Turkey Talk

I worked Thanksgiving in close proximity to a "Quick-Check-Urgent Care" walk-in clinic type of place ---- surprisingly, most of the patients pretty much needed to be there. Lots of antibiotics were flowing. Not too many people wandered in on Thanksgiving Day to have that rash checked that they've had for 3 weeks, or to get a handle on that blood sugar that's been out of control since last Thanksgiving. So that was a pleasant surprise.

I did get several people who wanted me to 'guarantee' that their prescription would work.
Like, the person getting a Z-Pack (I know, who doesn't get a Z-Pack?) who said in reference to their ailment, "And this will TAKE CARE OF IT, RIGHT?" Or the woman who demanded to know if the phenazopyridine would work IMMEDIATELY for her UTI. As I opened my mouth to answer, she said NO, I MEAN IMMEDIATELY !!!

I can't guarantee that prescriptions are going to work. Prescribing is as much an art as a science. Every so often someone tries to return something because it "didn't work" or they just didn't like it and we have to explain that legally we can't take the medication back and re-sell it again. I had to explain to a customer once that "you wouldn't want me to dispense medication to you that had already been taken home by someone else, right?"

On Black Friday afternoon a customer brought in a prescription for an anti-nausea med for pre-treatment of chemo. The (naturally) expensive medication wasn't covered. We asked when the chemo treatment was scheduled.... "Monday morning." Date of the prescription: 1 week ago. Doctor's phone goes to voice mail. Possibility of getting a prior authorization on Friday afternoon? Slim to none. Moral of the story: bring those prescriptions into the pharmacy ahead of time. I sure hope they figured something out on Monday.....

The Drink

We have a customer, a relatively young individual, who's been through a succession of reflux medications and got rather agitated when his new PPI prescription wasn't covered.
I spoke directly to the prescriber, a younger female physician who actually sounded kind of scared of the guy. "What he really needs to do is put away the vodka," she informed me.

Obviously many of our pharmacy customers have conditions that they have no control over, but others can attribute a lot of their medical problems to things like obesity, smoking, and alcohol. I recently read a small news item in Newsweek magazine that stated,

British researchers find that alcohol is more destructive to individuals
and society than any other drug, including heroin and crack.

Pretty eye-catching statement, but I think it's true. I'm thankful that my parents were only social drinkers -- it was an occasional thing, holidays and special occasions, and no one ever got drunk. I am the same way. I wasn't aware of it as a kid, but I realize now that I have numerous extended family members who are approaching middle age looking back at a legacy of broken relationships, estranged children, shaky financial status and general poor health as a result of the erratic and unpredictable behavior that comes with alcohol dependence.

I work with people who talk about 'going to the bar' like it's a destination in itself. That's their weekend activity. They leave their kids in the care of others so they can hit the bars.
Their kids eventually catch on to this and recycle the behavior later themselves. People describe something to me that happens at home with their (haha) 'plastered' spouse and I think to myself, YOUR HUSBAND IS AN ALCOHOLIC. Why can't you see that? I'm not talking about college students here; these are full-grown adults.

Think about the percentage of police calls that are related in some way to alcohol. (Watch an episode of "Cops".) It's phenomenal. I once heard someone say that beer is the most underrated drug in America.

Unfortunately, smarter people than me don't know what can be done about it. Alcohol is never going to be illegal. Humans are social animals and alcohol is associated with that. We've created a stressful society where people are looking for ways to take the edge off. I believe some people are genetically predisposed to 'addictions' while others will never come close to any kind of problem. But the impact of alcohol on our society really is very dramatic, when you think about it.

Just another observation from behind the counter.....

The Incredible Missing Prescriptions

I know some folks out there who work for big chains perhaps aren't directly involved in the mailing-out of prescriptions. Everybody has to do it now (for free) to remain competitive. But what is your company's policy when the patient tells you they didn't receive it (and it's documented as being mailed, the address is correct, etc.?) People seem to feel it's our responsibility to simply replace it, at no cost to them, and that is regardless of whether we can bill insurance again. We are getting burned on this big-time. I'm curious to know how it's handled elsewhere.... Thanks!

Theater of the Absurd

Prescription medication for customer is being increased from 40mg per day to 60mg per day. Thus, the prescription is written as 40mg tabs, take 1 and 1/2 daily, because there is no 60 mg tablet. Easy -- peezy !!!

Insurance company says no, we will only pay for one 40mg tablet daily. We advise the customer that this medication is inexpensive, and he can buy a month's supply for cash at under $14.00.

Customer says NO WAY and wants it covered under his insurance. Since we're all about the customer service, we send it off to the doctor's office for a Prior Authorization.

A few days pass. A nurse actually calls (!) and says the prior auth is approved. I run the prescription again -- it rejects. I call the insurance company and sit on hold for about 10 minutes. Finally the person on the other end tells me it is approved, but the customer must take three 20mg tablets instead of 1 and 1/2 of the 40mg strength.

OK. I run that through, and the copay is MORE than if the customer had just paid cash for the month's supply of the DAMN 40mg.

Customer comes in later, and when given the two options elects to pay cash price for the 40mg. Customer also is pissy and registers his unhappiness that the insurance company is telling him 'what to do.'

I wish I could total up the salaried time that everyone involved spent on this. Sometimes you just have to laugh in this job. And again, I am reminded of (a) why healthcare is so expensive in this country, and (b) why your prescriptions take so long to fill.

On another note........ we all hate it when management dictates we have to give a spiel to the customer at checkout, whether it be upselling or telling them about a special or asking for a donation to something. I was reminded how much I hate this myself when I attempted to buy a cheap paperback book the other day at Barnes and Noble.

Check out lady: Are you a member with us?
Me: No.
C-O-L: Do you know about the program?
Me: Yes, and no thanks.
C-O-L: Would you like to donate a book to our book drive?
Me: Not at this time, thanks.
C-O-L (now typing into the computer): What is your e-mail address?
Me (silently): CAN I PLEASE JUST PAY FOR THIS GODDAMN LOUSY BOOK AND GET OUT OF HERE ???? AAAAAAAGGGGGGGGGGGGHHHHHHH !!!!!
Me (out loud): I don't use e-mail.


By the way, I TOTALLY lied cause I do use e-mail!!

Can't wait for the Christmas shopping season.

All Tied Up Over Tylenol

Overdosage with Tylenol is the most common cause of acute liver failure, and attempts have recently been made to educate the public that Tylenol (or acetaminophen, or APAP) is not an innocuous drug. People may not be aware that acetaminophen is present in many products other than "Tylenol" leading to doubling-up and inadvertent overdose, and there can be confusion over strengths of different products -- regular strength tabs, extra-strength tabs, chewable tabs, infant drops which are 100mg/ 1ml, and children's liquid which is 160mg per 5ml. For adults, 4000mg per day is the maximum dosage, or 8 tablets of 'extra strength' Tylenol equivalent, and there is talk of lowering that recommendation.

Anyway, the thing that worries me most is the kids, because of the aforementioned strength differences and the lack of faith I have in many of the caregivers who give the doses. You remember when they pulled all those OTC pediatric cough/cold products off the market not long ago? It wasn't because the medications were inherently unsafe, it was because there were too damn many dosage errors to justify leaving them out there. Every time I sold one of those things I attempted to make sure the parent knew how much to give, but they rarely initiated the question themselves.

Getting back to Tylenol, we get a lot of prescriptions for it because it is covered by state assistance for those who are eligible. Pediatric dose, as we all know: 10 to 15 mg per kg every 4-6 hours, maximum 5 doses daily. But after checking the child's weight, we consistently get doses that are written too high. Usually they creep up into the 16-17-18 mg/kg range, sometimes more. Okay, maybe a couple of doses isn't a big deal, but legally as far as that labeling is concerned it's OK for that child to get that dose every 4 hours for the next... well, indefinitely. I'm often nervous about assuming that a non-English speaking parent even remembers what 1.2 mL looks like on that dropper. We always have this conundrum --- should we call and bug the doctors/nurse about it EVERY time and hold up the prescription till they call back? Should we go ahead and change it to a more correct dosage and initiate a phone call or fax back to the office and hope it gets changed in their medical record? Or do we decide we've called them enough times and just tell the parent the correct dose and make sure they know how to give it? Is it worth all the time spent? It happens virtually every day. Are we just getting too wound up about the whole thing?

I'm curious as to how other folks handle prescriptions for OTC items like this.

For the record, I never use those dosing charts that give a weight 'range' and assign a dose for it. I calculate 12mg/kg (right smack in the middle) and then round up or down to the next logical dosage unit (1/2 - 1 - 1 & 1/2 teaspoon, dropperful, etc.) Done.

The Generic-Go-Round

I'm still surprised by how often customers don't understand what 'generic' means. The ones that do understand are the 'prescription pros' whose eyes actually light up when you tell them their medication is now available as a generic, because they anticipate the price coming down. But many people still look very skeptically at you and ask, "But it's the same thing, right?" I feel as though they think I'm trying to put something over on them.

I've tried out a few different ways of explaining 'generic.' Some of them are:

1. It's the same active ingredient as the brand name drug, it just looks different and is made by a different company. (This one doesn't go over that well. It sounds kind of fishy.)

2. It's exactly the same medication as Zocor, they just can't call it Zocor because that's a
protected trade name. (Sometimes this is met with a nod of understanding.)

3. You know when you buy Del Monte Canned Pears and right next to it on the shelf there is a can of "Great Value" Canned Pears? They're both canned pears. One just has a fancier label. (This one is only used when I'm hitting rock bottom.)

People get funny ideas about generics. We all have the customer who swears, "the generic doesn't work for me," (even though there is no earthly reason why it shouldn't) or "I'm allergic to the generic." I don't dismiss these people out of hand. Generic products can contain different inactive ingredients (colors, flavors, fillers) that theoretically someone could have an allergy to. The lack of effectiveness is a little harder to buy, although again, theoretically a person could absorb the generic product somewhat differently which might affect its action. I recently had a customer beg me for a few tablets of Cardura because since he was switched to the generic, "I can't pee." ( I gave him a few and started the prior auth. procedure -- he did look really uncomfortable).

Other times I think people get it in their head that the generic is not going to work and then proceed to enable that very thing by sheer willpower. I took a call from an exasperated nurse who needed to start a prior auth for Duac Gel because the patient would not use its two --- cheaper---- components separately (Clindamycin gel and Benzoyl Peroxide gel) because she claimed that did NOT work. I'd have a tough time with that. I'm glad to see that occasionally docs will refuse to do prior auths for some of this stuff.

Then there's the flip side of the coin, when someone is presented with a higher-than-expected copay for what is a very pricey brand name drug, and their first question is "Isn't there a GENERIC??" I have to answer, "No, not for this one."

And I get that skeptical look, AGAIN............

The Truth Goes Marching On

OK, so the makers of the delicious Sun Chips recently started packaging their product in a compostable bag made of plant-based materials. Better for the environment and a good idea, right?

Wrong. They have decided go back to the old packaging for all but one flavor. Why?
According to news reports:

"But that which makes them compostable also makes them loud. The bags have a different molecular structure from the original packaging, and they're stiffer. So people complained about the noise. Groups on Facebook abound with names such as "I wanted SunChips but my roommate was sleeping..." and "Nothing is louder than a SunChips bag."

Spokeswoman Aurora Gonzalez said the company received complaints about the noise from the bags, although it also received thanks from customers who liked being able to recycle them.

So the decision was made to remove the bulk of the biodegradable line."

Sigh. Some times I worry about this blessed land of ours. Yeah, the environment's important and all, but DO NOT, I REPEAT DO NOT, mess with our salty snacks and our ability to partake of them when the roomie is asleep. There are certain things that are sacred.

Why is this pharmacy-related? It isn't really, except that I often throw a handful of Sun Chips into the pitiful lunch I wolf down back in the stock room. It was a noble try, guys.