A Head-Scratcher

The topic of prescription drug abuse has been in the news more and more lately, although to most pharmacists it is not a new topic. All of us have seen customers descend into this hellish cycle. They keep coming in with ever-increasing dosages and quantities or more potent drug prescriptions, and each time they look just a little bit worse. I'm not talking about the "pill-mill" prescriptions -- I'm talking about legitimate prescriptions from doctors we know and patients we know -- but they have entered this cycle that no one seems to be able to stop. As a pharmacist I feel completely helpless, and unless there's something illegal going on I am often at a loss to intervene, and often my input is not greeted with much enthusiasm.

There was an interesting article in the New York Times a few days ago, called "Tightening the Lid on Pain Prescriptions" (check it out online). A couple of things stood out to me:

Quote #1:

“If doctors understood how hard it is to get patients off of these drugs, they would not prescribe them to begin with".

I tend to agree with that, and I've often looked at someone's first Oxycontin prescription with great trepidation (Doc, are you SURE you want to do this?). I'm not a physician and I can only imagine how hard it is to see a patient with chronic pain who answers every drug name you suggest to them with the words "doesn't work." But I also question starting someone on powerful narcotic medication without a plan. How are we going to get them off it?

Quote #2:

"The long-term use of opioids to treat chronic pain is relatively new. Until about 15 years ago, the drugs were largely reserved for postoperative, cancer or end-of-life care. But based on their success in those areas, pain experts argued the medications could be used to treat common kinds of long-term pain with little risk of addiction."

WHAAAAAA????????? Little risk of addiction???? Here's where I'm scratching my head. Can someone explain how chronically dosing someone with a known chemically addictive substance poses little risk of addiction? It's true that many of these drugs were originally marketed for end-of-life care (OxyContin, MS Contin) or serious pain in a hospital setting (oxycodone, hydromorphone, fentanyl, etc.) Now they have leaked out into the community and into the realm of family-practice doctors who are prescribing them for neck pain, back pain, knee pain, TMJ, migraines and a bunch of other stuff for which they are not intended.

The NY Times article concludes with this:

"If the patients were taken off the medications, many would experience severe withdrawal or have to take addiction treatment drugs for years. Even avid believers in the new direction, like Dr. Ballantyne, suggest that it might be necessary to keep those patients on the opioids and to focus instead on preventing new pain patients from getting caught in the cycle.

“I think we are dealing with a lost generation of patients,” she said."

It's not about the broccoli

Y'know, it was really disheartening to hear one of the current presidential hopefuls sneer that it
was 'snobbish' for the current President to encourage people to go to college (actually, all he said was that people should aspire to at least a year of post-secondary education or training.) There are some days when I am overwhelmed at the questionable level of intelligence demonstrated to me by some of my adult, fully grown-up customers. For example, the ones who know they have a large packet of new insurance information at home but don't feel it's their responsibility to open the envelope. The ones who seem unable to follow simple directions, read what is written or listen to what is told to them. They are entitled to SO many things, but don't have to hold up their end of the bargain. They don't have to study, learn, remember or pay attention. They are spectators -- it's someone else's job to do it for them. Oh, and then there are the emails from my own managers and superiors that are written at a 4th grade grammar level and full of spelling mistakes. It really gets me down sometimes.

My apologies for not posting too often lately -- I was lucky enough to take a vacation to Europe and as always, enjoyed making some observations about health care. Pharmacists are a first-line resource for health care over there, and that makes a lot of sense to me. How many people do we see coming from a doctor's appointment clutching a piece of paper on which the doctor has
scribbled "hydrocortisone cream", or "Benadryl" or "Sudafed?" There are a lot of people who go to the doctor for minor things because they simply don't know what else to do. I guess they don't trust anyone but a doctor to tell them what to take. People have to understand how expensive this is. And then there are stories like the one Dr. Grumpy linked to, where a guy called 911 because he had scabies, and the full force of the American Health Care System weighed in to the tune of a thousand bucks. It's madness.

I had a conversation with someone in Britain who needed to go to an 'urgent care' clinic for
some severe traveler's diarrhea. Yeah, she had to wait a little while (just like here), but was seen by a clinician who prescribed totally appropriate treatment, handed her the box of antibiotic tablets (no pharmacy visit involved), told her what to do and she went on her way. No money changed hands and no bill was generated. I know it's just one example, but it seems pretty simple (and a lot cheaper) to me.

What's missing in the health care debate are the voices of the people who actually work in health care. Why don't we see them on TV instead of a bunch of extremist political pundits screeching about losing their 'freedoms?' I simply can't watch it anymore without getting depressed, yet I probably have an obligation to watch. We spend more on health care per person that any nation in the world, and get poorer results when it comes to basic preventive care. How do we get that through to people who can't understand the words "THIS CARD REPLACES YOUR OLD ONE??"

In The System

Well the beginning-of-the-year nightmare scenario has eased somewhat, however I'm still getting customers who positively assert that they have been to my pharmacy many times before, and that all their current information is 'in the system.' Alas, a quick check of the system reveals no record of them whatsoever. Are people really not paying attention to where they are on this earth?? When you can't remember where you have had prescriptions filled, you're getting way too many.

Erratic staffing forces me to spend much more time at the cash register than I ever want to. I barely make it to the window when the person is swiping their credit card with a giant wave of the arm. Please, wait a minute. Let me at least tell you how much it is --- that way, we won't complete the entire transaction before you think to ask me "Why is it that much?" or "I think I won't take that one." Because you know, to reverse a credit card charge is about a 20-step process on our incredibly complicated register system. And incidentally, I've already given up on the idea that you might want me to tell you something about your prescription.

A couple of things that people still don't "get":

--- Dropping off seven new prescriptions means you're going to be waiting awhile. Don't look so surprised. There are people ahead of you, and the staff here still have to wait on other customers and answer the phones while we plow through those prescriptions. Come back later.

-- For a doctor to continue to prescribe medications for you, they generally have to see you for an appointment at least once a year. That's the way it is -- snapping at me that you NEED it, or you don't want to pay an office copay is not going to change it.

Hell hath no fury like an entitled, middle-aged guy who suddenly discovers his Viagra is not covered on his new insurance plan. Jeez, I had a tough time keeping my cool with that jerk. He was incredulous that the doctor's office had not responded to the request for a prior authorization the next day. Move to the back of the line, EVERYONE. This guy goes first.

A lot of people are writing prescriptions now who are not M.D.'s (as Pharmacy Chick referred to in a recent post.) Many of them are very competent and save the system time and money by treating medical conditions within the scope of their practice and under the 'supervision' of an M.D. However, some of these prescribers write for some heavy duty stuff, and I am really uncomfortable filling prescription after prescription for C-2 narcotics from a nurse practitioner. Sorry, I just am. I had a customer decline (with my blessing) to fill a $250 inhaler the other day from an NP, stunned that this had been prescribed for a "little cough." Or the guy who said he was switched from simvastatin to Lipitor, merely so he could "eat grapefruit." (??) Another NP near us seems compelled to write multiple prescriptions for everyone, and I think only succeeds in confusing the hell out of people.

Me included.

REEEE--- JECTED !!

OK, the end of January is approaching and I can't get over the feeling of just spinnin' my wheels.
Work has been an endless parade of insurance rejects...." patient not covered....ask patient for new ID card..... non-matched cardholder.....refill too soon......we are rejecting this claim because it's a day with an 'r' in it, ha ha !!.....and a million other reasons that I've never even seen before. People who have completely changed insurance plans, did not bring the card, and expect me to figure it out for them. I ask people POINT BLANK when they drop off their prescription, "HAVE YOU CHANGED INSURANCE IN 2012?" They reply, "no, nothing has changed." Fifteen minutes later we finally get to their prescription, it rejects, we ask them about it and they say, "yeah, I have a new card." Honestly, I feel like I'm being punked in a reality show or something. And of course the person's next question is, "Is it ready yet?" Things never change.

The prescription transfers are still plentiful. As usual, people don't understand that this takes extra time. I feel bad about calling the same pharmacies multiple times a day, but what else can I do...

Anyway, the other things on my mind are:

--Staffing. Why do we never have the right amount of people when we need them? One of the busiest times in retail pharmacy is between 4pm and about 6:30 pm, when people are picking up prescriptions on their way home from work. Working people, as well, tend to want to schedule doctor's appointments at the end of the work day so they don't have to miss too much time.
Day after day we get slammed at the same time, we don't have the proper staffing, we rack up overtime and get our hands slapped for it, like we are incompetent or something.

-- Security. I never thought about it much before, but I'm becoming more aware of security lapses in the pharmacy and no one else seems to care. It costs money to beef up security, so it's not something I can do without the company's help. I really don't want us to learn the hard way.
I'm trying to figure out how to approach this without stepping on anyone's toes or sounding alarmist. But I'm going to keep at it.

-- Getting fired. It actually happens! We've had two support staff members get fired in the last couple of months. You would think people want to hang onto their jobs right now, but apparently the mere threat of firing wasn't enough for these two. I'm glad someone in the company actually has the balls to do it, but there are still other people who inexplicably get a pass.

Onward.

Happy New Yea------- Oh, wait.

Aw yuck. What a hellish "new year's week" it was.

It included a major software change in the way we submit on-line claims to insurances. The end result, in a nutshell, is that there are approximately 1,000 new and different ways for a claim to reject, and I think we saw every one of them.

It included the usual insurance plan changes for customers, with the associated freak-out when
their new copays were revealed to them at the cash register. "But I've always paid (X) dollars!!"
was #1 on the week's hit parade. #2 was, "I don't have a deductible!!" followed by a grumbling
return later in the day, after they had called their insurance company.

It included one of the major corporations in town switching to a new pharmacy benefits card.
I don't even work for them, and I knew about it months in advance. These employees are educated, white-collar workers -- some are even health care professionals. Do you think even ONE of them had the card with them when they came in? Do you think the majority even understood that the benefits they signed up for during open enrollment screamed "CHANGE" ? Alas, no.

And of course it included the transfers out of Walgreens for Express Scripts customers. Most of the Walgreens I called had a message asking me to leave the information for the transfer and they would fax it to me. However, since no one plans ahead and many people wanted it while they waited, I had to ask to speak to someone right away. To my surprise, all the Walgreens pharmacists I talked to seemed pretty darn nice about it. I can't imagine how they are dealing with all that.

It also included assorted other computer glitches I don't even want to get into.

One of my co-workers said she felt like crying. Me, I had to fire up the ol' cocktail shaker
at the end of the week. Simple, yet effective.

We shall steel ourselves for the week to come.

The Ball Drops......

It's the last (week)day of 2011. Things are chugging along fairly smoothly in the ol' pharmacy, until about 4:20 pm. And at that point things go completely, totally to hell. The phone starts ringing nonstop, because the whole world has discovered that:

a) they still have money in their flex spending accounts that needs to be used up before the new year, or

b) having met their deductible and having no copays, they really really want to squeeze in one more refill of their medications before the copays kick in again on January 1st.

Now, I'm not blaming anyone for wanting to save some money, but I do blame them for waiting until the VERY LAST minute to cheerily advise me that they'll be stopping by in 15 minutes. God, it's frustrating. And if they have no refills remaining (as is often the case) then they're stunned that I can't snap my fingers and make it happen. True, perhaps they haven't filled that prescription since 2009, but what's the big deal "I'm sure my doctor will OK it." And damned if some of them don't get on the horn to the doctor's office (apparently), because I start getting calls from exasperated nurses telling me to go ahead and fill so-and-so's acne medication one more time. The doctor's offices must be as sick of this as I am.

Also had one customer, getting on an overseas flight that afternoon, plop down a bunch of empty bottles and then proceed to get restless once 10 minutes had passed and we weren't finished. Only had a few tablets of one of his meds in stock -- it was a 'nonessential' so had no problems telling him he was SOL. In fact, even if it was an essential medication, I guess he would have been SOL.

The end result was standing-room-only in the pharmacy well past closing time. The Overtime Gods will not be happy.

HAPPY NEW YEAR.....!

Holy Crap, It's December?

I haven't been keeping up too well on blog posts lately, not because I've lost interest but I just can't freakin' believe where the time goes. Amazing how this leaving home at 7:30am and coming back at 7:00 pm cuts into one's free time.

I can't really get into Christmas this year. Each year I find myself less and less enthusiastic. The stores are full of the same crap and every sad news story reminds me that it's really just another day for a lot of people. Forgive me, but I don't really look forward to Christmas 'get-togethers' with co-workers either. Nothing against them at all, I just associate work with a different mind-set and it's hard for me to put it away when I'm looking at the same faces outside of work. When that gate comes down, I just want to get out of there. I suspect a lot of people feel the same way but are good sports about it anyway.

Seems like December 1st brought about some formulary changes for a lot of customers. I get the impression a lot of people are changing insurance plans in the new year and there's going to be a lot of confusion -- more than usual, maybe? People have been asking about generic Lipitor for weeks now, even delaying their refills till it came out. They thought the price was going to plunge immediately and wanted to know what their insurance would charge them for it. (Completely unknown to us!) We've had to caution them that they may or may not see a difference right away, and that has been borne out.

I've struggled mightily with more and more customers who speak little or no English. In fact I've become quite discouraged at what I see is a waste of money and resources in the polypharmacy for these folks. How much of a chance is there that they're going to use the
Pulmicort Turbuhaler or the Medrol Dose-pak correctly, and therefore benefit from it? I'm not saying they don't deserve the appropriate treatments, but they can't read the label (I can see them trying to 'memorize' the directions for each bottle) and I have no idea how well they understand my game of 'charades' as I try to demonstrate with hand gestures, because that's all I can do. (Plus, I've got these ridiculous SureScripts prescriptions that print directions even I can't decipher half the time.) I've watched people go out the door with bags of very expensive medications that I have no real hope are going to be used correctly. I don't know what the solution is, if the person doesn't bring someone along who can translate. We can't keep written materials in every language and for every question. I also suspect that it's a cultural thing for some folks to decline to ask questions, particularly of a female pharmacist.

I dunno, man.... it's just been on my mind. Hey, I'm gonna watch "National Lampoon's Christmas Vacation" -- that will get me in the spirit!