The last day I'll ever be questioned…
Scumbag came in recently and wanted 12-hour pseudoephedrine. My tech asked him for his license, and he knew the routine and handed it to her...along with $5.79 (or whatever it costs...exact change -- no paper trail). She knew he was a dirtbag and a frequent Sudafed-Man as we call them. We've recently received intel from the our local DEA agent (and pharmacist) that if the laminant on the license is broken or tattered in any way, it is not a legal license (at least in my state of residence). It is a ticketable offense, apparently. We can refuse sale at this point, and the DEA agent made it seem like we should. I made this known around the pharmacy that this was our new policy.
Well, the man, probably used to being turned away, accepted his fate and slumped away. A few minutes later, he and one of our front-end assistant managers came back in a sort-of triumphant march. The look on Sudafed-Man's face was a I-got-you-now-motherfucker glare...as if this Assistant Manager was going to put me in my place.
"So, what's the deal here with this man's license." ~Dumb Ass. Manager [My tech conceded to me.]
"We no longer accept license that have a broken laminate. It's not a legal license, and it's a ticketable offense per our local DEA Agent." ~TAestP
"Well, that doesn't make sense to me. All the information is clearly readable and we'd accept this if he were trying to pass a check." ~Dumb Ass. Manager
"That's all well and good, but we're not passing checks here. We're selling a substance that is controlled by federal law and regulated by national legislation." ~TAestP
"I don't understand. I used it last week to buy some 4-hour Sudafed!" ~Sudafed Man
"Okay. I understand. This laminate deal just came to our attention very recently. How bout this. I'll sell you this box now, but from this point forward, it is the policy of this store that your license is illegal and will not be honored. You need to have a new one printed." [Then I glared at the Dumb Ass. Manager] "And you stick around. I want to talk to you for a second."
So, I made the sale. Then junior and I went into a secluded aisle.
"So, do you know what just happened here?"
"Well, I just..." [I cut him off here -- The crimson hue of my face should have told him to shut the fuck up]
"I'm sorry. That was a rhetorical question. I'm going to do the talking, and you just listen. Since you felt the need to come back here and defend a scumbag, you undermined my professional judgment. I understand that you accept that to verify checks. I'm not dealing with checks back here. I'm dealing with dangerous chemicals. Now, that man is going to take the dangerous chemical and make it into a VERY dangerous chemical by mixing it with a ton of OTHER dangerous chemicals and sell it for people to inject into their veins and get high. It's called methamphetamine.
You front end managers think you are doing people a solid by coming back here and challenging my decisions day in and day out, but all you are doing is causing MORE problems for me. You give stupid fucking idiots validation in their flimsy arguments against my professional decisions as the pharmacist on duty and the pharmacist in charge. You, by merely coming back and inquring, are saying that you and some fucking idiot are right and that I may be wrong.
From this point forward, you and the rest of your front-end staff are NEVER to come to my pharmacy and inquire about anything with related as to decisions I, or my staff have made. Your response from now on is the following: 'You are going to have to talk with the pharmacist on duty. If you don't agree with him you can ask for the pharmacist in charge or inquire about when he will be returning.' Even if I told a little old lady to shove a broom up her asshole, you tell people their only recourse is to talk to the pharmacist. You have no say in the pharmacy and you will get no say until you complete your doctorate of pharmacy in an accredited pharmacy school.
Are we clear?"
"Yes, sir. Absolutely." ~Dumb Ass. Manager
"Okay. Please pass this information on to EVERYONE else in this store that is not in the pharmacy....Good talk."
-=+=-
Now...That was fucking brutal wasn't it? You bet your ass it was.
I nearly made him cry, and I'm not shitting you all, that's almost word for word what I said to that poor bastard. And no, I'm not going to apologize or recant in any way.
That's once small step for a pharmacist and one giant leap for the profession. Never again will I let someone without R.Ph or Pharm.D after their name even attempt to question the policies and procedure I institute in my pharmacy.
Removing the wool
Many people in this world have wool drawn over their eyes. In some instances, this wool only causes their opinion to be skewed because they cannot see the big picture. When it comes to the field of medicine, this lack of vision causes the patient to get screwed over. I've hit on this before, but I'm going to discuss it again...because it really pisses me off.
In chemistry, many compounds are composed of isomers. Isomers have the same molecular formula but are structurally different. Basically, they are shaped a little different. Sometimes, the isomers have the same results in the body. Other times, the isomers of a compound have different effects altogether. Still yet, some isomers cause side effects and the other isomer gives us the intended result (or one isomer is active and the other is completely inert). All compounds are either levorotatory or dextrorotatory (Called l-DRUG or d-DRUG *or*Â (-)-DRUG and (+)-DRUG, respectively). Levo compounds rotate polarized light (in a polarimeter) counterclockwise and dextro compounds rotate the same light clockwise.
I'm not going to get into the difference between constitutional and spatial isomers, cis/trans isomers, or R and S notation. Mostly because I will get out of my realm of knowledge quite quickly.
Most drugs out on the market are racemic mixtures. This means that they are combinations of d- and l- isomer. Most drug companies have fucked the common man by doing some shady shit (thereby pulling the wool over everyone's eyes).
Citalopram (Celexa) is a racemic mixture. Only the Dextro isomer is active. It was a heavily used drug indicated for major depression, social anxiety disorder, and panic disorder. Forest spent millions ensuring that every doctor had a big breasted woman peddling the drug to them praising it. It *was* the best available. Until the patent ran out. Then, it was no longer good enough. Now, the inactive isomer has been removed. Escitalopram (Lexapro) is now the best drug available if you ask the crooks at Forest. It is also indicated for depression, social anxiety disorder, and panic disorder.
Here's some more (all with the exact same story -- new drug is "better"):
Venlafaxine (Effexor)Â ====>Â Desvenlafaxine (Pristiq) -- Wyeth
Loratadine (Claritin) ====> Desloratadine (Clarinex) -- Schering
Cetirizine (Zyrtec) ====> Levocetirizine (Xyzal) -- Pfizer for Zyrtec/Sanofi for Xyzal
Omeprazole (Prilosec) ====> Esomeprazole (Nexium) -- Astrazeneca
Methylphenidate (Ritalin, et al) ====> Dexmethylphenidate (Focalin) -- Novartis
Dexchlorpheniramine, Dexbrompheniramine =
Chlorpheniramine, Brompheniramine -- Various Manufacturers
Albuterol (Proair, Ventolin, Proventil) = Levalbuterol (Xopenex) -- Various/Sepracor
Imipramine (Tofranil) = Desipramine (Norpramin) -- Different Manufacturers
Nortriptyline (Pamelor) = Protriptyline (Vivactil) -- Different Manufacturers
In every case where the same company is involved in the new drug, no improvements were made. Of course, the manufacturers would lead the unwitting MDs to believe that side effects were cut down, efficacy was increased, and the old drug causes users to grow an extra appendage on their neck. So, "everyone needs to be switch NOW! In fact, here's a stack of preprinted prescriptions for you to sign and hand out to your patients."
I say fuck that. No one ever asks me about these new drugs, well, now I'm saying it. All this shit does is cause more work for me. How, you ask? Has anyone out there ever gotten a Xyzal to go through? Hell no you haven't. Why not? It's too fucking expensive because the same drug is now available OVER THE COUNTER. So, I have to call the MD and have them get a PA. Then, some nurse wastes time calling the insurance company. Then, the patient has to pay a $45 copayment for a drug available on aisle 9 for $5.99/15 tablets. These drug companies are out of control -- as profit margin continues to shrink and edge closer and closer to 2%, these fucking guys are finding new ways to nickle and dime us indirectly. The time wasted, along with the crap repayment from this drug of equal efficacy, is merely another way to bone us.
Make a stand with me. You get a script called in or brought in for these damn drugs, call the doctor. Get it changed. They don't answer or you leave a message, change it anyway. Make it a "fill--call." If they say no, call the doctor a stupid motherfucker then overlook it. He'll never notice or know.
He's too busy with his head buried in some drug rep's tits pushing the new DRUG OF CHOICE FOR GENERALIZED ANXIETY DISORDER -- levoparoxetine or desmethylfluoxetine or some other bullshit.
Stupid Voicemail
I've never really bitched about this much, but the quality of the voicemails I receive has deteriorated to a point that I cannot take it anymore. I'm tempted to shut my VM system off and require all practicioner's offices speak with a pharmacist. I have the powah! I can do it...
I've got a pretty good system installed. I can replay or even fast forward or rewind a second by pressing a button (many seconds if hit repeatedly). But, when nurses are calling in these fucking scripts as one long word, it doesn't matter. Worst of all, no one spells anymore - Not patient names, not doctor names, nothing.
Case in point: Nurse today called in an Rx that sounded like this (read as fast as possible and slur the words together) -- "Hey this is Ann calling from doctor Badduda first name Mowaffaq prescription is for Shalonda Teddleston date of birth 5-5-75 for Lortab 7.5 #15 taken 1 BID prn pain office call back number is 555-6969."
Here's what is wrong with this voicemail:
1. She works for a foreign doctor. You have GOT to spell those names. I could care less where they are from, but I'm not familiar with spelling of their names. If it were John Smith, I'm cool with it. It's not. Spell the fucking name.
2. Patient's name could be spelled multiple ways. Is the last name spelled with T's or D's -- they sound the same in a crappily left message.
3. Birthday of May 5th? FIVE FIVE sounds like NINE NINE. Make sure you are audible!
4. Lortab was mumbled. I misheard it. I originally wrote down FORTAZ. Of course, once I reread it, it didn't make sense. So, I read between the lines. (Fortaz is an injectable antibiotic and wouldn't be given prn and it's a 1g+ dose -- not 7.5mg).
5. In a fast, mumbled message, BID can sound like TID. How much fucking more time does it take to say twice a day or every 12 hours?
6. Office number is always given so fast it's pretty much inaudible. You know it by heart, I don't. Would you fucking slow down?
As you can see, the voicemail system has given me 6 opportunities to screw something up in a 15 second voicemail. If the voicemail had been 30 seconds and the bitch had slowed down a bit, there would have been no problems on my end and no gripes.
There's just no rationalization these fucking LPNs and RNs can give that makes this ok. It's unsafe. They sound more retarded than they actually are, and they are putting our 'healthcare team' at risk for making a dangerous mistake...all because they don't have an extra 15-20 seconds to speak slower. Way to go, bitches.
Now, the fun goes both ways. I've been known to leave a fast voicemail in my day -- mostly in response to this kind of bullshit. Next time I have a refill request for this bitch, I'm gonna talk as fast as possible. She won't get it. She won't put one and one together (well, if she does, she'll get eight).
Most of my calling has been converted to faxing. I'm pushing to move ALL of it there....because of this bullshit.
I'll probably call her tomorrow and explain the situation to her...slowly. See if maybe I can reason with her. It won't work, but maybe, just maybe, the hamster wheel in her head will turn a few times and she can spare 15 seconds for me.
-=+=-
Here's a fun game I like to play. Some nurses call in and "want to talk to the pharmacist" to phone in a prescription. When I get fast talked, and I'm actually TALKING to the asshole --err-- nurse, I always take my time. I write as slow as possible. I repeat everything, maybe even twice. I speak as if I've had a stroke and in a thick southern accent...think Deliverance mixed with Cleveland from Family Guy. I love it when they get frustrated and try to hurry up and get off the phone. "Just to make sure I get everything right, please repeat the prescription back to me again." I end the phone call by saying that they need to slow down a little bit or the patient could be the one that pays for their haste. "Would you rather me fill your child's prescription as fast as possible, or diligent and correctly? Only one can happen. Your haste makes mistakes. If you don't have time to call in a prescription get a fax machine, hire more help, or call them all in at the end of the day when you have time. Your patients will wait, they have no choice, and they will rejoice that you are giving them Toprol rather than Topamax."
Did I do something wrong?
So, I was approached with a weird question recently, in confidence of course. A man came to me and asked me a very serious question. "Hello, sir. I am addicted to heroin, and I've hit rock bottom. I cannot afford the treatment options that are available, and I want to detox myself at home. What over the counter drugs will help me in the process, and what do I do to make this as easy as it can be?"
That's a mouthful, eh? I know that opiate withdrawal (and any withdrawal for that matter) can be a complete bitch to go through. I do also know, however, that opiate withdrawal is not fatal. Dying from it, especially a 20-something year old man that *wants* to get his life straight, is unlikely.
Here's what I told him (ad-libbed here, of course): I would urge you to try and find a methadone clinic or a doctor that could prescribe you Suboxone. I know that they are not cheap, but the doctors that deal in this would know of the avenues for you to find financial assistance. I can find you those numbers, those doctors, and I will even call them and speak with them before you go and meet with them. [He responded negatively here] Okay, well, my official position is that you need to seek a physician's assistance with this, and you are refusing to do so due to the cost aspect. [Affirmative] So, I will help you with this because if I don't, you would be lost at what to do. [Affirmative] Here's what you need and why:
1. Diphenhydramine 25mg taken every 4-6 hours because your nose will run like crazy and it will keep you drowsy and sleeping through most of it...hopefully
2. Ibuprofen and Tylenol alternating full doses of the two drugs every 2 hours. Every little ache and pain is going to feel like a compound fracture until your body begins producing the endogenous opioids such as enkephalin and endorphins at normal levels again.
3. Loperamide at near double doses of what the packaging says. You're going to have diarrhea, and it's going to be bad. You've been flooding your system with a drug that stops you from pooping, now your going to to have diarrhea many, many times a day after every bite of food you take. You can easily ween off of this over the coming days to weeks as you feel better.
4. Exercise. It's often been noted that exercise produced endophins with a strenuous amount of exertion -- perhaps you've heard it called the 'runner's high.' While I've never read any literature to corroborate this (because I've never looked), it makes sense that it will help. It will also make you tired and help you sleep through this.
5. Alcohol. I know it sounds horrible and as if I'm saying to trade one drug for another, but you might consider drinking a little bit to help you transition through the rough spells. Of course, you don't want to become an alcoholic, and most people know their limits. But, it may help for the first you days to use it as a 'sedative' so to speak. NOTE: I did go into how EtOH and Ibuprofen over the long term can cause ulcers and to skip the pain meds whilst drinking.
Overall, I think the guy really wanted my help and listened intently. He understood what I was talking about. I, of course, wrote all this shit down in a notebook I keep. I write down everything I think is important (Thank, Jim!) and tuck it away in case I ever need it again.
So, my judging readers. Was my advise wrong? Was I wrong to instruct him on what to do? I know it was wrong to suggest alcohol, but I honestly think that it will help more than hurt over the next two weeks or so. I doubt the likelihood that he would get an ulcer in two weeks along with Ibuprofen. If so, it's no worse for him to be pumping heroin into his veins.
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