Below, I'm going to post several different things that came to me via email or the CONTACT link. I'll lead with the user's name, and if you wish to reply to one, just reference that name....or don't...I don't care...

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Liz writes:    In the past few weeks, our pharmacy has started checking ID for controlled drugs, scanning in new Rx and scanning in hard copies.  All of a sudden, our workload has tripled, but our company is cutting tech help.  Is anyone else finding this hard to manage?

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Rodney writes:   I work as a reimbursement specialist at an LTC Pharmacy, and I'm writing to share an interesting exchange I've had with representatives at Prescription Solutions over the past few days.

I've had a few basic rejections which, were the representatives at Prescription Solutions even modestly intelligent by today's decidedly low standards, should have been able to resolve with much rapidity. Instead, I got stuck with slack-jawed yokels and embittered, defensive inner-city youth. They turned requests for overrides to simple rejections into drawn out, unintelligible arguments, and once they'd been cornered or otherwise became bored with the exchange, they hung up on me mid-sentence.

I may not be the bubbliest person in the world. On the contrary, I'm frank and to the point, but never did I become enraged, and never did I insult or otherwise disrespect the reps in any way. Prescription Solutions - hell, the insurance industry as a whole - has no shortage of stupid, rude, and disinterested people, but I've never had any with the gall to abruptly hang up on a service call. Now, over the past two days, it has happened to me four times.

Though I feel somewhat vindicated by the fact that return calls yielded exchanges with intelligent reps who applied the necessarily overrides with absolutely no hassle, I am perturbed by this sudden shoddy treatment. I know PS has seen extraordinarily long hold times as of late, what are the odds the reps have been granted free reign to terminate calls from "problem callers" (that is, of course, callers who question the rep's ill-informed initial judgment)?

Any thoughts? Similar experiences?

[TAestP's thoughts: I believe the reasoning behind this is, as always, money. When the question is, "Why?" most of the time, the answer is money. In this case, I'd bet if you timed your calls, you got hung up on at specific intervals....something like 3 minutes, 59 seconds. If the agents keep their calls (or a certain percentage) less than 4 minutes, they probably get higher ratings or a bonus at the end of the day. They may also have rewards/cut offs at 10 minutes or 15 minutes. Of course, the person could have just been an asshole, accidentally hung up, or hung up on you because they are lazy and/or didn't know the answer.]

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Lillian writes:     I found your blog a few days ago and I love it so far. From your posts, you seem to know a lot about retail pharmacy so I was wondering if you could answer a question for me: Is it true that the field is getting very saturated, very quickly?

A few of my professors warn us that it will be much harder to find a job in retail by the time we graduate (2016). And I've been hearing a lot of people saying that retail is going downhill.

I know there will be more competition for the jobs in several years because of there are more students going into pharmacy now. And I get the feeling that maybe one of my professors is exaggerating the situation to encourage us to go into other pharmacy fields. But do you think this saturation is something to be seriously be worried about?

For the record, I would try to go into retail no matter what the situation is...I just don't want to be completely caught off guard after graduation.

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Kristin Writes:
Dear TAestP,
I know someone who filled a Rx at a CVS.  The pharmacist later called and texted her saying "Remember me from CVS?  Would love to get coffee with you some time?--Weirdasspharmacist [sic] "  She responded that she wasn't interested. She didn't get any more fills there, but she was afraid of contacting his manager or pharmacy baord because CVS had her information on file and the pharmacist could look it up and perhaps do something scary like stalking.

TAestP, what would you recommend doing?

[TAestP's thoughts: If this is true, it is creepy as hell. You are right that CVS would have the info, and he would have access to it. But, he's already pretty much risked his license by doing this -- taking it from creepy to full on stalking would definitely result in a meeting with his state's Board of Pharmacy. If he is not the pharmacy manager at that location, I would call and speak with the pharmacy manager about the incident. Tell her it made you (or her) uncomfortable and that you would like the manager to give your information to their district manager so he/she can call you at their earliest convenience. Then discuss the matter with the DM. I'd be almost anything this would squash absolutely any issue -- cause that DM does NOT want you making a formal complaint with the board. If he is the manager at that store, call a nearby store's pharmacy manager and do the exact same thing. If this does not get you to an ends that you are happy with -- or you get blown off at any level -- google the state's board of pharmacy. One call to them with an accusation like this would definitely result in an investigation and something would be done. Tell your friend I'm sorry my text creeped her out -- she's not gonna like the photos I'm sending tonight....just kidding of course.....:-D]

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Mike writes:   so...i witnessed a patient ingest 90mg of methadone...the patient's prescribed dose was 40mg...i gave him the wrong bottle

i'm getting kicked out of pharmacy school 4 months before graduation...what do i do now?  should i submit my resume to the nearest McDonald's?

[TAestP's Thoughts: Either this is untrue and you're trying to waste my time, you're just a general dumb ass,  or you have done a ton of other stupid bullshit.  Regardless of what anyone may think, there is only one person responsible for what pill goes out the door and into the hands of a patient -- the pharmacist on duty. I don't care if the technician accidentally typed in Oxycodone instead of Omnicef for an infant, I still believe the ultimate responsibility should lay on the pharmacist that verified the prescription. (intentional bullshit and other types of lying and deceit aside -- I'm talking about true accidents by ancillary staff not caught by the pharmacist)   However, it does sound like you are in some other kind of facility or setting. Since you witnessed the patient do it -- not sure what that means as a patient should never be handed a pill by pharmacy staff to take -- that changes the role from dispensing to administering which we cannot do (in terms of pills).

If the school threw you out, and this is a true story, you're probably fucked. Sorry dude. I guess you could appeal and plead to the school, but that's the thing with private universities, they can do whatever the hell they want whenever the hell they want. Other than that, see if another school will take you or get a lawyer....or get a job and good luck paying back all those loans....]

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That'll do for now....check back for the next post coming soon....

2000 B.C. - "Here, eat this root."
1000 B.C. - "That root is heathen, say this prayer."
20 A.D. - "That prayer is good, but you have to pray in my name me to get through to Dad."
1850 A.D. - "That prayer is a superstitious chant, drink this potion."
1940 A.D. - "That potion is merely snake oil, swallow this pill."
1970 A.D. - "That pill is ineffective, take this antibiotic four times a day."
1980 A.D. - "Bacteria aren't the problem. Viruses are enemy number 1! Get this vaccination, but you still better take our pills too!"
1990 A.D. - "Taking pills four times a day? That's ARCHAIC! Take this tablet once-a-day."
1999 A.D. - "That once-a-day tablet is cost prohibitive. Take this cheaper generic. It's the same thing."
1999 A.D. - "Their generic once-a-day tablet isn't good enough anymore. Our 'XR' tablet is now the standard of care. And you only have to take it once-a-day!!!"
2000 A.D. "This XR antibiotic kills all the bacteria in your stomach. Take this bacteria capsule four times a day."
2000 A.D. - "Those vaccines are still working, but our data shows they definitely cause autism and some other nasty shit."
2001 A.D. "No, they don't. The data never showed that. Shit happens."
2003 A.D. - "Bacteria are now resistant to this once-a-day antibiotic. We're probably fucked."
2011 A.D. - "Oh yeah, we have immune systems. That's why the vaccines work. Let's just drink the damn tap water and shut the fuck up."

Note: I amused myself writing this. I know the dates aren't even close to right, but it's all so true. Feel free to fill in the holes and make corrections via the comments. Let's tweak this, finish it up, then send it around the Internet like some of the other stupid bullshit I get.

Additionally, he had the plastic device jammed into a Aerochamber in reverse -- so if you somehow were able to dispense a dose, it would spray upwards rather than into the chamber.

Now, I can see how one could say that this is merely a failure on the part of the pharmacist to effectively counsel on proper use of the inhaler...and you're probably partially right. In all likelihood, when he picked this up for his child, we BOTH assumed that a grown man would have sense enough to either use an inhaler with aerochamber or read one of the three separate inserts / literature that were purposefully put into the patient's bag. The assumption was proven incorrect. This patient was obviously too intelligent to be bothered with reading those stupid papers that patient's so often vehemently deny and exclaim, "throw all that crap away I've got tons of it at home," only to attempt to jam a square peg in a round hole and break the entire contraption. Wow...just wow...

Finally, this gentleman was mad at ME for not repairing the inhaler OR replacing the inhaler at my cost. I got him an override for an early refill (the TIME spent was my cost...right?). As he left he asked "when the boss was gonna be back." I, of course, don't do well with this comment because it's a slap in the face and passive aggressive. Just tell me what your fucking problem is and assume I have sense enough to come to a reasonable end-game.

Prior to this I took the time to look up the number to GSK for him to call and see a coupon or refund for the product he obviously broke. He was mad about it still, and his only concern was "What if I pay for this one, get it home, and it don't work neither?" -- Well, considering you broke the first one, I'd say the likelihood of you breaking another is rather high considering you still haven't opened up to me trying to show you how to effectively use it...Alas, you have more copies of the literature (illustrated ones this time -- for the kids!). If you don't break this one and it "still don't work" -- it's STILL NOT MY FAULT.

I'm sorry, I don't service inhalers. No pharmacy does. If it doesn't work, it's the manufacturer's fault. If you don't know how to use it -- that's my fault. I've done what I can to help on that front. You're gonna have to be a big boy and make a phone call for the rest -- rather than "gimme gimme gimme gimme..." like usual...

Here's the Abstract:

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My name is Steve Moore and I am an independent pharmacy owner from New York.  I am wondering if you would consider sharing your thoughts on the following topic, one I think that most pharmacists would be interested in.

When it comes to business side of our profession, most pharmacists don't have a clue as to what is going on.  As an owner, it affects me more than most, and I don't comprehend all of the complexities.  After speaking to some other pharmacists in my area, I came to realize that they are under the impression that mail order pharmacies were simply discount pharmacies, that mail order just filled prescriptions at a lower price than retail pharmacies.  That may or not be true, the larger issue is that mail order pharmacies are able to offer deeply discounted medications because they are purchasing medication a better price than retail pharmacies.  PHARMA grants them a special class of trade (COT).  I attempted to find a law/rule/etc that grants mail order pharmacies these special buying privileges as a different COT and was unable to do so.  I wrote to consulting companies and wholesalers and I was told that there is no such list.  If there is no government approved or provided COT list, what makes mail order special other than the fact that PHARMA says so?

My question is, if mail order can do it, why can't community pharmacy designate itself as a special COT?  Mail order promotes safety and accuracy, we have a robots and workflow too.  We can fill antibiotics and pain meds, mail order cannot.  We can deliver meds the same day, mail order cannot.  Mail order simply cannot meet 100% of our pharmaceutical needs.  If any group deserves a price break from PHARMA, shouldn't it be the group that can meet more needs?

There is a federal law known as the Robinson-Patman Act which specifically prohibits companies from selling the same products to competitors at different prices (order of magnitude wise).  Exemptions to this act exist to allow nonprofits (such as hospitals) to purchase medication for their own use at a discounted price.  In addition to the hospital COT, there is a 340b class (for now), a long term care class, and depending upon who you ask, anywhere from 7 - 23 classes.  The one constant is that the retail pharmacy COT pays the most for medications.  COT designations have been challenged in the past but were usually lost on the basis of own use.  That meaning, the nonprofit was purchasing medications to use for its patients/employees/etc and was not in competition with retail pharmacies.  Mail order pharmacies are for profit and are clearly competing with retail pharmacies, so in my mind a Robinson-Patman exemption should not apply.  I understand supply and demand and that some people can pay more than others for the same product, but we are not talking about a few bucks here and there, rather exponential differences.  The local hospital pays about $9 for 100 tablets of brand name Coumadin, what does the price sticker on the bottle in your store read?

The fact that mail order pharmacies are buying  medications at a lower price than retail pharmacies has an impact on every pharmacist filling 90 day prescriptions at retail for mail order rates.  I am not saying that if reimbursement improves, working conditions will improve, but it can't hurt to make pharmacists aware of what is going on.  I have contacted our trade associations and industry publications but am also reaching out to bloggers such as yourself.  If you feel that this may be something you would like to blog or post about, I can provide some links and references.

Thanks for your time.

Well, Imitrex is going off patent, and Dr. Reddy's is itching to get into that generic migraine therapy market that is currently absolutely DOMINATED by ridiculously expensive name brand medications. As you can see above, these fucking things are $27 PER TABLET. As you might have expected, now that Imitrex is going to have an AB-rated generic equivalent, it is complete junk and no longer efficacious for migraine headaches (with or without aura).

So, what comes to mind when you see what GlaxoSmithKline is doing here? To me, I think of the assraping of American citizens that are already struggling to make ends meet in a time of economic hardship. I think of GSK playing tricks on Americans that may not have as much education as their local pharmacist. I see that GSK knows that people who are suffering from migraines will pay anything to no longer be suffering from migraines. They are banking on that fact. Now, they are hoping that maybe just once, Imitrex didn't provide you full relief -- just enough of a chance to get you to call up your doctor and ask for a prescription for that new drug, Treximet, that you just saw on television. [I've seen Treximet ads on 5 different channels today.]

Ya know, I wouldn't be surprised in the fucking LEAST if GSK hasn't been slowly dropping the potency of Imitrex tablets over the last few months -- in hopes that their migraines won't clear up and they'll seek out a new therapy.

But TAestP, WHAT IF TREXIMET REALLY IS BETTER????

I don't doubt the efficacy of Treximet. But, I have a few insights here. Does Naproxen alleviate your migraine symptoms? I'm sure you tried it initially as it's in every major migraine algorithm after Acetaminophen and Ibuprofen. If you're taking Imitrex, that probably means you failed Naproxen therapy. So, why are we adding it back on board now?

Does anyone know how much Sumatriptan tablets are going to cost? It doesn't really matter exactly how much they are going to cost -- we know that the generic is going to be cheaper. We also know that NAPROXEN IS DIRT FUCKING CHEAP. So, once again, big pharma has taken two seemingly inexpensive drugs, combined them, called them gold, and made them just as expensive.

Here's a few notes I'd like to share:
- Clinical Pharmacology lists "Krymchantowski AV. Naproxen sodium decreases migraine recurrence when administered with sumatriptan. Arq Neuropsiquiatr 2000;58:428—30." as a source for why the combination is better. What's wrong with this study? Well, how about the fact it was tested in 67 (56 women) people by ONE researched in RIO DE JANEIRO. It's way too brief. The methods are weak. It is a poorly done study.

- Also listed as a reference is: "Brandes JL, Kudrow D, Stark SR, et al. Sumatriptan-naproxen for the acute treatment of migraine: a randomized trial. JAMA 2007;297:1443—54." -- This one is cited because it shows that 'more patients had sustained pain free responses 2-24hrs after the dose with decreased recurrance rate in combo vs either drug as monotherapy or placebo. I didn't even read this study -- I flipped to the back page, as I always do, and saw all that I needed to see.

Funding/Support: The 2 clinical trials (MT-400:301 and MT-400:302) described in this article were funded by GlaxoSmithKline in partnership with POZEN, the IND sponsor of the investigational drug MT-400 (sumatriptan–naproxen sodium).

Role of the Sponsors: GlaxoSmithKline and Pozen Inc provided financial and material support, monitoring, data collection and management, and data analysis to the authors and study investigators.

In case you were wondering, POZEN INC is a puppet company of GlaxoSmithKline. And, as you can see, they performed the ENTIRE FUCKING STUDY.

Also of note regarding this filth of a study fabricated to bilk money from the American people, of the 10 'researchers,' two admitted to working for 'Pozen' and two for GSK --- all of which work in Chapel Hill, NC.

-The final study listed in ClinPharm boasting this drug is merely a safety and tolerability study. Well, fucking duh this drug is tolerable. How often do you think people need to take Sumatriptan? Once every other day? Once a week? Heck, the max daily dose is 2 tablets. So, the most Naproxen you could get is 1000mg -- a normal daily dose -- which wouldn't be ingested that often. Of course it's safe.

Of course it's non-inferior. Of course it's safe. But, is it cost effective? No. It's not. Because you motherfuckers at GSK have no fucking morals. You're soul-less pieces of deep fried pig shit, and I hope all of you get the pleasure of having Alzheimer's as you age. You all deserve to be beheaded on Al-Jazeera. You're nothing. You're wastes. I wouldn't shit on you if I got paid a million dollars to fill "2Guys1Face." I hate you more than I hate everything else combined. I just wish that there was some way I could just remove the money from you via osmosis and have you thank me for it -- much like the unsuspecting public is doing now.

You may give them a $20 coupon or even a few free pills, but I'm hip to your game GSK. I'm not gonna play. My pharmacy will NOT carry your product. My pharmacy will NOT dispense your product. If someone brings me a script for this bullshit, I'm going to be having a conversation with a doctor. I'll end up filling two prescriptions and having a little education session. I just pray that you don't send some fucking big-tittied Treximet Drug Rep to me. That bitch will leave in tears...

-=+=-

Has anyone else had this issue? Do people really think that NON-DROWSY means insomnia?

Does Non-Profit mean that an organization is designed to LOSE money?

Just wondering...

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.

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

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).