Talking About Waste (Again)

"The Drug Enforcement Administration says people turned in more than 188.5 tons of unwanted or expired prescription medications in the agency’s third National Prescription Drug Take-Back Day on Oct. 29."

This kind of bothers me. What a waste! There are a lot people around the world who have little or no access to quality pharmaceuticals and you wonder how much of this stuff might have helped someone.

Sure, there are a lot of reasons why prescriptions are wasted or not completed. A patient starts a new medication and can't tolerate it; they start an antibiotic and it has to be changed later because of lab results; a patient is prescribed 30 tablets of pain medication for a minor procedure and needs only one or two. But there are a lot of situations where I feel like I'm looking waste right in the face, like:

-- a person starting a brand new medication, and is prescribed a 90-day supply right off the bat...

-- a tiny little baby prescribed voluminous quantities of a topical product (the jar of ointment is almost bigger than the kid)...

-- OTC products that are prescribed in multiple packages at a time (this is especially unsettling when the recipient of the prescription seems completely clueless on what they're supposed to do with it)

-- a gigantic bottle of some horrific-tasting liquid medication, for a kid who I can tell you right now ain't having none of it after that first dose....

-- boxes and boxes and boxes of expensive nebulized medications, inhalers, aerochambers going out the door ---especially for anyone who can't look up from their cell phone long enough to even answer me, when I ask if they know how to use the stuff.

When someone complains that they can't get more than a 30-day supply with their insurance, or that they can't get an 'early' refill, I'm kind of sympathetic but I understand what the point of that is --- it's to try and keep the waste to a minimum. I don't feel like a lot of people have the respect for prescription medication that it warrants. And sorry, but I see NO reason why any prescription should be 'lost.' Things happen, but I really grit my teeth when someone airily tells me they misplaced their $200 inhaler like it was a bag of M & Ms.

And of course, don't even try to figure out why you fill all those prescriptions that never get picked up----

That's my little rant for today.

What Up, Walgreens?

Why has this happened to me more than once? A patient calls and says they need to transfer their prescription from me TO a Walgreens. They have contacted the Walgreens, as they should, but the Walgreens tells them I have to call THEM (Walgreens) to give them the prescriptions. (For the non-pharmacy folk, this is not the way it's done. The pharmacy that will be filling the prescriptions calls the other pharmacy for the information). I hate to put the patient in the middle of this, but they are adamant that the Walgreens refuses to call me, as they are supposed to. Sure I could call them and happily give away my business, but it's the principle of the thing.

When this happened the other day, I held my ground and told the customer to call the Walgreens back. They know better, I told him. I know it wasn't the patient's fault, but why does this keep happening?

E-Prescribing can be E-vil

The prevalence of electronic prescribing and faxing of prescription orders has generally made things more convenient for customers and probably decreases wait time as well, but as all pharmacists know it is a mixed blessing. The attempts to plug in a 'personalized' prescription into a computer program can lead to some pretty interesting prescriptions, like "Apply 9999 applications topically ", or my personal favorite from this week, a prescription for Plan B, quantity 60 tablets, with 11 refills. Customer then arrives and is totally taken aback that it's not 'ready yet,' either because we have received no prescription or the one we did receive is completely nonsensical. Heaven help me, there are days when I really miss the old fashioned exercise of someone visiting their doctor, being handed a prescription, and then being responsible for choosing a pharmacy and bringing that prescription TO IT. Y'know, kind of like having a little responsibility all their very own self.

So now we not only have the responsibility to fill your prescription correctly, with all the usual challenges associated with that, but we seem to be charged with hunting down that prescription and obtaining it for you as well. If we didn't get it, then it's up to us to seek it out, right? Clear the decks, folks, I'm about to spend 20 minutes on the phone trying to track down one prescription from Giganto Orthopedic Surgery Group and by the way, it's lunch time and please leave a message.

The problem is even worse when, like me, you work in a medical building/clinic when we seem to be held accountable for any prescription written by any doctor in the building whether the patient fills it with us or not. It doesn't matter how many times you tell me "THEY TOLD ME THEY SENT YOU MY PRESCRIPTION" --- I can't fill a prescription that I don't freakkin HAVE. Really, I wouldn't lie to you. We actually had a customer claim her doctor had faxed us
her prescription, watched us tear apart the pharmacy looking for it, acted like a complete bitch and finally rolled her eyes and said, "Well, I've got it out in my car -- do you want me to go get it?" I said, yeah that would be swell. Then I went in back and looked for a sharp object to do myself in with.

And then there are the people who want to 'read' you their prescription over the phone because they didn't want to be bothered stopping at the pharmacy, nor do they want to wait while it's being filled. Sigh.

When it comes to electronic prescribing I know there's no going back, but some days I feel there are just as many errors, just as many problems to clarify, AND the added bonus of leaving people with the notion that everything's going to be done for them. It's the fast-food, drive-through-ability of everything. We'll find the prescription, we'll figure out what your insurance is, we'll wrap it up and tie a bow on it and do it in 10 minutes. Dang, it's frustrating.

What Can You Say.

From the New York Times, Oct 14th:

A 13-month-old boy died after he apparently swallowed pills from a bottle of prescription drugs that his parents had given him to play with as a rattle, the authorities said on Friday.

The boy, Edwin Perocier Jr., was put in his crib in his parents’ apartment, on Southern Boulevard near 156th Street, in the Bronx, about 9 p.m. on Thursday, a law enforcement official said.

One or both of the parents, Edwin Perocier, 44, and Zoraiva Santiago, 22, gave the child a bottle of Suboxone that belonged to Mr. Perocier, the official said. The medication is used to treat people who are addicted to illegal or prescription opioid drugs.

A short time later, Ms. Santiago went to check on Edwin and found the bottle open. Some of the pills had fallen out and one of them was wet. Ms. Santiago took the pills away, gave the child a bottle of milk, and went to sleep, a law enforcement official said.

At 7:45 a.m. Friday, the parents awoke and found Edwin unconscious in his crib. They called 911, and Edwin was taken to Lincoln Medical and Mental Health Center, where he was pronounced dead on arrival.

No charges had been filed as of Friday night, a police official said.

Ms. Santiago’s 4-year-old daughter was taken into custody by the Administration for Children’s Services, according to a law enforcement official.

Adderall and the Gift of Function

Back in March of this year I wrote a post called "The Supply Chain, Adderall, and Flying by the Seat of your Pants" and it has been very interesting and informative for me that I am still getting comments on it 7 months later. It looks like the supply of generic Adderall and Adderall XR are going to continue to be spotty for at least the rest of 2011.

I continue to find it worrisome that we fill so many prescriptions for ADD meds for children and adolescents, however I do recognize that it's a godsend for many of them in conjunction with other forms of therapy. No argument there. Is there lots of inappropriate use? --- Probably. But again, the folks who really benefit from it are penalized by the abusers, just like with other controlled substances.

I have gained a lot of sympathy from the comments by adult patients. I appreciate the fact that they are not blaming me for the shortage situation -- I personally try to help people figure out alternatives, make some phone calls for them, and I certainly don't look down on them for just trying to fill their prescription. However, as I said in the post, frustration sets in when a few people's sense of entitlement overshadows the reality that we're all 'in the same boat' here.

I especially sympathize with people who unquestionably need the medication to function --- to hold down a job, to go to school, to interact socially. Let's face it, without these basics it's a very tough road. These needs go to the root of a successful and happy life, and a mental disorder that interferes with them certainly is terribly burdensome. Then, when someone finds a medication that actually helps and allows them to function, I can see how being told that medication is unavailable indefinitely can cause utter panic.

One commenter said their doctor will no longer prescribe Adderall tablets --- maybe this is because his office got tired of phone calls from patients and pharmacies saying they couldn't get it. If I get a phone call asking me if we have it in stock, I have no problem giving a yes or no answer. Unfortunately though, I can't "reserve" it for anyone. If I hear of another pharmacy that has stock, I'll pass that on. I'll check the other pharmacies in my organization. I would hope most pharmacists would try to offer some assistance, as long as people realize we may not be able to drop everything and deal with it right away. It's another part of the job that we didn't ask for -- so if your pharmacist finds your medication somewhere else for you...... show 'em some luv.

Dear Diary

I wrote a blog post back in July about my frustration with the constant "how long is it going to take to fill my prescriptions" battle that we fight every day, and I'm afraid I have to write another one today, if only to give myself some self-therapy. Maybe I'm just late to the party, but this is something I really think is going to cause me a meltdown one of these days. Before this I guess I just took it for granted that being speedy was supposed to go with the job. Forget about counseling, profile review, MTM or whatever you want to call it now -- it's ALL about the customer convenience, and that means be FAST. Nothing else matters.

I made a minor error this week while trying to check a bucketload of prescriptions for someone who kept asking how much longer it would be. Nothing really significant, but it required a phone call and it made me very angry because I knew exactly why it happened. I was trying to hurry. I tried to glance at it too fast -- there was no other reason. I was so, so mad at myself for allowing this.

Another customer brought 3 prescriptions and actually got snotty when we told her it would be about 15 minutes. Yep, and she even asked if we could 'call them to another pharmacy' (we did not). You see, the idea that she would have to sit and wait, even if it's just 15 minutes, is intolerable. But if we 'call' the prescriptions elsewhere then they will magically be ready when she gets there, and so technically she doesn't have to actually 'wait.' Just stop for a minute and imagine this scenario in any other business on the planet. W...T...F.

And then, a customer brings in a prescription... there's a couple of people ahead of him. Probably about 10 minutes passes, and we discover the prescription is not covered, and needs a prior authorization. I explain the situation to him, and since he just came from the doctor's office I offer to call them and see if they could prescribe something else that is covered. And his question to me is, "Well, how long will THAT take?"

So, I'm trying to HELP you, and all you can ask is how long it will take. Well, damn it , forget it then. I'm going to send you away with no medication and tell you the doctor needs to do the Prior Auth. Buh-bye. I will then fax the form to the doctor's office where it will linger in the Prior Authorization Black Hole for a few days. You will call several times and ask me if your prescription is ready. I'll say no, I haven't heard that it's been authorized, and why don't you call your doctor. Then I'll get a call from the doctor's office telling me they never got any fax. I'll send it again (when I have 2 minutes to spare). Your doctor will be out for the day and the nurse will call me back when she doesn't have your prescription insurance information and doesn't know how or what to send them. Days will pass, probably more phone calls back and forth until someone takes the bull by the horns and either gets word back on the prior auth., or changes the prescription. Meanwhile, you will recount this to everyone you know and bitch about how screwed up the health care system is.

So, looking back, it probably wasn't such a bad idea for you to wait another few minutes for me to make that phone call, huh?

Help me. I'm afraid I may hurt someone.

Sorry for the Sour Tone Here, but I'm Tired

.....and so in the spirit of Jimmy Fallon's "thank-you" notes, here are a few of mine:

Thank you...... Walgreens, for handing your pharmacists the responsibility for 'walk-in' flu shots. I know it's a big money maker and all, but when I call them for a copy on a waiting customer's prescription and get told to call back later because the pharmacist is 'giving flu shots right now,' it's a little frustrating.

Thank you..... pharmacist who worked yesterday, for not ordering the drugs that I need to fill prescriptions today. Yes, there were things about the prescription that needed to be clarified. But now that everything has been straightened out, it's Friday and I don't have the drug, and now won't have it till Monday. Would it have killed you to order it in, inventory be damned, knowing the prescription was pending and was eventually going to be dispensed??? Now the customer is probably going to take it elsewhere, after we did all the legwork, and I don't blame them.

Thank you...... manager for whom I am filling in today, for establishing a nice lax and borderline unprofessional atmosphere in your pharmacy. The staff loves you for it, but I sure don't. Staff seem to show up when they feel like it, come and go as they please, and pretty much operate in a bubble of their own entertainment, into which neither the customers nor I am invited. I am truly embarrassed at times. In addition, because you're such a social animal everyone else in the medical building seems to have chosen the pharmacy as their hang-out spot to come in and shoot the breeze. GET OUT OF MY WORKSPACE AND GET OUT OF MY PHARMACY. My services are devalued enough without you coming in here and assuming that what I'm doing requires no concentration at all. There's gonna be a showdown here, mark my words.