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....

Had a lady call me for a refill (on we'll say 3/19) on her (surprise) Norco 10/325 last week because she was (surprise) going out of town. It had been 9 days since we had refilled it. The prescription was for 50 tablets taken every 6 hours. I put it in as a 13 day supply. I told her that it would be "a few more days" before it could be filled. She, of course, did not agree with me. She tried to tell me that it was a 12-day supply and we, meaning my pharmacy, "always fill it three days early." Well, she's wrong...maybe two days early...on a 30 day supply...if the patient isn't a problem....

The fact that she argued with me about filling it early, about it being a 12 day supply versus a 13 day supply, and told me what MY pharmacy always does got me interested in her profile.

I booted up my trusted internet browser and navigated to my state's Prescription Drug Monitoring Program, plugged in her information, and I was quite shocked at what I found.

Date                        Drug                                       Qty/Days    Prescriber   Filled by:
3-14         Hydrocodone/APAP 10/325     90/30          J. Smith          CVS
3-14         Alprazolam 1mg                               90/30          J. Smith          CVS
3-10        Hydrocodone/APAP 7.5/325    50/13          B. Jones          MY PCY
3-10        Alprazolam 0.5mg                           30/10         B. Jones          MY PCY

And this shit continued for the last 3 months or so. Let me share the most SHOCKING piece of information -- there was another column titled "Payee" which will say Medicaid, Commercial, or CASH. Usually, we would expect this to say CASH at one pharmacy and COMMERCIAL or MEDICAID at the other when we encounter doctor shoppers. In this instance, THEY ALL SAID COMMERCIAL!!!

This lady was doctor shopping using her insurance card...from her benefits at work! WOW! I can only assume the insurance company didn't catch it because the strengths had different NDC -- maybe even different manufacturers? Not sure....

I called and confirmed all of this with my friend Remy at CVS, and we each canceled all of her refills. I then printed all of this out and faxed it to the physicians involved (and every pharmacy in town). I heard back from both offices very quickly -- and they were pissed. They canceled the refills (of course) and each fired her as a patient.

When she called back the next day, it was precious. She said, "Well, will it go through today? It's been 10 days and it's a 12 day supply."   I said, "No, it's still a 13 day supply, and it has come to our attention that you have been getting the same drugs in different strengths at CVS."

"That's just not true!"
"Oh, yes it is. And this has been going on for several months now."
"Well.......(long, awkward pause)......how do I fix this? I'm not sure I know what's going on...."
"Well.......yesterday, I fixed it by faxing this information to both doctors and every pharmacy in town. The doctors then called me back and canceled all remaining refills and wanted me to let you know you were released as a patient. Now, what they are going to do? I don't know. For your sake, I would hope they don't call the police because it appears crimes have been committed here..."
"Eck..." [Really odd sound she made here. I'd say it was the sound of disbelief.]
"If you really and truly have no idea what's going on, you need to call and talk to CVS and both of these doctors immediately...." [I said this in a really shitass tone]
"Okay. Thank you very much!" [Being nice...praying *I* don't call the police]

----------------------------

"I was wondering, if I brought a list of my medicines up here, could you tell me how much each of them would cost?"

"Are you on file here? And do you have insurance?"

"I've never been here before, but I have Paid insurance."

"Well then, unfortunately, I cannot. Your best be would be to look on the back of your card and call the Member Services or Customer Service number listed there. They can tell you exactly how much each prescription will cost. All I can give you here is the cash price which doesn't do you any good when your insurance will foot the bill in most cases."

"I don't understand. Can't you just put it in the computer and see?"   [Gotta love that all-powerful, "computer" that does all and knows all!]

"That's not how it works. If I had valid prescriptions on file for each one, I certainly could just push a button or two and tell you, but you aren't on file here. So, I can't do anything to help you. If you'd rather bring me a stack of prescriptions I can get you prices then..."

"Well. That doesn't make any sense. I've got a list at home with all the prices on it. Why can't you just tell me what they cost? You're a pharmacist!"

"Wait. You have a list of all the medicines, what they cost, and you want ME to tell you what they cost? You want me to tell you what that list already says?"

"Noooo....well, not exactly. You see, at the last pharmacy I went to they gave me special prices on some medicines. Not the expensive ones. They ran those [the expensive ones] on my insurance, but there were some that were cheaper if they didn't use my insurance."

"Are you talking about the '$4 list' generics?"

"Yeah! That's it. How much are those here?

"Well, they are $4...we honor that program. Unfortunately, I don't have them all memorized, but if you bring in what you got, I can figure it all out."

"Well, I've got a list of the ones that are $4 at Wal-Mart at home. Don't you have that list?"

"Wait. You have the list of what your prescriptions cost on your insurance at home. You ALSO  have the list of ALL the $4 prescriptions at home. But, you want to bring me a list of your prescriptions. You want me to look at those two lists that you have at home in your possession and tell you what those lists, that you have in your possession, say. And you want me to compare those two numbers and tell you which is cheaper."

"Exactly. Which is cheaper HERE..."

"Really? ..........[Long Pause of disbelief].......... Sure...bring everything you have to me...I've got nothing better to do. I'll show you how to do one and we'll see if you can get it from there....If not, I'll get you a quote."

What he got from our conversation: That nice pharmacist will put my prescriptions in the computer and tell me what they cost if I bring him a list.

4) REPLY TO ALL FAXES REQUESTING YOU GET A PRIOR AUTHORIZATION BY SIGNING IT AND AUTHORIZING "1+2" REFILLS. This is a GREAT way to both waste a pharmacist's time and really frustrate them. In most instances, they've told the patient 48-72 hours. By replying to the fax with refills, you show that you really want the patient to get the medicine, but it shows the pharmacy that you've got better things to do than read their stupid faxes. To really put a cherry on top of this one, schedule the fax to send at 4:55pm. This will ensure that even if the fax even goes through successfully in the first place, the pharmacy can't contact you again until the next day because the phones cut off at 5pm on the dot (and you cut out at 4:30pm in the first place)!

3) When they call you the next morning, make sure they have to leave you a voicemail. If you're feeling particularly randy, respond to that with a copy of the fax from the day before and a SNARKY  NOTE at the bottom of the fax. Some suggestions for the note are:
"Authorized (1+2) yesterday. Is your fax machine working?"
"I got your VM -- here's the auth you need. Thought I faxed this yesterday. WEIRD!!
You could also just skip the reply all together...

2) When they finally get a hold of you at the end of the second or the third day, tell them your office's standard is at least 3-5 business days on a PA Request. Tell them you'll get back with them at the beginning of next week. After you say this, don't do anything. Don't even ATTEMPT to get the prior authorization. Why you ask? Duh -- the pharmacist will probably call and remind you again on Tuesday or Wednesday when you actually need to do it anyway. Out of sight out of mind! [If you wanna be a real bitch, at this point you need to send another refill authorization in to pharmacy. No note this time -- you don't want to appear "catty."]

1) After they call you Wednesday, if it's a different pharmacist than the one you talked to the previous week you need to go off on him. Make a huge scene. Act as if everything that was sent in and you cannot figure out why the pharmacy refuses to fill the prescription. When they explain the PA Process to you, acknowledge it, say you'll get right on top of it, and completely ignore every word of it. At this point you need to go straight to your doctor and tell them the following, "Doc, I don't know what the heck is wrong with Walgreens. They are pretty much refusing to fill Mr. Johnson's _________.  I've dealt with several different members of their staff. I've faxed in the prescription at least two different times, called it in once, and I can't seem to get them to fill it!" Then, the doctor will call and ABSOLUTELY TEAR THAT STUPID PHARMACIST A NEW ONE! Sit back and laugh. You've done a good job. You've waste almost a week of the pharmacist's time, and you've not had to do much work or call for the PA.

Final Step) Now, when the doctor returns to you,  he'll explain to you that they just need you to get a PA. They'll be so scared of the doctor, they won't say anything about your prior shenanigans. Your response should be, "Well, why didn't they just SAY THAT!?! STUPID PHARMACISTS!" He will agree and, at this point, you need to call the pharmacy again and have them fax you the information on how to get the Prior Authorization. They will probably say something about how they sent you the information -- just tell them you never got anything. Now, buckle down and actually get the PA...dag nabbit!!

And that is how you get a PA!

Now, this young lady didn't say that -- it was a variant that can be equally suspicious, "How much does this cost? Cash Price. I no longer have insurance." The fact someone says this isn't always suspicious, but the fact she said it twice (and awkwardly at that) did set off my bullshit detector. She told me that she wasn't on file -- luckily she was -- and lookie there....A MEDICAID CARD! I, of course, didn't tell her that I had this information.

I ran it, and low and behold, it rejects. I call up Medicaid to inquire about doses, quantities and where. They tell me a Norco 7.5/325 #90 (30 day supply) filled at a nearby CVS about 14 days ago. [The Medicaid agent gave me the Fraud Line and urged me to call. She also said that the new Rx could be filled in NINE DAYS based on carryover days, etc.] The Vicodin prescription was written 4 days ago. I called CVS, verified Name, birthday, medicaid ID number, and made sure it was picked up. Now, we have a problem.

I wrote her Medicaid ID number right next to her name (very big). I also wrote a note explaining the entire situation on the face of the full page prescription. When she came back to pick up the prescription, we had the following exchange:

[The most unfortunate thing here is that while the following is occurring, there is a 4 or 5 year old little girl stumbling around in front of the pharmacy munching on a cherry Dum-Dum I had given her...unable to comprehend the gravity of what was going on in front of her...the mistakes her mother was making before her eyes.]

"We have a bit of a problem here. We had you on file, and we happen to have your Medicaid Card and ID number on file. As we ran this it came back that it was a refill too soon and duplicate therapy."
"I don't have any insurance or medicaid. I didn't fill anything at CVS..."
"Stop lying to me. I called Medicaid and they told me that #90 Norco 7.5/325 tablets were filled at CVS 14 days ago. I called CVS and verified this information. They also checked the signature logs and found your name signed to the electronic pad. Now, if you genuinely have no idea how this prescription got filled or what is going on here, I can pursue this matter further. However, if you are lying to me, of which I have ZERO reason to believe you are telling the truth, this will end very badly for you."
"No Sir. That won't be necessary."
"I was told by Medicaid that you can fill that in 9 days. I wrote that date on the prescription along with a little note in case you decided to try and take it anywhere else. I've also notified the area hospitals, clinics, and pharmacies through our area 'doctor shopping fax tree.' I also have no choice but to call the Medicaid Fraud Line and notify them of this. I hope these measures prevent you from making any more attempts to acquire controlled medications. Up to this point, you haven't been caught. In the future, you will get caught, and what you are doing is a felony, and it's fraud. Now, for your young daughter's sake, I would hope you turn over a new leaf."
"I will. I promise. You don't have to worry about me ever again. You don't have to call anyone about me. I'm sorry. Thank you. Have a nice day...." [And she scampered off as quickly as possible with her daughter in tow.]

For what it's worth, I did not call any hospitals, doctors, or clinics, and we don't have a "doctor shopping fax tree" (but now that I invented the idea of it, it sounds like a great idea!). I also have no yet called the Medicaid Fraud Line because I was on hold for more than an hour (I left it on speaker), so I gave up and hung up. I said all that stuff in an attempt to scare a 23 year old girl back onto the straight and narrow path. Maybe it was too harsh. Maybe I was wrong in doing all of that. What do YOU think?

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...

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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.

I've also had a recent brash of problems with patients being rude/uncaring about the difference between requirements of a pharmacist versus services provided by a pharmacy. Some things we do are required by laws, federal or state, while some things are done to ensure patients have a good pharmacy experience and return with more pieces of paper.

Requirements:

1. I take the prescription from you. I ensure it meets all legal requirements (Name, Date, Drug name, directions, quantity, refills, doctor signature, and in my state, the Rx symbol on the face of the prescription).
2. I input in the computer (the computer system is not required. I could use a typewriter or even hand write the labels).
3. A prospective DUR (Drug Utilization Review) is performed by either the pharmacist manually and/or the computer system automatically ensuring that there are no drug-drug, drug-disease, or drug-patient interactions requiring concern. If there is, the physician in contacted. The patient is educated or the drug is changed to an alternative at this point. If there is no problems, we move on:
4. A label is generated and placed on an amber bottle.
5. The appropriate drug is counted and placed into the bottle.
6. Final check is performed by pharmacist and all aspects of the process is verified again. Finalized product is bagged and put into the pharmacy's WCB (Will Call Bin).
7. Patient picks up medicine. Patient is provided the opportunity to ask a pharmacist any questions concerning the medicine with the magic question, "Do you have any questions for the pharmacist?" -- this requirement not being added until 1990.

Services:

1. Billing your prescription insurance (or Medicaid) for the cost of your medicine (I don't have to take any insurance - let alone YOUR insurance). Some compounding pharmacies refuse to accept insurance and are cash-only.
2. Calling your insurance if their is a problem such as them not wanting to pay for the expensive name-brand drug your doctor wrote for, the quantity he wrote for, or for any of millions of other reasons they could dream up. Perhaps you remember when CVS made the decision to not call your insurance for problems any more. They accomplished this by placing a phone in the waiting room. It didn't go over well, but it proves my point.
3. Calling your doctor for refills when your prescription runs out. This is the job of the PATIENT that has been performed by pharmacy's striving to merely keep patients from having the opportunity to take their pieces of paper elsewhere if they are forced to visit the doctor for refills.
4. An easy open lid is placed on your bottle instead of the safety lid which is the legal requirement. (Screw your arthritis - I don't have to cater to you!)
5. Paging your name overhead when your prescription is ready -- that's all southern hospitality, buddy!
6. Taking checks or credit cards is also optional. Cash is the only requirement -- read the dollar bill. Does your credit card or check say that I *have* to take it? Nope.
7. Flavoring your child's antibiotic with out FlavorRx system.
8. Anything or everything related to having a drive-thru or providing services through it.
9. Being nice to you in any way, shape, or form. I just have to be there and be sober...I don't have to be my normally delightful self...

I'm sure this second list has a BUNCH more items on it. Fill in the holes for me...I'll add them to the list.

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.

Now, I really like PharmacyTales Version (WHERE DID YOU GO, PT?), but the problem with it is that it is much too wordy. A visitor to the normal, American pharmacy would see that, scream TL;DR and run away screaming. The American public wants lists and pictures. I will now provide the perfect document to give to patients explaining WHY THEIR PRESCRIPTION TAKES SO DAMN LONG TO FILL!

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Dear Pharmacy Visitor,
Recently, we've noticed an increase in prescription wait time due to many factors. To ensure all our patients have full knowledge of our policies and procedures, we've developed this list-type document so that each and every person knows the time and effort put into every prescription.

Prescription Filling Process: 
Drop-off of Prescription(s) by Patient [Usually 1 to 15 New Rx's or Refills]
New Patient Addition (OR Existing Patient Information Verification)
New Insurance Addition
Scanning of New Prescription (In some of our locations)
Input of Prescription into Computer System
Pharmacist Verification of Typed Prescription
Computer-Based Drug Utilization Review (DUR)
Pharmacist Acknowledgement, Review and Resolution of DUR Issues
     - These range from wrong/missing drug, dose, route, quantity, to drug interactions, poor doctor handwriting, unsigned prescriptions, and early/late refills.
Billing and Insurance Adjudication via Online Processes
Resolution of Various Insurance Issues (or Lack Thereof) via Phone Call to Insurance
Resolution of Other Ins. Issues via Phone Call to Doctor's Office for Info/Change
Selection of Correct Drug/Dose from Shelf
Counting of Correct Quantity
Placement in Bottle/Labelling
Pharmacist Verification of Tablet Dispensed to Original Rx
Printing of Supplemental Patient Drug Information
Bagging of Prescription(s) With Correct Pamphlets
Cashier Verification of Correct Patient
Ringing of Prescription/Additional Store Items
Correction of "Patient Issues" with Billing Amount
Patient Signing for Insurance Payment/HIPAA Policy
Patient Payment for Rx/Other Items
Pharmacist-Patient Private Consultation

Other Pharmacy Related Tasks -- Not *Directly* Related to Your Prescription:
All of the Above Steps for the Person(s) in Front of You in Line
Numbering/Sorting of Older Prescriptions for our Filing System
Shelving of Incoming Drug Orders/Stock Replenishment
Stocking/Straightening of OTC Drug Shelves
Calling of Drs. for Rx Refills for Other Patients [as a Courtesy]
Calling of Drs. for Order Clarification/Prior Authorizations/Etc
Answering of Patient OTC Drug Questions
Answering of Assorted Store-Related Questions
Answering of Phone Calls Concerning ANY Issues
Taking Refill Requests from Pts Refusing to Use Computer-Automated Refill
Taking of NEW Prescriptions from Doctor's Offices
Ringing out of Items Not Related to Rx Sales
Ringing out/Logging of Pseudoephedrine Sales
Printing Rx History Forms for Patients for Tax Purposes
Cleaning of Pharmacy Area
LUNCH - We get one just like you!
Bathroom Breaks - We gotta go sometimes, too!

If you think you can help us optimize any of these steps, feel free to give our toll-free number a call at 1-888-ANG-REST.

Sincerely,

Your Phriendly Pharmacist