asking “What about the other 15 capules?” He claimed that my company was overcharging him and no other pharmacies did this and he was calling the Better Business Bureau and whatnot.
I had to tell him that there were no other 15 capsules, his doctor had only authorized 15 and that is all I could fill. I didn’t set his copays, I billed claims to his insurance and they tell me what to charge. He thought that 1/2 prescription should have 1/2 copay (or $30) no matter how many times I told him it didn’t work like that. I told him he was welcome to call his insurance company and ask them about it.
After he left, I sat here fuming, wishing I would have said this:
“Listen up, if anyone is at fault for this high copay on only 15 capsules it is not the pharmacy. Let me tell you the three entities you should be blaming.
Number one: YOURSELF. Last month your doctor’s office told you that you need an appointment, that it had been more than a year. You ignored them. Now, when they only authorize 15, you have only yourself to blame. If you had made an appointment, they would have authorized a month or more.
Number two: your doctor’s office. Most doctor’s offices know that there are flat copays on brand name drugs, and that you will have to pay the same copay no matter how many you get. Even if you haven’t had an appointment in more than a year, they should still authorize 30. Unless it’s a controlled substance.
Number three: your insurance company. They are the ones that you should call and bitch about copays to, because I have absolutely NO CONTROL over them. You might as well bitch at yourself because you’re the one that picked the plan. Oh, and your doctor, too, because he’s the one that prescribed that non-formulary medication for you.
I, on the other hand, was nice enough to fax your doctor three times for the refill on this prescription. As you can now see, me and my pharmacy had nothing to do with this situation, and if you still can’t understand why there is nothing more I can do for you.”
Thanks, I feel better now.
Don't Lie to Your Pharmacist, Part II
A woman just called me and asked me to transfer a prescripton for Ultram from Wal Mart. She said the pharmacist there wouldn’t fill it, because it’s early. The doctor had called to authorize an early refill, but the pharmacist on duty still would not fill it three weeks early (go unknown Wal Mart pharmacist!)
She said she was going to a funeral in Montana and the nearest pharmacy was “80 miles” from where she was staying or she would transfer the prescription to another pharmacy to fill when it was due.
I told her that I would have to ask about her history at the other pharmacy before I would transfer it (I knew that I wouldn’t either way) and inquired as to where she was traveling in Montana, as I’m from that part of the country.
She said the funeral would be in Missoula.
I told that I had been to Missoula on several occasions and there were most definitely pharmacies within city limits, and when I did a Google search with “pharmacy” and “Missoula” as subjects, I got no less than 9 local business results, including a Wal Mart Pharmacy. In fact, I think that there are probably no places in the lower 48 states that are 80 miles from a pharmacy.
When I told her that, she hung up on me. I hope the next pharmacist she calls knows Montana’s geography, too.
Or has a highly attuned bullshit sensor
She said she was going to a funeral in Montana and the nearest pharmacy was “80 miles” from where she was staying or she would transfer the prescription to another pharmacy to fill when it was due.
I told her that I would have to ask about her history at the other pharmacy before I would transfer it (I knew that I wouldn’t either way) and inquired as to where she was traveling in Montana, as I’m from that part of the country.
She said the funeral would be in Missoula.
I told that I had been to Missoula on several occasions and there were most definitely pharmacies within city limits, and when I did a Google search with “pharmacy” and “Missoula” as subjects, I got no less than 9 local business results, including a Wal Mart Pharmacy. In fact, I think that there are probably no places in the lower 48 states that are 80 miles from a pharmacy.
When I told her that, she hung up on me. I hope the next pharmacist she calls knows Montana’s geography, too.
Or has a highly attuned bullshit sensor
At Least Barristas Get Tips
This morning I was getting my daily dose of caffeine at Starbucks. I was in line behind 3 or 4 people, but the line was moving along. The barristas were friendly, chatting with customers as they steamed milk for lattes and blended ice and sugar-water for frappuccinos. A woman rushed in, interrupted the transaction of the person that was paying at the register and demanded to know how long the wait was.
The barrista replied smartly, “It depends on what the people in front of you order.” It totally killed the friendly mood of the Starbucks staff, they kept glaring at the impatient woman tapping her foot and checking her watch.
I had deja vu later today when another woman (why is it always women? I hate to be a traitor to my kind, but jeez) interrupted me with exactly the same question regarding prescription wait times.
This takes me back to that stupid USA Today article that I can’t quit thinking about. People want it (whatever IT is) FAST, not right. I’m sure they could have sold the in-a-hurry woman a cup of expired milk or dishwater and it would be fast, but it wouldn’t be the grande-triple-shot-skinny-soy-sugar-free-vanilla/hazelnut-extra-hot-no-foam-latte that she wants. People need to understand that they can have things FAST or RIGHT.
As with their Starbucks order or their prescription, accuracy takes patience. Slow down, people.
The USA Today article points out that high prescription volume increases chance for errors. I have worked in a high-volume store. There is a big difference between filling a lot of prescriptions for people coming in tomorrow (no huge rush) versus having 20 people in the waiting room glaring at you because their prescription isn’t being filled fast enough.
I guess the moral of my story is to call in your prescription a day or two before you need it, and to be patient with the barristas at Starbucks. They might just spit in your cup, otherwise.
The barrista replied smartly, “It depends on what the people in front of you order.” It totally killed the friendly mood of the Starbucks staff, they kept glaring at the impatient woman tapping her foot and checking her watch.
I had deja vu later today when another woman (why is it always women? I hate to be a traitor to my kind, but jeez) interrupted me with exactly the same question regarding prescription wait times.
This takes me back to that stupid USA Today article that I can’t quit thinking about. People want it (whatever IT is) FAST, not right. I’m sure they could have sold the in-a-hurry woman a cup of expired milk or dishwater and it would be fast, but it wouldn’t be the grande-triple-shot-skinny-soy-sugar-free-vanilla/hazelnut-extra-hot-no-foam-latte that she wants. People need to understand that they can have things FAST or RIGHT.
As with their Starbucks order or their prescription, accuracy takes patience. Slow down, people.
The USA Today article points out that high prescription volume increases chance for errors. I have worked in a high-volume store. There is a big difference between filling a lot of prescriptions for people coming in tomorrow (no huge rush) versus having 20 people in the waiting room glaring at you because their prescription isn’t being filled fast enough.
I guess the moral of my story is to call in your prescription a day or two before you need it, and to be patient with the barristas at Starbucks. They might just spit in your cup, otherwise.
I Wish I Was a Drug Rep for Azithromycin
Filled 83 prescriptions the other day. 9 of them were for Zithromax (either a Zpak or Zithromax oral suspension). That means 10.3% of my presription volume was an azalide antibiotic.
What about doxycyline, amoxicillin, sulfamethoxazole/trimethoprim? What about fluoroquinolones (except ciprofloxacin, which has little activity against Streptococcus pneumoniae)?
What about delaying or avoiding antimicrobial therapy, as most cases of respiratory infections are viral in nature?
CDC guidelines for adults suggest that only 10% of pharyngitis cases are caused by group A beta hemolytic strep. If the infection is determined to be caused by strep, treatment of choice is PENICILLIN (or erythromycin for penicillin allergic patients).
Rhinosinusitis infections are caused primarily by viruses. If symptoms last longer than 7 days, infection with the bacteria Streptococcus pneumoniae or Haemophilis influenzae may be considered, and should treated with antibiotics that cover both bacteria (amoxicillin, Augmentin, Ceftin, or Bactrim would work, as well as Zithromax and Levaquin).
Bronchitis can be treated with a Zpak, but prescribers can also use Bactrim, doxycycline, Augmentin, Ceftin, Cipro, or Levaquin.
Overuse of a single antibiotic increases bacterial resistance to that product. Maybe spread the love around a little, guys.
What about doxycyline, amoxicillin, sulfamethoxazole/trimethoprim? What about fluoroquinolones (except ciprofloxacin, which has little activity against Streptococcus pneumoniae)?
What about delaying or avoiding antimicrobial therapy, as most cases of respiratory infections are viral in nature?
CDC guidelines for adults suggest that only 10% of pharyngitis cases are caused by group A beta hemolytic strep. If the infection is determined to be caused by strep, treatment of choice is PENICILLIN (or erythromycin for penicillin allergic patients).
Rhinosinusitis infections are caused primarily by viruses. If symptoms last longer than 7 days, infection with the bacteria Streptococcus pneumoniae or Haemophilis influenzae may be considered, and should treated with antibiotics that cover both bacteria (amoxicillin, Augmentin, Ceftin, or Bactrim would work, as well as Zithromax and Levaquin).
Bronchitis can be treated with a Zpak, but prescribers can also use Bactrim, doxycycline, Augmentin, Ceftin, Cipro, or Levaquin.
Overuse of a single antibiotic increases bacterial resistance to that product. Maybe spread the love around a little, guys.
Pharmacy and My Ayn Rand Obsession
What is your favorite smelling drug?
Most pharmacists agree that products manufactured by Abbott smell appetizingly like vanilla. Almost wants me want to take Depakote. Benicar smells like butterscotch.
Chewable carbamazepine 100mg tablets smell good. Well, I guess most chewable tablets smell yummy. Brand-name Amoxil suspension’s smell brings me back to when I was a kid and bubblegum was my favorite flavor. It still smells good.
Least favorite smelling drugs are easier. My least favorite is spironolactone. The brand name
Aldactone tablets were perfumed to smell minty-fresh. The generic sort of smells like dog farts. It is disgusting.
Brand-name Glucophage smells like rotting fish, and surprisingly the generic metformin doesn’t. I will not count Armour Thyroid tablets (made of crushed up animal thyroid glands) until I absolutely have to because smelling them makes me throw up in my mouth a little. I have to hold my nose. Everyone knows that cephalexin smells like gas. That’s flatulence gas, not gasoline.
My absolute favorite smelling drug is Midrin capsules. Brand, generic: it doesn’t matter. Those things smell GOOD. Not in a food-good way, either. Kind of like architect’s erasers. Every time I have to fill a prescription for them I have one of those funny dream sequences where I imagine myself in a compromising position on the drafting desk of Howard Roark.
So, pharmacists and technicians, tell me. What’s YOUR favorite smelling drug?
Most pharmacists agree that products manufactured by Abbott smell appetizingly like vanilla. Almost wants me want to take Depakote. Benicar smells like butterscotch.
Chewable carbamazepine 100mg tablets smell good. Well, I guess most chewable tablets smell yummy. Brand-name Amoxil suspension’s smell brings me back to when I was a kid and bubblegum was my favorite flavor. It still smells good.
Least favorite smelling drugs are easier. My least favorite is spironolactone. The brand name
Aldactone tablets were perfumed to smell minty-fresh. The generic sort of smells like dog farts. It is disgusting.
Brand-name Glucophage smells like rotting fish, and surprisingly the generic metformin doesn’t. I will not count Armour Thyroid tablets (made of crushed up animal thyroid glands) until I absolutely have to because smelling them makes me throw up in my mouth a little. I have to hold my nose. Everyone knows that cephalexin smells like gas. That’s flatulence gas, not gasoline.
My absolute favorite smelling drug is Midrin capsules. Brand, generic: it doesn’t matter. Those things smell GOOD. Not in a food-good way, either. Kind of like architect’s erasers. Every time I have to fill a prescription for them I have one of those funny dream sequences where I imagine myself in a compromising position on the drafting desk of Howard Roark.
So, pharmacists and technicians, tell me. What’s YOUR favorite smelling drug?
Finally, Getting Some Publicity
An article printed in today’s issue of USA Today will hopefully help to improve pharmacists’ working conditions. It is called “Rx for Errors: Speed, High Volume Can Trigger Mistakes.” It details several prescription errors made by Walgreens and CVS pharmacists that may or may not be a direct result of large prescription volume.
The chains, of course, are denying that volume plays a role in whether or not mistakes are made. Internal documents showed that Walgreens expects pharmacists to fill and check prescriptions in two minutes, hardly leaving enough time to do a prospective DUR or counsel a patient. CVS times pharmacists on how fast they fill prescriptions and answer the phone. Sound stressful? It does to me. Do you think that stress and high volume would increase potential for human errors? The chains may try to deny it, but any sane person would agree that such an environment would only foster mistakes.
I have been a staff pharmacist in a store that filled 2000 prescriptions a week with 2 and 1/2 pharmacists. It was not unusual for us to fill over 400 prescriptions on a Monday. Sometimes I felt like my head would explode, and a lot of the responsibilities that I felt were mandatory for pharmacists (like counseling) were ignored. There just wasn’t time. When the chain I worked for was bought by CVS, I knew it would only get worse. It was only a matter of time before I made a serious error on a prescription because I didn’t have time to properly check it or didn’t talk to the patient (proper counseling is the BEST way to prevent errors). I was kept up at night, unable to sleep, dreaming about prescriptions I filled and having nightmares about prescription errors I could have made.
I was good at my job in the busy pharmacy. My techs were glad that it was me opening with them in the morning, because I was fast and accurate. We would fill 200 prescriptions from 9-1, when the other pharmacist arrived. I was praised by upper management. I would brag about how many prescriptions I filled and how short of time it took me to do it. But I knew that my patients were suffering because I didn’t have time to talk to them about their prescriptions. I knew that the company was squeezing every last drop out of me. I was being taken advantage of, and I was bragging about it! It had to stop. I quit before the CVS merger, and transferred to a job as a pharmacy manager in a grocery store chain.
Now, I work in a slow store, we fill roughly 500 prescriptions a week. Much of the time I am bored. But, thankfully, I have adequate time to fill each prescription that comes through my door. I counsel my patients, fax doctors detailed reports regarding drug interactions or side effects, and verify every prescription thoroughly. I have never made a mistake that I know of (Knock on wood). Yet. I know that I will eventually (I am human), but I am confident that, in my current job, I have enough time to do my job properly.
I work 12 hour days without breaks. So do many pharmacists that work for Walgreens or CVS (those guys work 14s). If I was in a more stressful environment, mistakes would be much more likely. It’s common sense. Your brain never has a chance to decompress.
Pharmacists for these chains need to refuse to fill prescriptions at such a rate. It is the individual pharmacist’s license on the line. If they feel they can’t do their job safely, they need to stand up and say it. It’s NOT WORTH IT to be the good-little-boy or girl pharmacist filling 2 prescriptions a minute and make a mistake that could cost someone their life.
The chains, of course, are denying that volume plays a role in whether or not mistakes are made. Internal documents showed that Walgreens expects pharmacists to fill and check prescriptions in two minutes, hardly leaving enough time to do a prospective DUR or counsel a patient. CVS times pharmacists on how fast they fill prescriptions and answer the phone. Sound stressful? It does to me. Do you think that stress and high volume would increase potential for human errors? The chains may try to deny it, but any sane person would agree that such an environment would only foster mistakes.
I have been a staff pharmacist in a store that filled 2000 prescriptions a week with 2 and 1/2 pharmacists. It was not unusual for us to fill over 400 prescriptions on a Monday. Sometimes I felt like my head would explode, and a lot of the responsibilities that I felt were mandatory for pharmacists (like counseling) were ignored. There just wasn’t time. When the chain I worked for was bought by CVS, I knew it would only get worse. It was only a matter of time before I made a serious error on a prescription because I didn’t have time to properly check it or didn’t talk to the patient (proper counseling is the BEST way to prevent errors). I was kept up at night, unable to sleep, dreaming about prescriptions I filled and having nightmares about prescription errors I could have made.
I was good at my job in the busy pharmacy. My techs were glad that it was me opening with them in the morning, because I was fast and accurate. We would fill 200 prescriptions from 9-1, when the other pharmacist arrived. I was praised by upper management. I would brag about how many prescriptions I filled and how short of time it took me to do it. But I knew that my patients were suffering because I didn’t have time to talk to them about their prescriptions. I knew that the company was squeezing every last drop out of me. I was being taken advantage of, and I was bragging about it! It had to stop. I quit before the CVS merger, and transferred to a job as a pharmacy manager in a grocery store chain.
Now, I work in a slow store, we fill roughly 500 prescriptions a week. Much of the time I am bored. But, thankfully, I have adequate time to fill each prescription that comes through my door. I counsel my patients, fax doctors detailed reports regarding drug interactions or side effects, and verify every prescription thoroughly. I have never made a mistake that I know of (Knock on wood). Yet. I know that I will eventually (I am human), but I am confident that, in my current job, I have enough time to do my job properly.
I work 12 hour days without breaks. So do many pharmacists that work for Walgreens or CVS (those guys work 14s). If I was in a more stressful environment, mistakes would be much more likely. It’s common sense. Your brain never has a chance to decompress.
Pharmacists for these chains need to refuse to fill prescriptions at such a rate. It is the individual pharmacist’s license on the line. If they feel they can’t do their job safely, they need to stand up and say it. It’s NOT WORTH IT to be the good-little-boy or girl pharmacist filling 2 prescriptions a minute and make a mistake that could cost someone their life.
Medrol is Over-The-Counter?
A woman asked for my help today finding an over-the-counter product that she was having trouble locating. “Of course,” I said. What she wanted, however, was Medrol.
She is allergic to contrast dyes and is having a radiological procedure tomorrow requiring contrast. The doctor’s office instructed her to premedicate with 50mg of Benadryl and 32mg of Medrol prior to the procedure. The office staff told her that she could get both products over-the-counter.
Not since I last checked. Benadryl, sure. But corticosteroids? Not so much.
I had to page the doctor since he was out of the office to get the order. The RECEPTIONIST that scheduled the appointment informed her that she needed the premedicate, and was the one to tell her to get the products OTC.
Thankfully, I got an oral prescription for the Medrol, she will take her dose in time, all is well.
Wouldn’t that be something, OTC methylprednisolone? Man, it would be great for hangover headaches.
She is allergic to contrast dyes and is having a radiological procedure tomorrow requiring contrast. The doctor’s office instructed her to premedicate with 50mg of Benadryl and 32mg of Medrol prior to the procedure. The office staff told her that she could get both products over-the-counter.
Not since I last checked. Benadryl, sure. But corticosteroids? Not so much.
I had to page the doctor since he was out of the office to get the order. The RECEPTIONIST that scheduled the appointment informed her that she needed the premedicate, and was the one to tell her to get the products OTC.
Thankfully, I got an oral prescription for the Medrol, she will take her dose in time, all is well.
Wouldn’t that be something, OTC methylprednisolone? Man, it would be great for hangover headaches.
Phony Rxs
Phony call-in Rxs are the worst.
The other day, just before 5pm a message was left on the voicemail system. The caller claimed to be a doctor phoning in a new prescription for #120 Lortab 10/500mg. The patient was new to me, and it just seemed funny. A little too perfect. The “doctor” even remembered to include his DEA number.
I called the office to verify the prescription and had to page the doctor on call. I always feel bad doing that; the doctor is done working for the day and I only page doctors when I feel it is absolutely necessary. The doctor laughed when I told him about the prescription and said that he absolutely did NOT call it in. He was glad I had paged him to verify it.
This is always when I start to get nervous. I processed the prescription but didn’t count it. I hoped the “patient” would come in before my technician left for the day. I work alone from 6pm to 8pm on Mondays. This was my plan: tell him I hadn’t counted it yet, I needed information/driver’s license because he was a new patient for me. Then call the cops. I hoped he would stick around long enough for them to arrive. It’s stupid how it isn’t illegal to call in a fake prescription, just to pick it up. It makes it so hard for us to catch these people.
He called after my technician left to see if it was ready. I swallowed hard, and told him it was. Then I called the police department. Remarkably, they sent an officer over right away, who hid in the back waiting for him to arrive. He must have seen the police car outside, because he never showed up to pick up the prescription.
The officer told me that this has been happening a lot recently. He said oftentimes the person picks up the prescription, and the pharmacy only learns it was a fake after it has already been sold. It is unfortunate that office hours and pharmacy hours are so different. Like myself, pharmacists are always reluctant to page doctors on call. So rather than tell the patient that they must wait until the following day to verify the questionable script, the pharmacist just fills it. A lot of pharmacists just don’t have their heart in it anymore. It’s easier to not make waves. If they learn it is a phony prescription, they just won’t fill it. They don’t call the police, they don’t try to stop the cycle. I always appreciate a pharmacist that does his or her part to stop drug diversion.
The other day, just before 5pm a message was left on the voicemail system. The caller claimed to be a doctor phoning in a new prescription for #120 Lortab 10/500mg. The patient was new to me, and it just seemed funny. A little too perfect. The “doctor” even remembered to include his DEA number.
I called the office to verify the prescription and had to page the doctor on call. I always feel bad doing that; the doctor is done working for the day and I only page doctors when I feel it is absolutely necessary. The doctor laughed when I told him about the prescription and said that he absolutely did NOT call it in. He was glad I had paged him to verify it.
This is always when I start to get nervous. I processed the prescription but didn’t count it. I hoped the “patient” would come in before my technician left for the day. I work alone from 6pm to 8pm on Mondays. This was my plan: tell him I hadn’t counted it yet, I needed information/driver’s license because he was a new patient for me. Then call the cops. I hoped he would stick around long enough for them to arrive. It’s stupid how it isn’t illegal to call in a fake prescription, just to pick it up. It makes it so hard for us to catch these people.
He called after my technician left to see if it was ready. I swallowed hard, and told him it was. Then I called the police department. Remarkably, they sent an officer over right away, who hid in the back waiting for him to arrive. He must have seen the police car outside, because he never showed up to pick up the prescription.
The officer told me that this has been happening a lot recently. He said oftentimes the person picks up the prescription, and the pharmacy only learns it was a fake after it has already been sold. It is unfortunate that office hours and pharmacy hours are so different. Like myself, pharmacists are always reluctant to page doctors on call. So rather than tell the patient that they must wait until the following day to verify the questionable script, the pharmacist just fills it. A lot of pharmacists just don’t have their heart in it anymore. It’s easier to not make waves. If they learn it is a phony prescription, they just won’t fill it. They don’t call the police, they don’t try to stop the cycle. I always appreciate a pharmacist that does his or her part to stop drug diversion.
I Hate Coupons, Part II
I posted recently about how I hate coupons. Now I hate them even more.
My district manager just called me about a complaint filed against my store and another store in my chain. The patient was angry that we would only provide one gift card per person. The one-per-person rule is printed as a limitation right on the coupon. The lady didn’t even understand that she was bending (hell, breaking) the rules by getting more than one coupon at different stores in the same chain. She yelled and screamed at my district supervisor. And what does he do? Just what he shouldn’t do. He offered her another $25 gift card at my store. I was instructed to appease her.
This is so frustrating.
We pharmacist bloggers rant about how poorly we are treated by the public. It is understandable why this happens. The public learns, like above, that throwing a fit and acting like a brat gets them their way. Why can’t my supervisors back me up? It undermines my authority as a pharmacy manager. I try to follow the rules, but all it takes is one angry customer call for them to bend them.
It is going to be very difficult for me to be nice to this lady when she comes in for a third gift card this month (one for her, one for her husband, and this new one). But I am expected to.
All of this makes me happy that groups like The Pharmacy Alliance exist. There is nothing wrong with the profession. It is the job that sucks. We pharmacists need to step up and say that it is not okay to treat us like this.
My job is not to:
- ring out coupons for the Gap that you get for free with your prescription
- clean toilets (see recent posts on The Pharmacy Alliance’s yahoo groups webpage)
- check out your groceries
- direct you to the charcoal/ketchup/vaccuum bags/bologna- know everything about each and every one of my patient’s insurance plans
- work for 12 hours without a lunch or bathroom break
- etc, etc, etc
The Pharmacy Alliance promotes DIGNITY, SELF-RESPECT, and INTEGRITY for the pharmacist.
We need to STAND UP and demand to be treated better by the companies we work for and by the public. Rather than look in the mirror and say “I’m good enough, smart enough, and gosh darn it people like me” every day, we need to say “I am a PROFESSIONAL and deserve to be treated as such.”
My district manager just called me about a complaint filed against my store and another store in my chain. The patient was angry that we would only provide one gift card per person. The one-per-person rule is printed as a limitation right on the coupon. The lady didn’t even understand that she was bending (hell, breaking) the rules by getting more than one coupon at different stores in the same chain. She yelled and screamed at my district supervisor. And what does he do? Just what he shouldn’t do. He offered her another $25 gift card at my store. I was instructed to appease her.
This is so frustrating.
We pharmacist bloggers rant about how poorly we are treated by the public. It is understandable why this happens. The public learns, like above, that throwing a fit and acting like a brat gets them their way. Why can’t my supervisors back me up? It undermines my authority as a pharmacy manager. I try to follow the rules, but all it takes is one angry customer call for them to bend them.
It is going to be very difficult for me to be nice to this lady when she comes in for a third gift card this month (one for her, one for her husband, and this new one). But I am expected to.
All of this makes me happy that groups like The Pharmacy Alliance exist. There is nothing wrong with the profession. It is the job that sucks. We pharmacists need to step up and say that it is not okay to treat us like this.
My job is not to:
- ring out coupons for the Gap that you get for free with your prescription
- clean toilets (see recent posts on The Pharmacy Alliance’s yahoo groups webpage)
- check out your groceries
- direct you to the charcoal/ketchup/vaccuum bags/bologna- know everything about each and every one of my patient’s insurance plans
- work for 12 hours without a lunch or bathroom break
- etc, etc, etc
The Pharmacy Alliance promotes DIGNITY, SELF-RESPECT, and INTEGRITY for the pharmacist.
We need to STAND UP and demand to be treated better by the companies we work for and by the public. Rather than look in the mirror and say “I’m good enough, smart enough, and gosh darn it people like me” every day, we need to say “I am a PROFESSIONAL and deserve to be treated as such.”
All Natural?
In Arizona, naturopathic doctors can legally prescribe any legend drug or controlled substance (except IV medications, chemo drugs, and antipsychotics). The only prescriptions I see from naturopaths are for phentermine and metformin. Usually for the same patient.
I guess the only disease that people go to naturopaths for is obesity. Well, not even that. The people who get prescriptions for phentermine from naturopaths are usually not obese. They are usually wealthy uppity women trying to fit into size 6 jeans that don’t care if their insurance doesn’t cover phentermine. They want it anyway.
This irks me. Phentermine isn’t particularly “natural.” Treating people with amphetamines and metformin seems a little out of naturopaths’ scope of practice. I wouldn’t care if people brought me prescriptions from their naturopath for St. John’s Wort, saw palmetto, or fish oil capsules (I even believe in the benefits of those natural products). Heck, it wouldn’t even bug me (that much) if they brought me prescriptions for digitalis, as it’s arguably more “natural” than phentermine.
But I do worry about the metformin, and stress the importance of laboratory monitoring of kidney function with my patients.
I know it’s legal. But there is a line between a conscientious naturopathic physician and a phentermine farm.
I guess the only disease that people go to naturopaths for is obesity. Well, not even that. The people who get prescriptions for phentermine from naturopaths are usually not obese. They are usually wealthy uppity women trying to fit into size 6 jeans that don’t care if their insurance doesn’t cover phentermine. They want it anyway.
This irks me. Phentermine isn’t particularly “natural.” Treating people with amphetamines and metformin seems a little out of naturopaths’ scope of practice. I wouldn’t care if people brought me prescriptions from their naturopath for St. John’s Wort, saw palmetto, or fish oil capsules (I even believe in the benefits of those natural products). Heck, it wouldn’t even bug me (that much) if they brought me prescriptions for digitalis, as it’s arguably more “natural” than phentermine.
But I do worry about the metformin, and stress the importance of laboratory monitoring of kidney function with my patients.
I know it’s legal. But there is a line between a conscientious naturopathic physician and a phentermine farm.
I Want to be a Pharmacist When I Grow Up
I am a preceptor for 2 colleges of pharmacy in the area. Today, I had my very first student. He is a first-year pharmacy student. He has to do two four-hour “shadow” rotations this quarter, one in a retail pharmacy and one in a hospital pharmacy. This student has never worked in a pharmacy before, but spent 4 hours with me today behind the counter.
I think that is kind of nuts.
I started as a clerk in an independent pharmacy at the age of 15. It was an after school job. I would put away the drug order, file prescriptions, answer the phone, and run the cash register. Before working in a pharmacy, I wanted to be a journalist when I grew up. I was on the newspaper staff and was the yearbook editor. But after working in a pharmacy for a few years, I fell in love with it and decided that pharmacy is what I would do.
Granted, pharmacy was a different thing then than it is now. I worked in an independent pharmacy. We were open 8-6:30 Monday through Friday, 10-2 on Saturdays, and closed on Sundays. The pharmacy filled about 1000 prescriptions a week, and did it with 3 full-time pharmacists, 3 full-time technicians, and me (the clerk). There was plenty of staff to get our jobs done, interact with our customers, and have fun at the same time.
The pharmacists that worked there were great. They had positive relationships with their patients; and taught me a lot about pharmacy. It was interesting to me, and I had lots of questions. “Why this drug? Why do these smell funny? What’s this medicine for?”
They would draw me chemical structures, explain a drug’s mechanism of action, and quiz me on my brand-generic names. One pharmacist would send me home with a list of drug brand and generic names to memorize in the evenings. He would usually do it by class; one evening I would have ACE inhibitors, the next it would be beta-blockers, etc. The pharmacists also taught me how to compound medications, I distinctly remember spending hours making diethylstilbesterol capsules (for canine incontinence) and a cocaine-based oral gel. I also used to “compound” my own flavored lip glosses that we sold at the counter.
I remember at that pharmacy the first brand-generic combo that I memorized was Sinemet. The pharmacist told me that she remembered the generic name by doing the “Sinemet cheer.”
Carbi-dopa levo-dopa RAH RAH RAH!
When I moved away to college, I got a job in a different pharmacy. This time my job title was actually “technician.” It was another independent with a closed-door operation (for nursing home prescriptions, we did lots of blister packing) as well as a retail operation. I started in the closed-door portion; I was responsible for all of the medications for a local convalescent center. They had weekly blister packs; I prepared the weekly packs and kept up-to-date charts to record medication changes. I also delivered to the center once daily to take them new orders. After a couple months, I transitioned that convalescent center to monthly blister packs instead of the weekly ones and moved to work in the retail operation.
The good part about working in an independent is that I always had a lot of responsibility. My pharmacy manager had me prepare the contract that the pharmacy made with the local women’s prison (we supplied their medications). They also sent me through a compounding training program (I made lots of ketamine PLO gels and hydrocodone lollipops) and taught me how to work under a laminar flow hood (mixing IVs).
When I got into pharmacy school, I moved again. This time, no jobs at independent pharmacies were available. I went to work as a pharmacy intern for a department store. This was my first experience working for a corporation. I took all the knowledge and experience that I had gained at independents and applied it to my new job. When the pharmacy’s technician hours were going to be cut because of decreased volume, I talked the pharmacy manager into letting me “detail” local nursing homes to see if they needed pharmacy services. I ordered blister packs and started medication filling and management for two nursing homes in the area, increasing our monthly prescription count by several hundred Rxs.
By the time I graduated from pharmacy school I had 7 or 8 years of experience under my belt, in several different practice settings. I knew what I was getting into. I can’t imagine graduating from school and getting a job, never having done it (except on rotations). I would have been scared shitless. As it was, I was pretty confident when I first got licensed, thanks to all my previous experience.
My student today didn’t know much of anything about pharmacy. I was explaining rejected claims and about prior authorizations. I told him that patients expect me to be an expert on their insurance but not on their drugs. The only “clinical” thing that I did was compound some testosterone vaginal cream.
I feel bad; he isn’t going to have nearly the experience I had going into pharmacy. Pretty much the only experience he will have will be his six-week retail pharmacy rotation. He is probably going to just end up working for CVS or Walgreens and never know all that pharmacy has to offer as a profession. It is truly amazing how much the practice of pharmacy has changed in a decade.
How does one decide to be a pharmacist without ever having worked in a pharmacy? What would be the appeal for someone who hadn’t ever done it? And how is this student going to fare his first year practicing as a pharmacist when his school teaches him virtually no “practical” knowledge that he needs to be a retail pharmacist?
I think that is kind of nuts.
I started as a clerk in an independent pharmacy at the age of 15. It was an after school job. I would put away the drug order, file prescriptions, answer the phone, and run the cash register. Before working in a pharmacy, I wanted to be a journalist when I grew up. I was on the newspaper staff and was the yearbook editor. But after working in a pharmacy for a few years, I fell in love with it and decided that pharmacy is what I would do.
Granted, pharmacy was a different thing then than it is now. I worked in an independent pharmacy. We were open 8-6:30 Monday through Friday, 10-2 on Saturdays, and closed on Sundays. The pharmacy filled about 1000 prescriptions a week, and did it with 3 full-time pharmacists, 3 full-time technicians, and me (the clerk). There was plenty of staff to get our jobs done, interact with our customers, and have fun at the same time.
The pharmacists that worked there were great. They had positive relationships with their patients; and taught me a lot about pharmacy. It was interesting to me, and I had lots of questions. “Why this drug? Why do these smell funny? What’s this medicine for?”
They would draw me chemical structures, explain a drug’s mechanism of action, and quiz me on my brand-generic names. One pharmacist would send me home with a list of drug brand and generic names to memorize in the evenings. He would usually do it by class; one evening I would have ACE inhibitors, the next it would be beta-blockers, etc. The pharmacists also taught me how to compound medications, I distinctly remember spending hours making diethylstilbesterol capsules (for canine incontinence) and a cocaine-based oral gel. I also used to “compound” my own flavored lip glosses that we sold at the counter.
I remember at that pharmacy the first brand-generic combo that I memorized was Sinemet. The pharmacist told me that she remembered the generic name by doing the “Sinemet cheer.”
Carbi-dopa levo-dopa RAH RAH RAH!
When I moved away to college, I got a job in a different pharmacy. This time my job title was actually “technician.” It was another independent with a closed-door operation (for nursing home prescriptions, we did lots of blister packing) as well as a retail operation. I started in the closed-door portion; I was responsible for all of the medications for a local convalescent center. They had weekly blister packs; I prepared the weekly packs and kept up-to-date charts to record medication changes. I also delivered to the center once daily to take them new orders. After a couple months, I transitioned that convalescent center to monthly blister packs instead of the weekly ones and moved to work in the retail operation.
The good part about working in an independent is that I always had a lot of responsibility. My pharmacy manager had me prepare the contract that the pharmacy made with the local women’s prison (we supplied their medications). They also sent me through a compounding training program (I made lots of ketamine PLO gels and hydrocodone lollipops) and taught me how to work under a laminar flow hood (mixing IVs).
When I got into pharmacy school, I moved again. This time, no jobs at independent pharmacies were available. I went to work as a pharmacy intern for a department store. This was my first experience working for a corporation. I took all the knowledge and experience that I had gained at independents and applied it to my new job. When the pharmacy’s technician hours were going to be cut because of decreased volume, I talked the pharmacy manager into letting me “detail” local nursing homes to see if they needed pharmacy services. I ordered blister packs and started medication filling and management for two nursing homes in the area, increasing our monthly prescription count by several hundred Rxs.
By the time I graduated from pharmacy school I had 7 or 8 years of experience under my belt, in several different practice settings. I knew what I was getting into. I can’t imagine graduating from school and getting a job, never having done it (except on rotations). I would have been scared shitless. As it was, I was pretty confident when I first got licensed, thanks to all my previous experience.
My student today didn’t know much of anything about pharmacy. I was explaining rejected claims and about prior authorizations. I told him that patients expect me to be an expert on their insurance but not on their drugs. The only “clinical” thing that I did was compound some testosterone vaginal cream.
I feel bad; he isn’t going to have nearly the experience I had going into pharmacy. Pretty much the only experience he will have will be his six-week retail pharmacy rotation. He is probably going to just end up working for CVS or Walgreens and never know all that pharmacy has to offer as a profession. It is truly amazing how much the practice of pharmacy has changed in a decade.
How does one decide to be a pharmacist without ever having worked in a pharmacy? What would be the appeal for someone who hadn’t ever done it? And how is this student going to fare his first year practicing as a pharmacist when his school teaches him virtually no “practical” knowledge that he needs to be a retail pharmacist?
I Hate Coupons
My company is almost finished with a coupon promotion for a $30 giftcard for any new or transferred prescription. Thank God.
The Board of Pharmacy should outlaw coupons. They only promote polypharmacy. I don’t think that anyone uses them the way they are supposed to be used.
You see, people, my company prints coupons so that you will transfer all of your prescriptons to my pharmacy and then STAY HERE for your refills. We do not make a $30 profit on your one transferred prescription, but if you get all your remaining 12 refills here, we eventually will. They are not made so that you can transfer your presription from pharmacy to pharmacy, collecting $25 to $30 with every transfer.
I really can’t blame these cusomters for doing that. It’s easy money. They don’t see the harm - we’re corporate giants and can afford it, right?
I am the pharmacy manager. When I reconcile my books the end of the week, I see the money I made, then I have to substract what I paid out in gift cards. Lately, this puts me in the red. It costs my company money to keep my pharmacy open. This does not make me, or my company happy.
I had a lady call me and ask if I would match Walmart’s $4 price on 60 metformin. Sure. She also wanted to use the $30 coupon. I looked in her profile, and she has received $80 in coupons over the past 2 years. All of the prescriptions were transferred in, filled once, and transferred out.
I told her no.
I will probably get in trouble with my corporate office if she complains, but I don’t care. This woman has numerous disease states (based on her drugs, at least). Having the same pharmacist fill her prescriptions every month helps with drug complaince, prevents over-lapping therapies (dual ACE inhibitors and the like), and can improve outcomes.
I don’t care if a customer uses another pharmacy besides mine. I just wish they would use the SAME pharmacy every month and not transfer prescriptions all over the place. How can I perform a prospective DUR on you when I transfer in one prescription and don’t know anything about the rest of your medication profile? How is the pharmacist that fills it at another pharmacy next month supposed to?
I wonder if there’s anything I can do to help my Board of Pharmacy outlaw coupons? Ideally, all of the corporations that own pharmacies would just get together, say “this is pointless,” and stop printing coupons.
The Board of Pharmacy should outlaw coupons. They only promote polypharmacy. I don’t think that anyone uses them the way they are supposed to be used.
You see, people, my company prints coupons so that you will transfer all of your prescriptons to my pharmacy and then STAY HERE for your refills. We do not make a $30 profit on your one transferred prescription, but if you get all your remaining 12 refills here, we eventually will. They are not made so that you can transfer your presription from pharmacy to pharmacy, collecting $25 to $30 with every transfer.
I really can’t blame these cusomters for doing that. It’s easy money. They don’t see the harm - we’re corporate giants and can afford it, right?
I am the pharmacy manager. When I reconcile my books the end of the week, I see the money I made, then I have to substract what I paid out in gift cards. Lately, this puts me in the red. It costs my company money to keep my pharmacy open. This does not make me, or my company happy.
I had a lady call me and ask if I would match Walmart’s $4 price on 60 metformin. Sure. She also wanted to use the $30 coupon. I looked in her profile, and she has received $80 in coupons over the past 2 years. All of the prescriptions were transferred in, filled once, and transferred out.
I told her no.
I will probably get in trouble with my corporate office if she complains, but I don’t care. This woman has numerous disease states (based on her drugs, at least). Having the same pharmacist fill her prescriptions every month helps with drug complaince, prevents over-lapping therapies (dual ACE inhibitors and the like), and can improve outcomes.
I don’t care if a customer uses another pharmacy besides mine. I just wish they would use the SAME pharmacy every month and not transfer prescriptions all over the place. How can I perform a prospective DUR on you when I transfer in one prescription and don’t know anything about the rest of your medication profile? How is the pharmacist that fills it at another pharmacy next month supposed to?
I wonder if there’s anything I can do to help my Board of Pharmacy outlaw coupons? Ideally, all of the corporations that own pharmacies would just get together, say “this is pointless,” and stop printing coupons.
Funny Pronunciation of the Day
A new prescription was left on the voicemail for a regular patient of mine.
“This is Sue from Dr. Smith’s office calling in a prescription for Mr. Sam Jones for spirono-lono-lono-lactone 25mg po BID number sixty two refills.”
hahaha
It’s “spir-ono-lactone.”
However, I can’t make fun toooo much, as when I first started as a clerk I thought GoLytely was pronounced “Goly-tely” instead of “Go-lightly.”
I used to mangle dipyridamole, too; and still have a small mental block when it comes to pronouncing that drug name.
“This is Sue from Dr. Smith’s office calling in a prescription for Mr. Sam Jones for spirono-lono-lono-lactone 25mg po BID number sixty two refills.”
hahaha
It’s “spir-ono-lactone.”
However, I can’t make fun toooo much, as when I first started as a clerk I thought GoLytely was pronounced “Goly-tely” instead of “Go-lightly.”
I used to mangle dipyridamole, too; and still have a small mental block when it comes to pronouncing that drug name.
Benzo Police
I had a woman bring me a prescription today for Klonopin 1mg BID with 3 refills. The doctor forgot to include a quantity, so I had to call and speak the the nurse to clarify. While I had her on the phone, I asked about the benzodiazepine use in this patient, as she had received #90 generic Xanax only two weeks prior from the same doctor.
The nurse said there was no record in the chart of the Xanax script and it must have been a forgery. I pulled the original - it was written by the doctor for #90 Xanax with 3 refills. He just forgot to document it. So anyway, I asked the nurse if he wanted her to have both the Klonopin and the Xanax.
“Well, of course! The doctor wrote both,” she said.
I tried to politely explain that they were both benzodiazepines and that since the doctor didn’t chart the Xanax prescription he probably didn’t remember giving it to her. I was almost positive that the doctor didn’t want both. She said she would have to call me back.
Eventually, she talked to the actual prescriber and the patient. Apparently, the patient wanted the Klonopin, not Xanax. The office told her to come in with the “extra” Xanax that she had that “didn’t work” to be destroyed before they would authorize her to pick up the Klonopin.
That changed her tune. Of course she didn’t have 2 weeks worth of pills left. She wanted both.
She said she would wait until next month for the Klonopin prescription; the doctor cancelled all the refills on the Xanax.
It’s frustrating because if I hadn’t been persistent and/or if the doctor hadn’t left off the quantity forcing me to call I would have dispensed Klonopin AND Xanax to this patient for 3+ months. The doctor didn’t chart the Xanax prescription, the nurse thought that the doctor was God and could not be questioned, and the patient was trying to abuse the system. All of these things contributed to this benzodiazepine miscommunication. But I straightened it out because I pay attention.
This is just one example of me “playing police” as a pharmacist.
It’s my job. It’s never fun to be the bad guy, but it’s what I’m for.
And really, I’m not being a “bad guy.” I’m looking out for the best interests of my patients. I’m decreasing driving while under the influence (do you want people on the road on two benzodiazepines?). I’m reducing drug diversion.
But the patients sure think that I’m a meanie.
The nurse said there was no record in the chart of the Xanax script and it must have been a forgery. I pulled the original - it was written by the doctor for #90 Xanax with 3 refills. He just forgot to document it. So anyway, I asked the nurse if he wanted her to have both the Klonopin and the Xanax.
“Well, of course! The doctor wrote both,” she said.
I tried to politely explain that they were both benzodiazepines and that since the doctor didn’t chart the Xanax prescription he probably didn’t remember giving it to her. I was almost positive that the doctor didn’t want both. She said she would have to call me back.
Eventually, she talked to the actual prescriber and the patient. Apparently, the patient wanted the Klonopin, not Xanax. The office told her to come in with the “extra” Xanax that she had that “didn’t work” to be destroyed before they would authorize her to pick up the Klonopin.
That changed her tune. Of course she didn’t have 2 weeks worth of pills left. She wanted both.
She said she would wait until next month for the Klonopin prescription; the doctor cancelled all the refills on the Xanax.
It’s frustrating because if I hadn’t been persistent and/or if the doctor hadn’t left off the quantity forcing me to call I would have dispensed Klonopin AND Xanax to this patient for 3+ months. The doctor didn’t chart the Xanax prescription, the nurse thought that the doctor was God and could not be questioned, and the patient was trying to abuse the system. All of these things contributed to this benzodiazepine miscommunication. But I straightened it out because I pay attention.
This is just one example of me “playing police” as a pharmacist.
It’s my job. It’s never fun to be the bad guy, but it’s what I’m for.
And really, I’m not being a “bad guy.” I’m looking out for the best interests of my patients. I’m decreasing driving while under the influence (do you want people on the road on two benzodiazepines?). I’m reducing drug diversion.
But the patients sure think that I’m a meanie.
Generic Bashing in the News
Just great.
This new article on the homepage for msn.com is just what I needed to freak out my patients about generics. We, as pharmacists, try to educate, educate, educate; and inflammatory articles like this just erase all that I try to teach my patients about generic substitution.
The article basically says that generics aren’t as good as brand-name medications. At the beginning….. then there is some better explaining.
This article wasn’t all that bad per se, but people need to read the whole thing. Unfortunately, most people will only read the headline and maybe a paragraph or two.
I, personally, don’t agree with the way my corporation goes about generics. They just send us whatever is cheapest from the wholesaler. That means with some drugs, I have to change the manufacturer every month.
I don’t think that I should substitute the generic for Synthroid or Levoxyl - and not because the generic versions of levothyroxine aren’t up to par (well, maybe Sandoz isn’t….lots of manufacturer recalls on that one), but just because I think that the generics shouldn’t be switched around on medications with a narrow therapeutic index. Same goes for warfarin. In my pharmacy, I make sure not to change around generics on diltiazem products (it is so confusing to remember which ones are AB rated), warfarin, thyroid preparations, or digoxin.
But, by and large, generics are exactly the same as the brand name medications. A lot of generic companies are OWNED by the brand name companies, and the tablets or capsules inside the bottles are identical (Lotrel and its generic by Sandoz, both owned by Novartis, is a good example of this). Greenstone generic company is owned by Pfizer, Dr. Reddy’s generic company is owned by Merck.
For most generics, the medication is THE SAME thing as the brand name drug.
The placebo effect is a real phenomenon. If people think that the medication they are getting isn’t as good as the one before, they will have have physical symptoms proving the “inferiority” of the new generic.
Dissolving two tablets in a test tube isn’t the same as the in vivo experience. To be granted FDA approval, Teva must have had to prove that their version of bupropion XL 300mg had a similar AUC to the brand name product. However, if one generic manufacturer’s version of a product is consistenly having problems, it is something that obviously needs to be addressed by the FDA. I hope that this doesn’t cause a panic
This new article on the homepage for msn.com is just what I needed to freak out my patients about generics. We, as pharmacists, try to educate, educate, educate; and inflammatory articles like this just erase all that I try to teach my patients about generic substitution.
The article basically says that generics aren’t as good as brand-name medications. At the beginning….. then there is some better explaining.
This article wasn’t all that bad per se, but people need to read the whole thing. Unfortunately, most people will only read the headline and maybe a paragraph or two.
I, personally, don’t agree with the way my corporation goes about generics. They just send us whatever is cheapest from the wholesaler. That means with some drugs, I have to change the manufacturer every month.
I don’t think that I should substitute the generic for Synthroid or Levoxyl - and not because the generic versions of levothyroxine aren’t up to par (well, maybe Sandoz isn’t….lots of manufacturer recalls on that one), but just because I think that the generics shouldn’t be switched around on medications with a narrow therapeutic index. Same goes for warfarin. In my pharmacy, I make sure not to change around generics on diltiazem products (it is so confusing to remember which ones are AB rated), warfarin, thyroid preparations, or digoxin.
But, by and large, generics are exactly the same as the brand name medications. A lot of generic companies are OWNED by the brand name companies, and the tablets or capsules inside the bottles are identical (Lotrel and its generic by Sandoz, both owned by Novartis, is a good example of this). Greenstone generic company is owned by Pfizer, Dr. Reddy’s generic company is owned by Merck.
For most generics, the medication is THE SAME thing as the brand name drug.
The placebo effect is a real phenomenon. If people think that the medication they are getting isn’t as good as the one before, they will have have physical symptoms proving the “inferiority” of the new generic.
Dissolving two tablets in a test tube isn’t the same as the in vivo experience. To be granted FDA approval, Teva must have had to prove that their version of bupropion XL 300mg had a similar AUC to the brand name product. However, if one generic manufacturer’s version of a product is consistenly having problems, it is something that obviously needs to be addressed by the FDA. I hope that this doesn’t cause a panic
Speed Talking Docs
Thursday after Christmas.
Busier than usual.
We just got a call back from a doctor’s office.
Our original message for them was left on 12/19/07, they were just now returning the call. The doctor had left a million-miles-a-minute message on the voicemail, a new prescription for a patient of ours. Well, it wasn’t new, really. The patient had been taking lisinopril 40mg po BID. The doctor called in linopril40mgpoqdnumbersixtynorefills. We called back and asked if they really wanted to change it to once daily dosing, as the patient had been taking it twice daily for quite some time. The quantity of sixty didn’t match up with the once daily dosing, either, since doctors rarely call in a two-month supply.
We had loaned the patient 10 tablets to get her through, as she was out of medication and we wanted to clarify the prescription before we filled it with once-daily dosing. It took them 8 days to return our call. I don’t understand why things like that take so long. How would the patient like it if it took us 8 days to call in a message to their doctor about a dose irregularity? I know it was around the Christmas holiday, but this woman’s hypertension doesn’t take a break. Neither did my pharmacy, unfortunately.
Busier than usual.
We just got a call back from a doctor’s office.
Our original message for them was left on 12/19/07, they were just now returning the call. The doctor had left a million-miles-a-minute message on the voicemail, a new prescription for a patient of ours. Well, it wasn’t new, really. The patient had been taking lisinopril 40mg po BID. The doctor called in linopril40mgpoqdnumbersixtynorefills. We called back and asked if they really wanted to change it to once daily dosing, as the patient had been taking it twice daily for quite some time. The quantity of sixty didn’t match up with the once daily dosing, either, since doctors rarely call in a two-month supply.
We had loaned the patient 10 tablets to get her through, as she was out of medication and we wanted to clarify the prescription before we filled it with once-daily dosing. It took them 8 days to return our call. I don’t understand why things like that take so long. How would the patient like it if it took us 8 days to call in a message to their doctor about a dose irregularity? I know it was around the Christmas holiday, but this woman’s hypertension doesn’t take a break. Neither did my pharmacy, unfortunately.
Drug Interactions
I also faxed 2 different doctors’ offices today regarding drug interactions potentially leading to serotonin syndrome. They made a big deal about serotonin syndrome in pharmacy school, but I didn’t actually see it until I was on my medicine rotation at the VA. The patient had to be adminstered cyproheptadine and cooled with ice packs. It was scary and totally preventable. So now I always watch for potential causes of it.
The first patient is currently taking dextroamphetamine and tramadol and was just prescribed paroxetine for anxiety. He had been taking buckets of alprazolam, so the doctor choosing an SSRI was a good idea to prevent anxiety. But with three serotonergic agents, the possibility of serotonin syndrome was there. I called the doctor’s office and they told me to fill the prescription anyway. I did, but talked to the patient about the possibility of serotonin syndrome and what to watch for. I also advised him not to use OTC cough and cold products that contain pseudoephedrine and to call me or his doctor if he had a question about what he could or could not take. I sent a fax to the doctor’s office advising them (in writing) of the interaction and about my conversation with the patient.
The second patient was a guy stabilized on sertraline. His doctor prescribed phentermine for weight loss, even though this guy is NOT fat (in my book at least). When I went over to counsel him I asked him, jokingly, what he was using the phentermine for. We talked about weight loss and I gave him some pointers on how to not to mess up his metabolism taking amphetamines (not to take it every day, etc) by trying not to become accustomed to the medication. I also gave him my serotonin syndrome talk and told him to say no to pseudoephedrine, triptans for migraine, other antidepressants (especially MAOIs) and tramadol for pain. I sent a fax to his doctor, too.
I usually only get a NEW drug-drug interation potentially leading to serotonin syndrome once a month or so. To get 2 in one day is a little strange. Most of the drug interactions that could cause serotonin syndrome are medictions that patients have been taking concurrently for months or years and they only ever have problems if they add a third or fourth serotonergic agent.
Drug interactions are difficult to navigate. Obviously some interactions are more serious than others, and some potentially lethal interactions are relatively rare. In some cases it is important to speak to the prescriber (ok, ok, the prescriber’s receptionist) before dispensing the offending drug, and sometimes I think informing the patient and faxing the prescriber will do. I know that when I do contact a prescriber’s office regarding a drug interaction, it usually takes them at least a week to return my call, and 99% of the time they say to dispense the medication anyway.
Or, as I’ve learned through experience, they change the drug to something else in the same family.
I fax on interactions between beta-blockers and calcium-channel blockers all the time.
Recent example: small elderly woman has been taking metoprolol and her doctor tried to add verapamil. Calcium-channel blockers can increase the pharmacologic effects of beta-blockers leading to symptomatic bradycardia (low heart rate), and they should be added with caution. The doctor had prescribed 240mg of extended-release verapamil without an initial trial/titration with a smaller dose. When I called on this interaction (and to suggest a smaller inital dose), the doctor just changed the medication to diltiazem XR 240mg.
Another non-dihydropyridine calcium-channel blocker.
With basically the same drug interactions. Granted, the diltiazem is a little bit better than the verapamil.
I dispensed the diltiazem to the patient after talking to her at length, and sent a fax to the doctor’s office about the interaction and my conversation with the patient. I told her to call 911 if she felt like her heart was beating slower than usual accompanied by dizziness and to call her doctor if she had any other side effects.
I hope nothing happens to her.
The first patient is currently taking dextroamphetamine and tramadol and was just prescribed paroxetine for anxiety. He had been taking buckets of alprazolam, so the doctor choosing an SSRI was a good idea to prevent anxiety. But with three serotonergic agents, the possibility of serotonin syndrome was there. I called the doctor’s office and they told me to fill the prescription anyway. I did, but talked to the patient about the possibility of serotonin syndrome and what to watch for. I also advised him not to use OTC cough and cold products that contain pseudoephedrine and to call me or his doctor if he had a question about what he could or could not take. I sent a fax to the doctor’s office advising them (in writing) of the interaction and about my conversation with the patient.
The second patient was a guy stabilized on sertraline. His doctor prescribed phentermine for weight loss, even though this guy is NOT fat (in my book at least). When I went over to counsel him I asked him, jokingly, what he was using the phentermine for. We talked about weight loss and I gave him some pointers on how to not to mess up his metabolism taking amphetamines (not to take it every day, etc) by trying not to become accustomed to the medication. I also gave him my serotonin syndrome talk and told him to say no to pseudoephedrine, triptans for migraine, other antidepressants (especially MAOIs) and tramadol for pain. I sent a fax to his doctor, too.
I usually only get a NEW drug-drug interation potentially leading to serotonin syndrome once a month or so. To get 2 in one day is a little strange. Most of the drug interactions that could cause serotonin syndrome are medictions that patients have been taking concurrently for months or years and they only ever have problems if they add a third or fourth serotonergic agent.
Drug interactions are difficult to navigate. Obviously some interactions are more serious than others, and some potentially lethal interactions are relatively rare. In some cases it is important to speak to the prescriber (ok, ok, the prescriber’s receptionist) before dispensing the offending drug, and sometimes I think informing the patient and faxing the prescriber will do. I know that when I do contact a prescriber’s office regarding a drug interaction, it usually takes them at least a week to return my call, and 99% of the time they say to dispense the medication anyway.
Or, as I’ve learned through experience, they change the drug to something else in the same family.
I fax on interactions between beta-blockers and calcium-channel blockers all the time.
Recent example: small elderly woman has been taking metoprolol and her doctor tried to add verapamil. Calcium-channel blockers can increase the pharmacologic effects of beta-blockers leading to symptomatic bradycardia (low heart rate), and they should be added with caution. The doctor had prescribed 240mg of extended-release verapamil without an initial trial/titration with a smaller dose. When I called on this interaction (and to suggest a smaller inital dose), the doctor just changed the medication to diltiazem XR 240mg.
Another non-dihydropyridine calcium-channel blocker.
With basically the same drug interactions. Granted, the diltiazem is a little bit better than the verapamil.
I dispensed the diltiazem to the patient after talking to her at length, and sent a fax to the doctor’s office about the interaction and my conversation with the patient. I told her to call 911 if she felt like her heart was beating slower than usual accompanied by dizziness and to call her doctor if she had any other side effects.
I hope nothing happens to her.
Don't Lie to Your Pharmacist
Never, ever lie to your pharmacist. Especially your pharmacist works in a slow pharmacy. That is a very bad idea if you are a drug addict.
A patient brought me a prescription for Lortab 7.5/500 #60 today. She asked how much it would be. I asked her if she had insurance - she said no. I asked her again to make sure: “You don’t have any insurance?” She said she did not. I told her the prescription would be ready in 20 minutes and that it would be $19.49.
I immediately called ABC/Pharmacy across the street and asked if she has insurance on file. Sure enough, she has Mercy Care. I billed the claim and was informed by the lovely online DUR system that she received #120 Vicodin ES on 12/13/07. I called Mercy Care and found out the prescription for #120 was filled at Walgreens. When I called Walgreens, the pharmacist working knew this patient well. She also had received #60 Vicodin 5/500mg on 12/19/07 from another doctor at his store. She picked up #15 Norco 5/325 at my store (no insurance) on 12/6/07.
That means in 15 days she had taken 195 tablets (most of it ES) and was trying to get 60 more.
Her poor liver.
Maximum daily acetaminophen usage should not exceed 4000mg to prevent hepatotoxicity. From these 195 tablets alone, she was taking the equivalent of 8325mg of actaminophen a day. And who knows what other pharmacies she was going to and paying cash for hydrocodone products.
Ouch.
When I confronted her about the “no insurance” lie, she feigned innocence and demanded the prescription back. I had already written that she had filled #120 on 12/13/07 on the face of the prescription. So I gave it back to her.
But when you lie to me and then don’t even apologize about it, I get even. I filled out a Fax Net form (an online form to report forgeries, bogus scripts, doctor shopping, etc to the Board of Pharmacy). I also sent a fax to the doctors’ offices with a copy of the Fax Net form informing them of her doctor-shopping/pharmacy-shopping behavior. The Fax Net form gets faxed from the Board of Pharmacy to every pharmacy in the valley.
I feel bad for people with legitimate pain - they need control of their pain, that is often why they are acting out and showing drug-seeking behavior. But doctor shopping and abusing the system will only eventually get you cut off. This woman needs to see ONE doctor for pain medictions that don’t include acetaminophen. Maybe her liver can still be saved.
I wish her luck. But I still hope she doesn’t lie to other pharmacists in the future.
A patient brought me a prescription for Lortab 7.5/500 #60 today. She asked how much it would be. I asked her if she had insurance - she said no. I asked her again to make sure: “You don’t have any insurance?” She said she did not. I told her the prescription would be ready in 20 minutes and that it would be $19.49.
I immediately called ABC/Pharmacy across the street and asked if she has insurance on file. Sure enough, she has Mercy Care. I billed the claim and was informed by the lovely online DUR system that she received #120 Vicodin ES on 12/13/07. I called Mercy Care and found out the prescription for #120 was filled at Walgreens. When I called Walgreens, the pharmacist working knew this patient well. She also had received #60 Vicodin 5/500mg on 12/19/07 from another doctor at his store. She picked up #15 Norco 5/325 at my store (no insurance) on 12/6/07.
That means in 15 days she had taken 195 tablets (most of it ES) and was trying to get 60 more.
Her poor liver.
Maximum daily acetaminophen usage should not exceed 4000mg to prevent hepatotoxicity. From these 195 tablets alone, she was taking the equivalent of 8325mg of actaminophen a day. And who knows what other pharmacies she was going to and paying cash for hydrocodone products.
Ouch.
When I confronted her about the “no insurance” lie, she feigned innocence and demanded the prescription back. I had already written that she had filled #120 on 12/13/07 on the face of the prescription. So I gave it back to her.
But when you lie to me and then don’t even apologize about it, I get even. I filled out a Fax Net form (an online form to report forgeries, bogus scripts, doctor shopping, etc to the Board of Pharmacy). I also sent a fax to the doctors’ offices with a copy of the Fax Net form informing them of her doctor-shopping/pharmacy-shopping behavior. The Fax Net form gets faxed from the Board of Pharmacy to every pharmacy in the valley.
I feel bad for people with legitimate pain - they need control of their pain, that is often why they are acting out and showing drug-seeking behavior. But doctor shopping and abusing the system will only eventually get you cut off. This woman needs to see ONE doctor for pain medictions that don’t include acetaminophen. Maybe her liver can still be saved.
I wish her luck. But I still hope she doesn’t lie to other pharmacists in the future.
I Love Generic Coreg
Refill for Coreg, I substituted the (new for this lady) generic.
Carvedilol 6.25mg tablets, #360.
Cost: $28.35
Copay: $2.15
Insurance payment: $187.78
Good for me, good for the patient. Happy all around. Considering on most prescriptions I make a dollar or two, these ones really make the difference.
Carvedilol 6.25mg tablets, #360.
Cost: $28.35
Copay: $2.15
Insurance payment: $187.78
Good for me, good for the patient. Happy all around. Considering on most prescriptions I make a dollar or two, these ones really make the difference.
I Can't Take it Back. Really. I Can't.
I had a mean and crazy lady complain about me yesterday.
She came in, demanding that I give her another #180 tramadol 50mg tablets because the generic I gave her are “inferior” to the ones she wants. She is a new patient of mine, and this is only the second fill of tramadol that we have done for her. She never said she was partial the Mutual brand, so we just filled it for the brand we had #180 in stock. How are we supposed to know otherwise?
I told her that I could not take the tablets back (it is illegal), but her doctor could call in a new prescription with specific “early refill ok” authorization and I would fill the prescription for the brand she wants. But she would have to pay out of pocket, since we have already billed her insurance for the claim for the month of December.
She threw a royal fit. I feel bad for everyone involved in this lady’s healthcare, from the office staff to the poor doctor who has to be alone in a small room with her. I shudder at the thought.
I wasn’t being a bitch, I was following the law.
So anyway, she complained to the store assistant manager (like that’s going to do anything). She told him that she knew more about drugs that pharmacists do and that she was going to sue me.
Man, if I only had a nickel for every time a patient told me that, I’d have…..about 40 nickels.
I won’t hold my breath.
She came in, demanding that I give her another #180 tramadol 50mg tablets because the generic I gave her are “inferior” to the ones she wants. She is a new patient of mine, and this is only the second fill of tramadol that we have done for her. She never said she was partial the Mutual brand, so we just filled it for the brand we had #180 in stock. How are we supposed to know otherwise?
I told her that I could not take the tablets back (it is illegal), but her doctor could call in a new prescription with specific “early refill ok” authorization and I would fill the prescription for the brand she wants. But she would have to pay out of pocket, since we have already billed her insurance for the claim for the month of December.
She threw a royal fit. I feel bad for everyone involved in this lady’s healthcare, from the office staff to the poor doctor who has to be alone in a small room with her. I shudder at the thought.
I wasn’t being a bitch, I was following the law.
So anyway, she complained to the store assistant manager (like that’s going to do anything). She told him that she knew more about drugs that pharmacists do and that she was going to sue me.
Man, if I only had a nickel for every time a patient told me that, I’d have…..about 40 nickels.
I won’t hold my breath.
The Angry Pharmacy Girl?
I hate all people.
Okay, not all. But most.
Especially today.
A woman called me on the phone. Here is a recap of the conversation:
Bitchy Woman: “Hi, my mom has Insurance X and her doctor is going to write her a prescription for Protonix. Is it covered?”
Pharmacy Girl: “I don’t know. I don’t have the formularies for every single insurance plan memorized.” (I might have had a not-so-nice tone there, because I think it pissed the Bitchy Woman off.)
BW: “Well, can’t you just run it through her insurance?”
PG: “No, not without a prescription. I suggest that you call the number on the back of the insurance card and ask them if it’s covered or not. Either that or have your doctor write the prescription stating ‘Protonix OR omeprazole OR Prilosec OTC’ so we can fill it for whichever medicine in that class that is covered.”
BW: “No, it has to be Protonix.”
PG: “Well, I guess you should call Mercy Care and ask them if it is covered.”
BW: hangs up on me.
Seriously, do people expect pharmacists to be insurance experts? There are thousands of insurance plans, and frankly I don’t have the brain power or desire to learn all of their formularies. I think people should feel lucky that I am even able to bill their insurance with the bullshit information I usually have to work with.
For example:
Dumb Patient: “I lost my card. But it’s Blue Cross of Norway or something.”
Pharmacy Girl: “I need a little bit more than that. How about a phone number?”
DP: “Maybe it’s Blue Shield. I don’t know. But I won’t pay more than my prescription is supposed to be with insurance, ten dollars.”
PG: “I can’t bill your insurance without more information than that.”
But magically, I do. I randomly call Express Scripts, Wellpoint, WHI, Medco, Argus, Cigna, Humana, HealthNet and Caremark and have them do a name search. I eventually get the prescription to go through. This isn’t what I went to pharmacy school for. Patients expect me to have infinite knowledge of insurance, not drugs.
...
This morning I had a STACK of prescriptions dropped off for a new patient. On Mercy Care. Hospital discharge orders…..urgh. The signature on the prescriptions was illegible, just a squiggle. How the hell do these doctors think I’m supposed to figure out who the prescriber is? There is a reason on those scripts that there is a line that says “PRINT NAME HERE.” Or if you just wrote down your DEA number, I would have a way to find out that the squiggle on this prescription means Dr. Parikh, or whoever.
Anyway, hospital discharge orders are the worst. They are usually written by residents or hospitalists, both of which don’t understand the dilemma that is insurance. Or how to write a complete drug order. Of the 14 prescriptions for this patient, I had to guess on a lot of what the doctor wanted. Dr. didn’t include a quantity on Reglan, I just gave a month supply (all the other prescriptions were written for a month…). Dr. wrote for Aggrenox, which isn’t covered. Good luck getting ahold of the prescriber on a Saturday, so I just sent a fax to the primary care doctor letting them know what the hospital doctor wrote for, and that it wasn’t covered so the primary care doc can change it or do a prior authorization. One of the prescriptions was for Renal Vitamins, which weren’t covered on the insurance. I just am going to make the patient pay for those ($7.99) because I don’t think the doctor can even do a prior authorization on that vitamin.
...
I also had a patient drop off two prescriptions and want them both. One for Tylox (oxycodone/APAP 5/500) #60 from a doctor in Phoenix and one for Percocet (oxycodone/APAP) #90 from a doctor in Tucson. The Tucson doctor didn’t include which strength of Percocet to dispense (it comes in 5/325, 7.5/325, 10/325, and 10/650) on the prescription. I told the patient that the prescriptions were virtually for the same medication and I would not fill them both. He wanted the Tylox prescription back, but I didn’t give it back before I wrote “filled #90 Percocet 12/8/07″ on the face of the prescription with my pharmacy name and phone number.
I dispensed #90 Percocet 5/325 to the patient and sent a fax to the Tucson doctor asking them politely to include a strength on future Percocet prescriptions (and told them what I dispensed), and alterted them to the fact that the patient is also seeing a doctor in Phoenix for Tylox prescriptions.
All in all, a frustrating day. After such a rant, you are going to have to start calling me the Angry Pharmacy Girl
Okay, not all. But most.
Especially today.
A woman called me on the phone. Here is a recap of the conversation:
Bitchy Woman: “Hi, my mom has Insurance X and her doctor is going to write her a prescription for Protonix. Is it covered?”
Pharmacy Girl: “I don’t know. I don’t have the formularies for every single insurance plan memorized.” (I might have had a not-so-nice tone there, because I think it pissed the Bitchy Woman off.)
BW: “Well, can’t you just run it through her insurance?”
PG: “No, not without a prescription. I suggest that you call the number on the back of the insurance card and ask them if it’s covered or not. Either that or have your doctor write the prescription stating ‘Protonix OR omeprazole OR Prilosec OTC’ so we can fill it for whichever medicine in that class that is covered.”
BW: “No, it has to be Protonix.”
PG: “Well, I guess you should call Mercy Care and ask them if it is covered.”
BW: hangs up on me.
Seriously, do people expect pharmacists to be insurance experts? There are thousands of insurance plans, and frankly I don’t have the brain power or desire to learn all of their formularies. I think people should feel lucky that I am even able to bill their insurance with the bullshit information I usually have to work with.
For example:
Dumb Patient: “I lost my card. But it’s Blue Cross of Norway or something.”
Pharmacy Girl: “I need a little bit more than that. How about a phone number?”
DP: “Maybe it’s Blue Shield. I don’t know. But I won’t pay more than my prescription is supposed to be with insurance, ten dollars.”
PG: “I can’t bill your insurance without more information than that.”
But magically, I do. I randomly call Express Scripts, Wellpoint, WHI, Medco, Argus, Cigna, Humana, HealthNet and Caremark and have them do a name search. I eventually get the prescription to go through. This isn’t what I went to pharmacy school for. Patients expect me to have infinite knowledge of insurance, not drugs.
...
This morning I had a STACK of prescriptions dropped off for a new patient. On Mercy Care. Hospital discharge orders…..urgh. The signature on the prescriptions was illegible, just a squiggle. How the hell do these doctors think I’m supposed to figure out who the prescriber is? There is a reason on those scripts that there is a line that says “PRINT NAME HERE.” Or if you just wrote down your DEA number, I would have a way to find out that the squiggle on this prescription means Dr. Parikh, or whoever.
Anyway, hospital discharge orders are the worst. They are usually written by residents or hospitalists, both of which don’t understand the dilemma that is insurance. Or how to write a complete drug order. Of the 14 prescriptions for this patient, I had to guess on a lot of what the doctor wanted. Dr. didn’t include a quantity on Reglan, I just gave a month supply (all the other prescriptions were written for a month…). Dr. wrote for Aggrenox, which isn’t covered. Good luck getting ahold of the prescriber on a Saturday, so I just sent a fax to the primary care doctor letting them know what the hospital doctor wrote for, and that it wasn’t covered so the primary care doc can change it or do a prior authorization. One of the prescriptions was for Renal Vitamins, which weren’t covered on the insurance. I just am going to make the patient pay for those ($7.99) because I don’t think the doctor can even do a prior authorization on that vitamin.
...
I also had a patient drop off two prescriptions and want them both. One for Tylox (oxycodone/APAP 5/500) #60 from a doctor in Phoenix and one for Percocet (oxycodone/APAP) #90 from a doctor in Tucson. The Tucson doctor didn’t include which strength of Percocet to dispense (it comes in 5/325, 7.5/325, 10/325, and 10/650) on the prescription. I told the patient that the prescriptions were virtually for the same medication and I would not fill them both. He wanted the Tylox prescription back, but I didn’t give it back before I wrote “filled #90 Percocet 12/8/07″ on the face of the prescription with my pharmacy name and phone number.
I dispensed #90 Percocet 5/325 to the patient and sent a fax to the Tucson doctor asking them politely to include a strength on future Percocet prescriptions (and told them what I dispensed), and alterted them to the fact that the patient is also seeing a doctor in Phoenix for Tylox prescriptions.
All in all, a frustrating day. After such a rant, you are going to have to start calling me the Angry Pharmacy Girl
Only in My Dreams?
A patient presented a prescription this week written for “nifedipine XL 120mg 1 po QD.”
Nifedipine is a calcium-channel blocker used for high blood pressure, heart rhythm irregularities, angina, and a few other things. The highest strength available is 90mg. I’ve never seen it dosed higher than that. Facts and Comparisons states that “titration to doses above 90mg a day is not recommended.”
The patient had been taking 90mg previously and told me the doctor was increasing his dose. I still felt like I had to call and verify it. I would have had to dispense 4 x 30mg tablets or 2 x 60mg tablets and have the patient take all the tablets at one time, once daily.
It made me wish that doctors had a way to note on the script that they know that the dose they are prescribing is a little high/low/weird, and that they are aware of the irregularity and want it anyway. It would prevent me from having to call on all of the funky prescriptions that doctors write - half the time I don’t know if they are getting a blow job when they write the prescription (are distracted and making mistakes) or if they really want that strange dose of X medication.
I should keep dreaming, shouldn’t I?
As for the nifedipine guy, I sent the office 2 faxes requesting them to verify the dose and also left a voice mail message. They have not returned my call or faxed me back, and it’s been 5 days. This is why I hate having to contact them in the first place.
Nifedipine is a calcium-channel blocker used for high blood pressure, heart rhythm irregularities, angina, and a few other things. The highest strength available is 90mg. I’ve never seen it dosed higher than that. Facts and Comparisons states that “titration to doses above 90mg a day is not recommended.”
The patient had been taking 90mg previously and told me the doctor was increasing his dose. I still felt like I had to call and verify it. I would have had to dispense 4 x 30mg tablets or 2 x 60mg tablets and have the patient take all the tablets at one time, once daily.
It made me wish that doctors had a way to note on the script that they know that the dose they are prescribing is a little high/low/weird, and that they are aware of the irregularity and want it anyway. It would prevent me from having to call on all of the funky prescriptions that doctors write - half the time I don’t know if they are getting a blow job when they write the prescription (are distracted and making mistakes) or if they really want that strange dose of X medication.
I should keep dreaming, shouldn’t I?
As for the nifedipine guy, I sent the office 2 faxes requesting them to verify the dose and also left a voice mail message. They have not returned my call or faxed me back, and it’s been 5 days. This is why I hate having to contact them in the first place.
It Takes a Celebrity
Actor Dennis Quaid is suing Baxter Healthcare Corp after Cedars-Sanai Medical Center in California inadvertently flushed the catheters of his twin infants with 10,000 units/mL heparin instead of the 10 units/mL concentration that they should have used. At least one of the twins was administered protamine to reverse the effects of heparin, a blood thinner.
The hospital has said the error was preventable. The two strengths come in vials that are similarly sized, shaped, and colored. Mr. Quaid isn’t suing for a huge amount of money (only $50,000) - he simply wants the company to recall the product and make sure that the vials are distinguishable from each other. He doesn’t want this to happen again. According to the article, this med error also happened recently in Indiana, killing three infants.
Look-alike, sound-alike drugs are and have always been a problem (see Jim Plagakis’s blog about when he asked a nurse to clarify whether the doctor wanted hydralazine or hydroxyzine and she just said “yes”). I know in retail pharmacy it’s easy to grab the wrong bottle - especially when the manufacturer makes all their products look the same (I’m looking at you, Merck. Who can tell the difference between a bottle of Hyzaar, Cozaar, Zocor, Proscar, or Singulair without scrutinizing it?). Thankfully we have a scan-verify system where the label is scanned and then the correct drug product. If it’s the wrong drug, the system alerts us to the mispick. Unfortunately, it’s a “voluntary” scan-verify system. Prescriptions can still be sold if they were not scan-verified.
I make an effort to scan each and every prescription I dispense. I do not think that I am invincible. And as careful and competent as I am, I know I can still make a mistake. I take every advantage that I can.
I wonder if the hospital had the same sort of system for the nurses to use? Scan a barcode on the patient’s wrist or bed, then the drug vial - if that system was in place, this error would not have been as likely to occur.
I’m actually surprised that more drug administration errors aren’t reported by the media. Most nurses are highly competent and diligent about administering the right drug to the right patient. However, mistakes happen. It is up to the drug companies, hospitals, and individuals working with medications to make sure that error risk is minimized.
I think Mr. Quaid has the right idea about suing Baxter. I guess we, as healthcare professionals, have to be thankful that a celebrity is focused on this issue: it brings a lot of media attention and awareness to the problem. Such different strengths of heparin SHOULDN’T be kept in vials that look almost exactly the same. And unless the healthcare system is doing nothing to prevent errors, we are just waiting for them to happen.
The hospital has said the error was preventable. The two strengths come in vials that are similarly sized, shaped, and colored. Mr. Quaid isn’t suing for a huge amount of money (only $50,000) - he simply wants the company to recall the product and make sure that the vials are distinguishable from each other. He doesn’t want this to happen again. According to the article, this med error also happened recently in Indiana, killing three infants.
Look-alike, sound-alike drugs are and have always been a problem (see Jim Plagakis’s blog about when he asked a nurse to clarify whether the doctor wanted hydralazine or hydroxyzine and she just said “yes”). I know in retail pharmacy it’s easy to grab the wrong bottle - especially when the manufacturer makes all their products look the same (I’m looking at you, Merck. Who can tell the difference between a bottle of Hyzaar, Cozaar, Zocor, Proscar, or Singulair without scrutinizing it?). Thankfully we have a scan-verify system where the label is scanned and then the correct drug product. If it’s the wrong drug, the system alerts us to the mispick. Unfortunately, it’s a “voluntary” scan-verify system. Prescriptions can still be sold if they were not scan-verified.
I make an effort to scan each and every prescription I dispense. I do not think that I am invincible. And as careful and competent as I am, I know I can still make a mistake. I take every advantage that I can.
I wonder if the hospital had the same sort of system for the nurses to use? Scan a barcode on the patient’s wrist or bed, then the drug vial - if that system was in place, this error would not have been as likely to occur.
I’m actually surprised that more drug administration errors aren’t reported by the media. Most nurses are highly competent and diligent about administering the right drug to the right patient. However, mistakes happen. It is up to the drug companies, hospitals, and individuals working with medications to make sure that error risk is minimized.
I think Mr. Quaid has the right idea about suing Baxter. I guess we, as healthcare professionals, have to be thankful that a celebrity is focused on this issue: it brings a lot of media attention and awareness to the problem. Such different strengths of heparin SHOULDN’T be kept in vials that look almost exactly the same. And unless the healthcare system is doing nothing to prevent errors, we are just waiting for them to happen.
Pharmacy Humor
A woman storms into a pharmacy demanding arsenic from the pharmacist… he calmly inquires as to why she needs it.
She says she want to poison her husband.
The pharmacist replies, “Lady, I understand you might be angry.. but you could go to jail for murder and I could be imprisoned as an accomplice.. I simply cannot sell you arsenic.”
She says nothing and pulls out a picture of her husband with the pharmacist’s wife in a hot and heavy position in his own bed. He calmly looks the lady in the eye and says…
“You should have told me you had a prescription”.
She says she want to poison her husband.
The pharmacist replies, “Lady, I understand you might be angry.. but you could go to jail for murder and I could be imprisoned as an accomplice.. I simply cannot sell you arsenic.”
She says nothing and pulls out a picture of her husband with the pharmacist’s wife in a hot and heavy position in his own bed. He calmly looks the lady in the eye and says…
“You should have told me you had a prescription”.
I Despise Prior Authorizations
Ah, prior authorizations.
For those of you that don’t work in a pharmacy or doctor’s office, the phrase “prior authorization” doesn’t strike fear into your hearts.
Today, I am victorious over the prior authorization system. It was a long and hard battle; my patient and I were both thoroughly frustrated. But she finally was able to pick up her prescription after 3 months of war between her doctor’s office, me, and her insurance company.
She was written a prescription for Lyrica in June. She had just become eligible for Medicare, and signed up for the AARP Medicare Part D Plan (for prescriptions) as well as for Medicare Part B (for doctors’ visits). When she brought me the prescription, I tried to run it through the AARP plan. Unfortunately, it was….
REJECTED: Prior Authorization Required.
This means that her doctor’s office needs to contact the insurance company and say that she has tried and failed other therapies for her diabetic neuropathy (amitriptyline, gabapentin). This is because Lyrica is usually a second or third-line agent; it is new and expensive. Insurance companies don’t want to have to pay for it if they don’t have to. So they make the doctor’s office jump through hoops. Standard procedure. I sent the doctor’s office a fax saying just that. I even included the insurance company’s telephone number, her insurance ID number, and the exact rejection message.
First, the doctor’s office DID the prior authorization. They even faxed me a copy of the form they sent to the insurance company. Problem was, they did a prior authorization through the WRONG INSURANCE COMPANY. They submitted the form to her old insurance, the one she had before she became eligible for Medicare and signed up for AARP. They didn’t read my fax that included an insurance company phone number and insurance ID.
So, after some phone tag and confusion, I sent them another fax. I wrote out that she was on MEDICARE PART D through AARP. I asked for a prior authorization for my patient. Again, I included a phone number and insurance ID. She is in constant burning pain from her neuropathy. Her current treatments weren’t working. I wanted to help her.
The next faxed letter I get is from Medicare, not AARP. The doctor’s office tried to get her Lyrica prior authorization through Medicare Part B. Now, Part B doesn’t cover things through the pharmacy except diabetic supplies, some nebulized medications and a few injectables/chemotherapy agents. They cover virtually no oral medications. They denied the prior authorization for Lyrica.
Obviously.
Who do they have working at this doctor’s office?
I
called. Left messages. Faxed. Gave the patient the fax to take to the office. I sent a fax spelling out EXACTLY what the office needed to do. I bolded, circled, underlined the insurance company’s phone number and her insurance ID number.
Today, all my hard work, nagging, and wasted paper has paid off. Her Lyrica went through - and her copay came back at $5. When I called to tell her, she almost cried.
For those of you that don’t work in a pharmacy or doctor’s office, the phrase “prior authorization” doesn’t strike fear into your hearts.
Today, I am victorious over the prior authorization system. It was a long and hard battle; my patient and I were both thoroughly frustrated. But she finally was able to pick up her prescription after 3 months of war between her doctor’s office, me, and her insurance company.
She was written a prescription for Lyrica in June. She had just become eligible for Medicare, and signed up for the AARP Medicare Part D Plan (for prescriptions) as well as for Medicare Part B (for doctors’ visits). When she brought me the prescription, I tried to run it through the AARP plan. Unfortunately, it was….
REJECTED: Prior Authorization Required.
This means that her doctor’s office needs to contact the insurance company and say that she has tried and failed other therapies for her diabetic neuropathy (amitriptyline, gabapentin). This is because Lyrica is usually a second or third-line agent; it is new and expensive. Insurance companies don’t want to have to pay for it if they don’t have to. So they make the doctor’s office jump through hoops. Standard procedure. I sent the doctor’s office a fax saying just that. I even included the insurance company’s telephone number, her insurance ID number, and the exact rejection message.
First, the doctor’s office DID the prior authorization. They even faxed me a copy of the form they sent to the insurance company. Problem was, they did a prior authorization through the WRONG INSURANCE COMPANY. They submitted the form to her old insurance, the one she had before she became eligible for Medicare and signed up for AARP. They didn’t read my fax that included an insurance company phone number and insurance ID.
So, after some phone tag and confusion, I sent them another fax. I wrote out that she was on MEDICARE PART D through AARP. I asked for a prior authorization for my patient. Again, I included a phone number and insurance ID. She is in constant burning pain from her neuropathy. Her current treatments weren’t working. I wanted to help her.
The next faxed letter I get is from Medicare, not AARP. The doctor’s office tried to get her Lyrica prior authorization through Medicare Part B. Now, Part B doesn’t cover things through the pharmacy except diabetic supplies, some nebulized medications and a few injectables/chemotherapy agents. They cover virtually no oral medications. They denied the prior authorization for Lyrica.
Obviously.
Who do they have working at this doctor’s office?
I
called. Left messages. Faxed. Gave the patient the fax to take to the office. I sent a fax spelling out EXACTLY what the office needed to do. I bolded, circled, underlined the insurance company’s phone number and her insurance ID number.
Today, all my hard work, nagging, and wasted paper has paid off. Her Lyrica went through - and her copay came back at $5. When I called to tell her, she almost cried.
Culichi Haiku
My g/f is bringing me lunch today to work. She is bringing me something that I crave continuously. I ordered it once, on a whim, at a divey Mexican restaurant in Mesa, AZ. I didn’t know what it was, the menu was in Spanish and none of the staff spoke English. It had a pretty name: Camarones Culichi. I knew camarones were shrimp. I didn’t yet understand the gloriousness of the “Culichi” part of the recipe.
I thought I’d write a Culichi haiku, because I’m not very good at poetry but Culichi deserves to have epic sonnets written about its deliciousness. A haiku is about the best I can do.
My love, Culichi
How decadent and gooey
Your cheesy shrimpness
I tired once to make Culichi at home, and failed miserably. My Culichi’s home is Taqueria Cajeme, and I will have no other.
I thought I’d write a Culichi haiku, because I’m not very good at poetry but Culichi deserves to have epic sonnets written about its deliciousness. A haiku is about the best I can do.
My love, Culichi
How decadent and gooey
Your cheesy shrimpness
I tired once to make Culichi at home, and failed miserably. My Culichi’s home is Taqueria Cajeme, and I will have no other.
Falling Through the Cracks
Saturday. 31 prescriptions.
I had a patient call me today, upset. She claims that we shorted her 7 lisinopril tablets. That is not very common, as pharmacists count by fives. Now, 25: that’s possible. Not likely (considering I can count to 30 in my sleep, and usually am able to pour 30 tablets out of the bottle), but possible.
But I wasn’t going to argue with her. It’s lisinopril. 7 tablets costs me a couple cents. And she was one of “those” patients.
She is confused all the time. I have to tell her the same thing every month regarding her prescriptions. She thinks that I will just get everything ready for her and that she should have “lifetime” refills on everything, even though she changes medications all the time. I tell her that I need her to tell me what she needs, but she still just shows up every month and expects everything to be ready without requesting her refills. She gets frustrated with her doctor every few months and switches doctor offices, so it’s always a challenge to figure out who to contact for refills, too.
She should be on Aricept (for Alzheimer’s Disease) but she’s not.
I feel bad, but there’s not a lot I can do for her. I have told her newest doctor’s office that I am not sure that she is taking her medications correctly, and that she may need to be evaluated for memory difficulties. The harried receptionist at the office just said, “Okay, whatever.” I doubt my message will be passed on to the doctor.
I’ve talked to this woman’s son. I told him that he should get his mom a pill box to put everything in so we can make sure she’s taking everything she should be, and at the right times. (I especially worry about her glipizide. What if she forgets to take it with food and becomes hypoglycemic?) I think he’s about as mentally “there” as she is. He’s too young for Alzheimer’s. He might be on drugs. Either way, he’s a few sandwiches short of a picnic, too.
So, I’m afraid that this lady is going to fall through the cracks. There’s not a lot else I can do.
And that’s frustrating.
I had a patient call me today, upset. She claims that we shorted her 7 lisinopril tablets. That is not very common, as pharmacists count by fives. Now, 25: that’s possible. Not likely (considering I can count to 30 in my sleep, and usually am able to pour 30 tablets out of the bottle), but possible.
But I wasn’t going to argue with her. It’s lisinopril. 7 tablets costs me a couple cents. And she was one of “those” patients.
She is confused all the time. I have to tell her the same thing every month regarding her prescriptions. She thinks that I will just get everything ready for her and that she should have “lifetime” refills on everything, even though she changes medications all the time. I tell her that I need her to tell me what she needs, but she still just shows up every month and expects everything to be ready without requesting her refills. She gets frustrated with her doctor every few months and switches doctor offices, so it’s always a challenge to figure out who to contact for refills, too.
She should be on Aricept (for Alzheimer’s Disease) but she’s not.
I feel bad, but there’s not a lot I can do for her. I have told her newest doctor’s office that I am not sure that she is taking her medications correctly, and that she may need to be evaluated for memory difficulties. The harried receptionist at the office just said, “Okay, whatever.” I doubt my message will be passed on to the doctor.
I’ve talked to this woman’s son. I told him that he should get his mom a pill box to put everything in so we can make sure she’s taking everything she should be, and at the right times. (I especially worry about her glipizide. What if she forgets to take it with food and becomes hypoglycemic?) I think he’s about as mentally “there” as she is. He’s too young for Alzheimer’s. He might be on drugs. Either way, he’s a few sandwiches short of a picnic, too.
So, I’m afraid that this lady is going to fall through the cracks. There’s not a lot else I can do.
And that’s frustrating.
Study Says Being Fat is Good
A new study published in JAMA suggests that being slightly overweight doesn’t increase a person’s risk of dying from cardiovascular disease or cancer.
Before I picked up the phone to order a pizza after reading this article, I started to think about it.
“Slightly overweight,” according to this study, is a person with a BMI from 25 to 30. For any of my (one) non-medical readers, the BMI (Body Mass Index) is a number that can be calculated based on a person’s height and weight - it is basically a measure of how “fat” you are.
A healthy BMI is considered to be between 18 and 25; a BMI value of 25 to 30 is considered overweight; and a BMI of over 30 is considered obese. I am 5′3″, and weigh 125 pounds. This calculates to be a BMI of 22.2. This is in the “healthy” range.
I wouldn’t consider myself to be fat. In fact, I think I’m pretty normal. I do consider myself to be slightly overweight, however. I wouldn’t frolic in a swimming suit or wear a tummy-baring shirt in public. I have junk in my trunk (that my g/f loves, thank you very much). To be “slightly overweight” for the sake of this study, I would need to have a BMI of 25-30. For me, that means my weight would have to be between 140 and 169 (eek!) pounds.
“Slightly overweight,” indeed!
According to the study, being a little overweight doesn’t increase risk of dying from cancer or cardiovascular disease, but does increase risk of diabetes and kidney disease. Neither one of those are a walk in the park, so I think I’ll stay in the “healthy” BMI range, thanks.
In other news, I just bought tickets to see Tori Amos in December…I am so excited, as I have loved her music since I was in junior high school. I will have to listen to her newest album “American Doll Posse” nonstop until then.
Before I picked up the phone to order a pizza after reading this article, I started to think about it.
“Slightly overweight,” according to this study, is a person with a BMI from 25 to 30. For any of my (one) non-medical readers, the BMI (Body Mass Index) is a number that can be calculated based on a person’s height and weight - it is basically a measure of how “fat” you are.
A healthy BMI is considered to be between 18 and 25; a BMI value of 25 to 30 is considered overweight; and a BMI of over 30 is considered obese. I am 5′3″, and weigh 125 pounds. This calculates to be a BMI of 22.2. This is in the “healthy” range.
I wouldn’t consider myself to be fat. In fact, I think I’m pretty normal. I do consider myself to be slightly overweight, however. I wouldn’t frolic in a swimming suit or wear a tummy-baring shirt in public. I have junk in my trunk (that my g/f loves, thank you very much). To be “slightly overweight” for the sake of this study, I would need to have a BMI of 25-30. For me, that means my weight would have to be between 140 and 169 (eek!) pounds.
“Slightly overweight,” indeed!
According to the study, being a little overweight doesn’t increase risk of dying from cancer or cardiovascular disease, but does increase risk of diabetes and kidney disease. Neither one of those are a walk in the park, so I think I’ll stay in the “healthy” BMI range, thanks.
In other news, I just bought tickets to see Tori Amos in December…I am so excited, as I have loved her music since I was in junior high school. I will have to listen to her newest album “American Doll Posse” nonstop until then.
One of Those Days
A patient of mine was just discharged from a nursing home. Her daughter asked that I contact her doctor for new prescriptions of what she had been taking now that she is home. One of the prescriptions she was on in the nursing home was lisinopril 20mg. Prior to the nursing home, she had been taking Altace 10mg.
I requested new prescriptions for her latest medications - thus, lisinopril instead of Altace. The nurse called me back today, annoyed.
Nurse: “Doesn’t she have refills on her old prescription for Altace on file?”
pharmacy girl: “Why yes, she does. But since she has been taking lisinopril in the nursing home and her daughter said it had been working just fine, I thought we would save her insurance company more than $50 a month and use the lisinopril instead of Altace.”
Nurse: “Well, the doctor wants Altace.”
pharmacy girl: “Are you aware that the lisinopril would cost her insurance about $5 and the Altace costs her insurance about $65? They are in the same family of medications: they are both ACE inhibitors, and work the exact same way. Altace is the only ACE inhibitor that is still available as the brand name only.”
Nurse: “Fill the Altace.”
pharmacy girl: “Fine.”
Click
Sometimes I don’t know why I even try.
Another lovely incident today: We sent a new prescription request for amoxicillin for a patient. The prescription was supposed to be called in yesterday, but it wasn’t. So I sent a nice little fax to the office. The fax is a fill-in-the-blank sort of operation, not too tricky.
For example:
Patient ________________________
DOB __________________________
Drug: Amoxicillin ______________mg
Sig ____________________________
Quantity _______________________
Signature ______________________
They filled it in and faxed it back right away, bless their hearts. They even managed to include a quantity. The nurse practitioner or whatever signed her name twice, though. Once in the place for “sig” and once in the place for “signature.”
Honest mistake, we thought. We faxed it back and wrote “Need sig, please” in magic marker on top of the fax. The office faxed it right back, only having circled her signature on the line that reads “sig.”
For a lay person, this might be confusing. But I have to assume that a nurse practioner has been a nurse before the practioner part.
And should know her medical shorthand.
“sig” is an abbreviation for “signa”, which in Latin means “write on label.”
I think I learned that one my very first day working in a pharmacy.
I requested new prescriptions for her latest medications - thus, lisinopril instead of Altace. The nurse called me back today, annoyed.
Nurse: “Doesn’t she have refills on her old prescription for Altace on file?”
pharmacy girl: “Why yes, she does. But since she has been taking lisinopril in the nursing home and her daughter said it had been working just fine, I thought we would save her insurance company more than $50 a month and use the lisinopril instead of Altace.”
Nurse: “Well, the doctor wants Altace.”
pharmacy girl: “Are you aware that the lisinopril would cost her insurance about $5 and the Altace costs her insurance about $65? They are in the same family of medications: they are both ACE inhibitors, and work the exact same way. Altace is the only ACE inhibitor that is still available as the brand name only.”
Nurse: “Fill the Altace.”
pharmacy girl: “Fine.”
Click
Sometimes I don’t know why I even try.
Another lovely incident today: We sent a new prescription request for amoxicillin for a patient. The prescription was supposed to be called in yesterday, but it wasn’t. So I sent a nice little fax to the office. The fax is a fill-in-the-blank sort of operation, not too tricky.
For example:
Patient ________________________
DOB __________________________
Drug: Amoxicillin ______________mg
Sig ____________________________
Quantity _______________________
Signature ______________________
They filled it in and faxed it back right away, bless their hearts. They even managed to include a quantity. The nurse practitioner or whatever signed her name twice, though. Once in the place for “sig” and once in the place for “signature.”
Honest mistake, we thought. We faxed it back and wrote “Need sig, please” in magic marker on top of the fax. The office faxed it right back, only having circled her signature on the line that reads “sig.”
For a lay person, this might be confusing. But I have to assume that a nurse practioner has been a nurse before the practioner part.
And should know her medical shorthand.
“sig” is an abbreviation for “signa”, which in Latin means “write on label.”
I think I learned that one my very first day working in a pharmacy.
The No Insurance "Conundrum"
A woman brought in a script tonight. After 5. She was a new patient, so I gathered all of the pertinent information.
Name
DOB
Address
Phone
Insurance (none)
Drug Allergies
etc
Lack of insurance is always the first red flag when you’re questioning a prescription. Why do people not ever get prescriptions for anything but pain medications and benzodiazepines when they don’t have insurance? It’s one of life’s great mysteries (not).
Red flag #2: Her DOB was written on the top right corner of the Rx in a different pen than the Rx. This means she tried to take it to another pharmacy, who gathered all of her information and for some reason gave the prescription back to her.
Red Flag #3: The prescription was obviously for a controlled substance. Which controlled substance, you ask? “Percacet.” Are there really any doctors out there that misspell Percocet?
Red Flag #4: The quantity was originally written for #30. Someone changed the 3 to a 9, and wrote the word “ninty” underneath the altered quantity. The word “ninty” appears to be written in a different pen than the prescription. Either this doctor is a really bad speller, or someone just tried to alter a prescription.
Red Flag #5: The script was written 3 days ago, but was brought into me after 5pm. And she needs it NOW.
Red Flag #6: Patient is trashy and pushy. People that have legitimate prescriptions are rarely pushy. They understand if I have a question on the prescription and need to contact the doctor.
However, the anti-red flag was when she asked me to page the doctor on call. If it was the doctor that wrote the Rx she wanted me to verify it, if another prescriber was on call she wanted me to call tomorrow. I can’t really figure out what this means. Unless the doctor’s kids are kidnapped by this lady and she’s instructed to verify any and all forged prescriptions that pharmacies call on?
I called and the doctor that wrote it was NOT on call, so I photocopied the Rx and sent a fax to the office to verify it in the morning.
I will be curious to see what happens.
If it is legitimate, I’ll feel like a jackass.
Name
DOB
Address
Phone
Insurance (none)
Drug Allergies
etc
Lack of insurance is always the first red flag when you’re questioning a prescription. Why do people not ever get prescriptions for anything but pain medications and benzodiazepines when they don’t have insurance? It’s one of life’s great mysteries (not).
Red flag #2: Her DOB was written on the top right corner of the Rx in a different pen than the Rx. This means she tried to take it to another pharmacy, who gathered all of her information and for some reason gave the prescription back to her.
Red Flag #3: The prescription was obviously for a controlled substance. Which controlled substance, you ask? “Percacet.” Are there really any doctors out there that misspell Percocet?
Red Flag #4: The quantity was originally written for #30. Someone changed the 3 to a 9, and wrote the word “ninty” underneath the altered quantity. The word “ninty” appears to be written in a different pen than the prescription. Either this doctor is a really bad speller, or someone just tried to alter a prescription.
Red Flag #5: The script was written 3 days ago, but was brought into me after 5pm. And she needs it NOW.
Red Flag #6: Patient is trashy and pushy. People that have legitimate prescriptions are rarely pushy. They understand if I have a question on the prescription and need to contact the doctor.
However, the anti-red flag was when she asked me to page the doctor on call. If it was the doctor that wrote the Rx she wanted me to verify it, if another prescriber was on call she wanted me to call tomorrow. I can’t really figure out what this means. Unless the doctor’s kids are kidnapped by this lady and she’s instructed to verify any and all forged prescriptions that pharmacies call on?
I called and the doctor that wrote it was NOT on call, so I photocopied the Rx and sent a fax to the office to verify it in the morning.
I will be curious to see what happens.
If it is legitimate, I’ll feel like a jackass.
Sick At Work, Part II
I am still sick. At work, again. They didn’t send me anyone yesterday from scheduling. My staff pharmacist never called me back. And I’m here, yet again.
I was a good pharmacygirl last night, too.
I went home when I got off at 8pm, and watched a little bit of a movie, and went to be early. After I drank 3 or so glasses of scotch. Hey, whiskey is a good cough suppressant, right?
So, this morning I got to work about 10 minutes early. I am behind the counter, starting up the computers, unlocking the gates, checking for faxes, etc. The lights are off. This guy can see me and starts shouting at me.
“It burns when my wife pees!”
I’m not even open. But I’m feeling generous (maybe because I’m sick?), so I come out and show him the Azo Standard, tell him to take his wife to an urgent care when he describes her symptoms.
He’s doubtful. He wants to wait until Monday to take her to the doctor. She’s not just having frequency, burning, and stinging. She’s also having cold sweats, a fever, and back and body aches. I assure him that it’s best to take her to an urgent care clinic today for antibiotics.
He probably won’t. But I did the best I could.
I should follow my own advice and go the doctor. I would if I didn’t have to be here.
I was a good pharmacygirl last night, too.
I went home when I got off at 8pm, and watched a little bit of a movie, and went to be early. After I drank 3 or so glasses of scotch. Hey, whiskey is a good cough suppressant, right?
So, this morning I got to work about 10 minutes early. I am behind the counter, starting up the computers, unlocking the gates, checking for faxes, etc. The lights are off. This guy can see me and starts shouting at me.
“It burns when my wife pees!”
I’m not even open. But I’m feeling generous (maybe because I’m sick?), so I come out and show him the Azo Standard, tell him to take his wife to an urgent care when he describes her symptoms.
He’s doubtful. He wants to wait until Monday to take her to the doctor. She’s not just having frequency, burning, and stinging. She’s also having cold sweats, a fever, and back and body aches. I assure him that it’s best to take her to an urgent care clinic today for antibiotics.
He probably won’t. But I did the best I could.
I should follow my own advice and go the doctor. I would if I didn’t have to be here.
Sick at Work
I’m sick today. At work. My nose is congested, I have a massive headache, and I feel phlegmy. I have taken 800mg of Ibuprofen. I have drank lots of tea. I still feel like crap. I called corporate to see if they could send me a floater.
No luck.
I knew I couldn’t call from bed this morning, there wouldn’t be anyone to open the pharmacy.
Scheduling said they MIGHT be able to send someone after 3. That means that I either get to work 7 hours sick or 12 hours sick. ‘Cause they probably won’t be able to send anyone at all.
My company doesn’t hire enough pharmacists. They expect all the other pharmacists to cover sick/vacation time for OT. This doesn’t make sense to me. You think it would be cheaper to hire one or two more full-time floaters than to pay pharmacists from Dependable if needed (at $100/hour) or pay overtime pharmacists who don’t want to work overtime anyway. I guess it’s not cheaper than forcing sick pharmacists to stay at work because there’s no one to cover their shift.
No luck.
I knew I couldn’t call from bed this morning, there wouldn’t be anyone to open the pharmacy.
Scheduling said they MIGHT be able to send someone after 3. That means that I either get to work 7 hours sick or 12 hours sick. ‘Cause they probably won’t be able to send anyone at all.
My company doesn’t hire enough pharmacists. They expect all the other pharmacists to cover sick/vacation time for OT. This doesn’t make sense to me. You think it would be cheaper to hire one or two more full-time floaters than to pay pharmacists from Dependable if needed (at $100/hour) or pay overtime pharmacists who don’t want to work overtime anyway. I guess it’s not cheaper than forcing sick pharmacists to stay at work because there’s no one to cover their shift.
Oh, How I Miss SOAP Notes
My friend, another pharmacist, called me today to ask a favor. She was wondering if the medications a patient is taking are contributing to some symptoms the patient is having: hearing loss, vision changes, and unexplained weight loss. My friend didn’t have time to do a thorough review of the medications, so she asked me to do it (because I have lots of time).
She started reading the list of medications to me.
Amitriptyline
Furosemide
Klor-Con
Fosamax
Atarax
Levothyroxine
Oxycodone
Vitamin D
Pangestyme
Warfarin
Lidocaine Viscous
Aldara
Zyrtec
Folic Acid
B12
Centrum
Senokot
Prilosec
Claritin
Off the top of my head, the only one I could think of that causes ototoxicity is furosemide. The dose wasn’t high, either (40mg). Without seeing labs, I couldn’t assess the patient’s renal function. But it still seemed unlikely that the loop diuretic was doing it. Other hearing problems can be caused by accumulation of salicylates. This is always a possibility I consider because patients often don’t read labels on OTC medications. She could be taking Exedrin for headaches, using Bengay for muscle pain, taking Pepto-Bismol for diarrhea, and using Alka-Seltzer for a hangover. I don’t know, but that’s a lot of salicylates. It’s always good to ask, especially if the hearing problem is ringing in the ears.
As for changes in vision, I looked at the medication list and thought: anticholinergic overload? Her prescription medications include a TCA and 3 antihistamines (although the hydroxyzine HCl has the greatest anticholinergic potential of the three). If she was taking any OTC antihistamines (Benadryl, Unisom, Tylenol PM, Bonine, Dramamine, NyQuil) on top of her prescriptions, she likely WAS overloaded with anticholinergics. Vision problems are common with excess anticholinergic use. She was also obviously constipated (using Senokot), which is a side effect of anticholinergics.
Or the patient just may be showing some signs of age. Hearing loss and vision changes tend to happen when you get old.
The unexplained weight loss and inability to gain weight are the most troublesome of her symptoms. Any time I hear “unexplained weight loss,” I have to think about cancer. Assuming that her doctor has done everything in his/her power to rule that out, other reasons for weight loss must be considered.
The patient is on levothyroxine. Again, without labs, I don’t know the patient’s TSH. Has the doctor ordered a free T4? Sometimes TSH isn’t a perfect indicator of levothyroxine levels; her pituitary gland may not be functioning properly (not reducing TSH production in response to elevated thyroid hormone function).
Why is she on Pangestyme? As it’s just a capsule full of digestive enzymes, I don’t see much harm in it. But why is she taking it? Is there an anatomical or gastrointestinal reason for her inability to gain weight?
There are a million different potential causes of unexplained weight loss. With the information I have about the patient today, this is about the best I can do.
To help her gain weight, I told the other pharmacist to talk to her doctor about possibly switching her hydroxyzine to cyproheptadine. It is an antihistaminergic/antiserotonergic agent that has been shown to promote weight gain in patients with AIDS-associated wasting, cachexia, and cystic fibrosis. It should also help with allergy symptoms. If overload of anticholinergics is indeed a causative factor for her vision problems, this would need to be evaluated. Like hydroxyzine, cyproheptadine has moderate anticholinergic activity.
I communicated my thoughts on her medications and symptoms with my friend, the other pharmacist. It’s up to her now to talk to the patient and doctor.
I have to thank my pharmacy professors for taking the time in case studies to do this sort of exercise with me. In school, our case studies were complete packages of information (labs, history, etc). In the real world, I never get a complete profile. But I do the best I can with the limited information I have available to me. I feel thankful that I have the opportunity, even if only occasionally, to use my pharmaceutical knowledge. It reminds me of why I went to pharmacy school.
On days when I can make some recommendations and have the potential to make a difference in a patient’s health, I love my job.
She started reading the list of medications to me.
Amitriptyline
Furosemide
Klor-Con
Fosamax
Atarax
Levothyroxine
Oxycodone
Vitamin D
Pangestyme
Warfarin
Lidocaine Viscous
Aldara
Zyrtec
Folic Acid
B12
Centrum
Senokot
Prilosec
Claritin
Off the top of my head, the only one I could think of that causes ototoxicity is furosemide. The dose wasn’t high, either (40mg). Without seeing labs, I couldn’t assess the patient’s renal function. But it still seemed unlikely that the loop diuretic was doing it. Other hearing problems can be caused by accumulation of salicylates. This is always a possibility I consider because patients often don’t read labels on OTC medications. She could be taking Exedrin for headaches, using Bengay for muscle pain, taking Pepto-Bismol for diarrhea, and using Alka-Seltzer for a hangover. I don’t know, but that’s a lot of salicylates. It’s always good to ask, especially if the hearing problem is ringing in the ears.
As for changes in vision, I looked at the medication list and thought: anticholinergic overload? Her prescription medications include a TCA and 3 antihistamines (although the hydroxyzine HCl has the greatest anticholinergic potential of the three). If she was taking any OTC antihistamines (Benadryl, Unisom, Tylenol PM, Bonine, Dramamine, NyQuil) on top of her prescriptions, she likely WAS overloaded with anticholinergics. Vision problems are common with excess anticholinergic use. She was also obviously constipated (using Senokot), which is a side effect of anticholinergics.
Or the patient just may be showing some signs of age. Hearing loss and vision changes tend to happen when you get old.
The unexplained weight loss and inability to gain weight are the most troublesome of her symptoms. Any time I hear “unexplained weight loss,” I have to think about cancer. Assuming that her doctor has done everything in his/her power to rule that out, other reasons for weight loss must be considered.
The patient is on levothyroxine. Again, without labs, I don’t know the patient’s TSH. Has the doctor ordered a free T4? Sometimes TSH isn’t a perfect indicator of levothyroxine levels; her pituitary gland may not be functioning properly (not reducing TSH production in response to elevated thyroid hormone function).
Why is she on Pangestyme? As it’s just a capsule full of digestive enzymes, I don’t see much harm in it. But why is she taking it? Is there an anatomical or gastrointestinal reason for her inability to gain weight?
There are a million different potential causes of unexplained weight loss. With the information I have about the patient today, this is about the best I can do.
To help her gain weight, I told the other pharmacist to talk to her doctor about possibly switching her hydroxyzine to cyproheptadine. It is an antihistaminergic/antiserotonergic agent that has been shown to promote weight gain in patients with AIDS-associated wasting, cachexia, and cystic fibrosis. It should also help with allergy symptoms. If overload of anticholinergics is indeed a causative factor for her vision problems, this would need to be evaluated. Like hydroxyzine, cyproheptadine has moderate anticholinergic activity.
I communicated my thoughts on her medications and symptoms with my friend, the other pharmacist. It’s up to her now to talk to the patient and doctor.
I have to thank my pharmacy professors for taking the time in case studies to do this sort of exercise with me. In school, our case studies were complete packages of information (labs, history, etc). In the real world, I never get a complete profile. But I do the best I can with the limited information I have available to me. I feel thankful that I have the opportunity, even if only occasionally, to use my pharmaceutical knowledge. It reminds me of why I went to pharmacy school.
On days when I can make some recommendations and have the potential to make a difference in a patient’s health, I love my job.
Pharmacist Pet Peeve
I recently had a patient try to pick up a prescription while on a cell phone. This is a pet peeve of mine (and probably every other pharmacist in America). I have a sign prominently posted on the counter that says “Please finish your cell phone conversation before you approach the pharmacy window.”
Anyway, this guy approached the window, chatting away on his cell phone. I ignored him and continued counting pills for refills. He yelled at me, “Can I get some service here?!” I told him that I would be happy to help him when he finished his conversation.
Some people just don’t get it.
And weren’t taught any manners by their mommas.
I always use HIPAA as an excuse to why I won’t help people when they are on their cell phone. I don’t think my corpo-bosses would like it if I started telling customers that I won’t help them while they are talking on their phones because it is ridiculously rude. I do tell customers that, sometimes, though. A girl can only take so much.
This guy on the cell phone freaked out. He demanded that I help him. I said no, because of the HIPAA law, I needed him to hang up his phone before I rang up his prescription. He wanted to see A COPY OF THE LAW and where in the law it alluded to cell phone use, and what law I was talking about. Can you believe this? Wouldn’t you have just hung up?
He wanted me to back down. I don’t back down. If someone argues with me, there is no freaking way that they will win. Not on early refills for hydrocodone, not on spotting them a few pills when their prescription was denied by the doctor, not anything.
I told him that it was the Health Insurance Portability and Accountability Act of 1996, that it went into effect in 2001, and that it stated I had to do everything in my power to protect the privacy of his health information. That means, to me, that I make sure the person on the other end of his call doesn’t know he is picking up a refill for Viagra, or getting a new prescription for Valtrex. Or whatever.
This isn’t McDonalds, people. I don’t even talk on my cell phone when I’m going through a fast-food drive-thru, or when I’m paying for gasoline, or anything. It’s rude. I wait until my conversation is finished, or I tell the person I will call them right back.
But I’m not even picking up prescription drugs.
Customers: I am dispensing potentially lethal medications to you. I need you to give me your full attention when you pick up a prescription. Sure, it may be a refill you’ve had a thousand times. But do you think that there may be more than one Mr. John Smith in our city? What if we accidentally gave you the other John Smith’s prescriptions? When I show you the tablets (we do show-and-tell dispensing), please look at them. Do they look the same as the ones you got last month? And as far as new prescriptions go, I need to talk to you about them. It’s required by law, and, beyond that, it’s important. I need to tell you about potentially life threatening allergic reactions (angioedema with ACEIs), dietary restrictions (warfarin), acetaminophen limits (Vicodin, Norco, Lortab, Percocet, etc) or other important information. I do not have your full attention when you are on your cell phone.
So, the customer with the attitude hung up his phone in a huff and told me he would be getting his refill elsewhere next month.
Good for ya.
Every pharmacy I have worked at has the same policy regarding cell phones.
Good luck, jerk.
Anyway, this guy approached the window, chatting away on his cell phone. I ignored him and continued counting pills for refills. He yelled at me, “Can I get some service here?!” I told him that I would be happy to help him when he finished his conversation.
Some people just don’t get it.
And weren’t taught any manners by their mommas.
I always use HIPAA as an excuse to why I won’t help people when they are on their cell phone. I don’t think my corpo-bosses would like it if I started telling customers that I won’t help them while they are talking on their phones because it is ridiculously rude. I do tell customers that, sometimes, though. A girl can only take so much.
This guy on the cell phone freaked out. He demanded that I help him. I said no, because of the HIPAA law, I needed him to hang up his phone before I rang up his prescription. He wanted to see A COPY OF THE LAW and where in the law it alluded to cell phone use, and what law I was talking about. Can you believe this? Wouldn’t you have just hung up?
He wanted me to back down. I don’t back down. If someone argues with me, there is no freaking way that they will win. Not on early refills for hydrocodone, not on spotting them a few pills when their prescription was denied by the doctor, not anything.
I told him that it was the Health Insurance Portability and Accountability Act of 1996, that it went into effect in 2001, and that it stated I had to do everything in my power to protect the privacy of his health information. That means, to me, that I make sure the person on the other end of his call doesn’t know he is picking up a refill for Viagra, or getting a new prescription for Valtrex. Or whatever.
This isn’t McDonalds, people. I don’t even talk on my cell phone when I’m going through a fast-food drive-thru, or when I’m paying for gasoline, or anything. It’s rude. I wait until my conversation is finished, or I tell the person I will call them right back.
But I’m not even picking up prescription drugs.
Customers: I am dispensing potentially lethal medications to you. I need you to give me your full attention when you pick up a prescription. Sure, it may be a refill you’ve had a thousand times. But do you think that there may be more than one Mr. John Smith in our city? What if we accidentally gave you the other John Smith’s prescriptions? When I show you the tablets (we do show-and-tell dispensing), please look at them. Do they look the same as the ones you got last month? And as far as new prescriptions go, I need to talk to you about them. It’s required by law, and, beyond that, it’s important. I need to tell you about potentially life threatening allergic reactions (angioedema with ACEIs), dietary restrictions (warfarin), acetaminophen limits (Vicodin, Norco, Lortab, Percocet, etc) or other important information. I do not have your full attention when you are on your cell phone.
So, the customer with the attitude hung up his phone in a huff and told me he would be getting his refill elsewhere next month.
Good for ya.
Every pharmacy I have worked at has the same policy regarding cell phones.
Good luck, jerk.
I Hope I Don't See Her Next Tuesday
I was talking to my technician today about the meanest patients we have ever had. The worst that I can remember was when I worked as a pharmacy intern. I wasn’t new to pharmacy by the time I made it to intern status - I started as a clerk when I was 15, and had worked as a technician for a couple years before I got into pharmacy school. But this experience was enough to make me rethink my career choice.
A woman came into the pharmacy on a blustery winter afternoon and requested a refill on her son’s Pulmicort Respules. I informed her that the prescription was out of refills but I would be happy to contact her doctor for additional refills. She proceeded to turn bright red. I could sense the tirade building up inside her. I backed up.
And then she did it.
She called me the C-word. As in c u next tuesday. Not just the C-word. “You LITTLE C-word.”
O M G
I freaking hate the C-word. I don’t know why. I was so shocked about the use of the C-word from this apparently Mormon Mommy, that it didn’t register at first.
Thankfully, my pharmacy manager came out from behind the counter, grabbed the lady’s arm, and dragged her out of the store. Not a word was spoken between them.
I personally cannot imagine calling a 20-year old intern such a horrible name when the lack of refills was in no way her fault. I’m sure when we dispensed it the month before, there was a big fat ZERO in the spot where the label indicates number of refills remaining.
The lady called back later and tried to apologize to me. I did not accept it. Cause I hold a grudge like that.
C-word use cannot be forgiven.
A woman came into the pharmacy on a blustery winter afternoon and requested a refill on her son’s Pulmicort Respules. I informed her that the prescription was out of refills but I would be happy to contact her doctor for additional refills. She proceeded to turn bright red. I could sense the tirade building up inside her. I backed up.
And then she did it.
She called me the C-word. As in c u next tuesday. Not just the C-word. “You LITTLE C-word.”
O M G
I freaking hate the C-word. I don’t know why. I was so shocked about the use of the C-word from this apparently Mormon Mommy, that it didn’t register at first.
Thankfully, my pharmacy manager came out from behind the counter, grabbed the lady’s arm, and dragged her out of the store. Not a word was spoken between them.
I personally cannot imagine calling a 20-year old intern such a horrible name when the lack of refills was in no way her fault. I’m sure when we dispensed it the month before, there was a big fat ZERO in the spot where the label indicates number of refills remaining.
The lady called back later and tried to apologize to me. I did not accept it. Cause I hold a grudge like that.
C-word use cannot be forgiven.
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