Irrational behavior

Posted by The *Angriest* Pharmacist as Drug Companies, Just a question, Me being a dick, PSE, Patient Education, Stupid People, True Story, Work Sucks

Due to the overwhelming results of the poll, I’ve reverted back to the old theme. If anyone wants to look for a new theme, I’d be willing to switch it again. I want two sidebars (left or right), one dominant color (like the orange on this one), and plenty of room at the top of the site to list pages (more than this theme has). Thanks and enjoy!

The human being, by nature, is irrational. Some people are able to overcome this with education and common sense — most others are not. We see this, as pharmacists, every single, solitary day.

Example 1:  50-year old white female presents to the pharmacy asking for a product called “Congestac.” I had never heard of it, so I looked it up on Clinical Pharmacology. I quickly found that it was merely 400mg of Guaifenesin and 60mg of Pseudoephedrine. So, rather than order 24 pills for $14 from my supplier, I grabbed a package of generic Mucinex-D (which is 600/60). I told the lady that it was the same two drugs and even had a little bit more of the drug for chest congestion. She told me, “Well, I don’t know. It’s for my son.” I asked her how old he was — he’s 25. What the fuck? Why is she scared to make an adult decision? Is she afraid she’ll bring home this alternate product, he’ll immediately judge it as inferior, and shove it up her sexin’ hole? After much explanation, rationalization, and even printing of ingredient lists, I ordered the $14 product. I hope the 9 dollar difference is worth it. We’ll call it the idiot tax.

Example 2: 75-year old male presents to the pharmacy asking for the person in charge of ordering the Bayer Aspirin. A much as I wanted to page, “Would the Angriest-Pharmacy Associate in charge of ordering the Bayer Aspirin please report to the pharmacy for customer assistance,” — I did not. I went out to the shelf and saw that we were, in fact, out of 81mg Bayer Aspirin. I asked the man if he had ever had a stroke or heart attack. He had not. I immediately grabbed a bottle of 81mg store brand Aspirin and handed it to the man. I told him it was half the price, made by a respectable generic manufacturer, and was the exact same thing. The man then proceeded to tell me that, “he had been taking Bayer-Brand Aspirin for 30 years, and he ain’t had nary a stroke, heart attack, or problem number one while takin’ it and he ain’t about to switch now.” Well, as irrational at that sounds, you can’t argue with the stupid. I tried to explain to him that they were the same drug. He then had the nerve to tell me that he *knows* that “Bayer is a better product and prevents more strokes than that cheap generic junk.” I then asked the man if he drank alcohol — he said he did — several Milwaukee’s Best per day. I then asked him if he had ever had cancer. “Nope. Never had any health problems at all.” I immediately attributed his lack of cancer to Milwaukee’s best, the cheapest beer on the market, and commented at how I needed to get me some of that. He laughed, but he did not get my point. The idiot tax will be applied to him upon his next visit when he buys Bayer Aspirin. [Fun fact: Bayer also manufactured and sold Heroin at one point]

Do you have a story of irrationality? I know you do. Please share it in a comment.

I’ll share more as they come up.

Removing the wool

Posted by The *Angriest* Pharmacist as Disgusting, Drug Companies, Insurance Companies, Money, Work Sucks

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*  (-)-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)  ====>  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.

We got a hotshot here

Posted by The *Angriest* Pharmacist as Drug Companies, Education, Hate Mail, Me being a dick, Pharmacy School, Stupid People, Update

So this guy flew off at the mouth in the comments on Circle of Spite by my former accomplice, Lil Laura. Here’s his comment and below that is my rebuttal.

Hey, I think it is important that patients be given the same brand that they have been taking. Its not the same, no matter what you learn in pharmachology school. Studies show that two brands of the same drug can vary as much as 20% in concentration. That is a big deal if your epilepsy dosage is a carefull balance of seizure control and side effects, or if you are taking psychiatric medications whereby flucutating concentrations can lead to mental instability. 20% can be a big deal and patients diserve reliabaility. Taking the same brand may at least lessen the likelyhood of dosage differences or drug release patterns in the case of XR formulations.

You’re right. The *can* differ as much as +/- 20% in AUC and +/- 3% concentration in the plasma per unit time. Here’s what *I* learned in pharmacy school — they don’t. The FDA has reported and actual indexed studies on PubMed (not your commoner WebMD bullshit) saying that most drugs vary in both of the above categories by minuscule amounts.

There are very few exceptions to the rule. For instance, Synthroid doses are measured in micrograms. When dealing with small doses like that, your 0.25% plus or minus could amount to a lot more (or less medicine). My second exception is an allergy to an excipient. Yes, I have taken the time to list out all excipients in a patient’s profile to figure out if an allergy can be attributed to them (or if there’s gelatin hanging around for the vegans). The final one is Comadin. With the weird every other day regimens and the time it takes to stabilize the patient. I don’t want to rock the INR-boat with that one. Just leave well-enough alone.

Are there any more *reasonable* examples?

Is there anyone out there that would be willing to delve into the pharmacokinetics studies on Pubmed and prove me right (or wrong)? I’m basing all my comment above on what I was told in Pharmacokinetics, Biopharmaceutics, Pharmaceutics, et al. I’d be willing to listen to CITED DISSENT, but I will not accept anecdotal bullshit. You come to me with a PubMed ID number or the Title and Author of a statistically and clinically significant randomized control trial — not with, “my 2nd cousin once removed was taking Allegra, then the druggist switched her to fexofenadine and she started sneezuhn and shit…Them generics and worth a lick.”

Let me explain something

Posted by The *Angriest* Pharmacist as Drug Companies, Me being a dick, Stupid People, Work Sucks

I don’t mind prescription coupons. I don’t really give a crap about putting them in. The info on them is always pretty self explanatory. Here’s what I hate about coupons though, being expected to keep track of them by drug reps and having to explain to people why they can’t use them — which pisses them off.

When a drug rep gives me coupons, most of the time I pitch them. Sometimes, I’ll slide it on the shelf next to the drug. However, I rarely remember I have them when a patient presents a script. I just forget or don’t care. So, they help no one!

The thing that pisses me off most of all is when a patient brings a coupon, and it’s expired. It says plain as day right on the front the expiration day. These assholes just think they are gonna sneak one by the dimwitted pharmacist. Not quite…Now, I’ve heard that sometimes they extend the dates on the coupons, so I input them and run them anyway just in case, but I inform the patient to not get their hopes up.

Then you have the older breed. The entire older generation is concerned with every single penny. They are the most frugal generation this world has ever seen. They have their social security, their Medicare, and their savings…and gosh damnit ‘you put that fucking coupon on there and I don’t care how the hell you do it’ — Tight wads. Little do they know, the coupon cannot be used because they are on Medicare Part D. They don’t understand the concept of that being illegal — against the rules — they just know that they have a 20 dollar coupon and the pharmacy is trying to cheat her out of it! We must get a cut of every coupon we cheat people out of. Hell, you can even show them the fine print on the coupon. They don’t care.

“Take off the medicare and just use the 20 dollar off coupon,” they say.
“But, ma’am this is $90 worth of medicine. Your copay would only be $28. It’s in your best interest to just forget about the coupon.”
“My doctor said to use it. He’s God and always right. So, call his office and maybe they can give you the machine code to get it to work.”
“Well, alright - it went though. Your total is $70.”
“I knew if you’d call ole Doc Cartwright he’d set you straight. He’s the best. Put you in your place didn’t he?”
“Ohh, yes ma’am, he gave me a grand scolding. Told me to kiss his ass!”

So, to sum things up:
Cash Customer = Coupon Great cost savings
Insurance Customer = Run on Insurance, Coupon covers copay
Medicare Part D = No coupon allowed, won’t understand why
Medicaid = No Coupon allowed, doesn’t give a shit because they don’t pay regardless

Headhunters

Posted by The *Angriest* Pharmacist as Disgusting, Drug Companies, Hate Mail, Me being a dick, Rude, True Story, Work Sucks

I got the message below from what I like to call a headhunter. What do they do all day? They call us, hardworking pharmacists in the trenches, at work. They bother us incessantly….non stop. Feigning interested in our day. Telling us about “exciting opportunities” in “various healthcare field” with “immediately openings available in our area of the country.”

That’s right. They call me at my job, who currently pays my bills, and asks me if I want to quit and work for any company that will take me. They will promise you the world. Can they deliver? They don’t know. They don’t care. They likely read off a script just like every other telemarketer in America.

I understand as well as anybody that it takes a ton of different people to make the world go around. For every job, there is a worker willing to take that job at that wage. It may not be what I would want to do, or what I could earn, but the job is there nonetheless.

But, how in the fuck do these people make their place in the world? I just don’t get it! I could not imagine a pharmacist, regardless of their level of disgruntlement, saying, “Yeah, I’ll quit this bitch for whatever job you can find me with XYZ company.” I’ve never heard of someone doing it. So, I’ve never heard of a success story. To make matters worse, they bother us at our already hectic jobs. This pisses us off and REALLY makes me want to jump ship!

What makes this specific commenter all the more asinine is that I had a run in with her a while back. The Pharmacy Alliance had an oft-used email listserv prior to their meeting in Texas. She chimed in with this same recruitment chum. I didn’t reply in a swear laden hate-speech. I didn’t even tell her to go fuck herself. I just replied with, “Whoa.”

Now, at work, I like to fuck with these people. The way I see it is that my time is money. I’m sure my time is worth more than there’s, but I’m a huge dick and I like to get a laugh at other people’s expense. I often ask them for all the details and not pay a lick of attention. Then I ask them again. After that I’ll ask them random questions they have no business knowing until they get the hint. “Ma’am, why can’t tigecycline be used for bactermia?” or “Why is Zyvox contraindicated in people on MAOIs?” or “What’s the max daily dose of Oxycodone in a properly titrated person” or my personal favorite, “Why can’t enteric coated aspirin be used to treat a headache?” If they still don’t get the hint, I ask them, “Why does Mickey Mouse have big ears?” — That’s usually the fuck off question that gets em.

Bonus points for answering the real questions in the comments.

A new submission (form: “Contact Form”)
============================================
Submitted on: June 4, 2008
Via: http://www.theangriestpharmacist.com/contact/
By <edited out IP> (visitor IP).

Medicare Part D — WTF?

Posted by The *Angriest* Pharmacist as Drug Companies

I received this email through the pharmacist-grape vine.

-=+=-

From:[Contact TheAngriestPharmacist for Sender's Email]
To: rick.larsen@mail.house.gov
Subject: Medicare Part D Merry Go Round 2008
Date: Wed, 28 Nov 2007 22:57:54 -0800

11/28/2007

Representative Rick Larsen
United States House of Representatives
1529 Longworth House Office Building
Washington, DC 20515

Dear Rick:

From time to time you have been able to stop in our pharmacy when on
Lopez Island and I always felt you listened to our concerns about health
care. I thought I’d share with you what I call the Medicare Part D
Merry-Go-Round. Each year the Medicare patient must reevaluate their
respective Medicare Part D drug plan, only because the coverage that they
had during the current year can and does change each year.

Plans have low balled premiums only to raise them in latter years
with the hope that most Medicare patients won’t change their plan. If they
don’t raise their premium they change what they cover. If that isn’t enough
the plans then still covers their drugs, but then changes the copays, or
other criteria for their drugs. This is a unbelievable complicated system
for our seniors. We try to help our patients make sense of the changes, and
when we can we provide education to them to show what their plan was, is or
will be. Again most of the plans are betting that the patient will not
change plans.

I’ve got a good grasp on the system and it takes me hours to
evaluate the plans, can you imagine how a Medicare patient that isn’t
computer savvy feels? This system needs to be fixed and fixed now. Think
about these common sense ideas.

1. Make a fixed list of drugs that are covered for a basic, premium and
deluxe plan.
2. Make copays fixed for generics and brand name.
3. Get the rebates that are lining the pockets of the managers of these
plans into the patients pocket by getting rid of the donut hole.
4. Let the PBM’s make their money by being claims processors, not slight of
hand artists in hiding their rebate dollars.
5. Remove the self-referrals that the PBM’s are making by steering the
Medicare patient into their own mail order pharmacies.
6. We need to allow medications to stand on their own two feet for their
effectiveness, not how many TV ads that can generate.
These direct to consumer ads are adding huge amounts to the cost of
prescriptions in this country. We all know that more dollars are spent on
promotions than on research.
7. Finally make one plan ran by Medicare itself, not by the private plans.

Our elected officials have the power to change this system and it
must be changed. What is important is getting quality care to our seniors.

Respectfully,

Richard C.McCoy,Jr.R.Ph.
Lopez Island Pharmacy
Lopez Island, WA 98261
360-468-#### x103 [Contact TheAngriestPharmacist for Phone Number]

***Reproduction and publication rights are granted on this letter to any
group or individual ***

I think Mr. McCoy has hit the nail on the head. The Federal Government conceded the fact they they could not handle adequately implementing Medicare Part D, so they allowed the insurance companies to step in and take a crack at it. Much as we would have expected, the PBMs have concerned themselves with their pockets and not with the welfare of our seniors/recipients.

I’ve said for a long ass time that direct-to-consumer advertising needs to be made illegal. The average American cannot be expected to comprehend the many factors that go into prescribing. And the fact that Pharma sidesteps the law by merely stating, “Ask your doctor about DrugX” really pisses me off. If they do not state the indication, they do not have to specify the potentially dangerous (and common) side effects. Another practice Pharma has resorted to is that of completely ignoring the law. Throw together a commercial. Get it on the airwaves quickly and widespread — then watch the profits roll in. They may be breaking the law, but by the time complaints can be registered and the FDA can get an injunction (they don’t have any real power) Big Pharma has already seen profits well above potential fines they may incur. That’s fucking bullshit isn’t it?

Don’t even let me get started about what Part D’s reimbursements have done to the independents. These guys are fighting tooth and nail to stay afloat. They don’t have a 200 thousand square foot store to account for losses incurred to balance things out.

Rick has also nailed the complexity of the plans. If I have to struggle to comprehend the assorted plans, I can’t imagine what our country’s seniors are thinking. This has created a viscious cycle. Pharmacists don’t have time to learn the plans and/or help the people due to the increased volume generated by the number of people covered and the decreasing number of pharmacies.

I’m pissed off — how about you?