Tuesday, March 17, 2009

Here's to St Patty's Day: Guinness and Antabuse anyone?

After some cursory reading online I was struck by yet another way pharmacists can dramatically reduce the current cost of healthcare: substance abuse programs.

Consider alcoholism. Studies have found that taking Antabuse by itself - without a community program or therapy - has little to no benefit for the patient. For those not familiar with this drug, Antabuse is much like Flagyl (metrodinazole) in that it impairs the livers ability to metabolize alcohol. Normally alcohol is broken down into acetaldehyde, then acetate. However, disulfiram and Flagyl both inhibit a key enzyme that converts acetaldehyde into acetate. The result? Acetaldehyde builds up in the body causing severe nausea, vomiting...and a regretful experience.

But patients who are in treatment for alcohol abuse who pick this up at the pharmacy to take in the comfort of their own home show little benefit from taking this medication, research shows. A better model is visits to a clinic where the medication is administered by a therapist or nurse three times a week. The reason is as much a compliance issue (patients actually taking their Antabuse as directed at home) as it is a psychological one (positive reenforcement, coaching and assistance).

Here's a thought: What if pharmacists filled that role? Couldn't a pharmacist, a doctor of pharmacy, an expert in medication and pharmacokinetics, assist a patient in understanding how they can combat an addiction to THE most commonly abused drug in the United States?

Just some food for thought.

Source: http://web.ebscohost.com/ehost/pdf?vid=6&hid=17&sid=d8f0bddb-8a14-486d-9ae1-2486b8ae38cb%40sessionmgr2

Sunday, March 8, 2009

Diabetic Discrimination: An Exhibition of Educational Ignorance

In America, we're endowed with the unique opportunity - despite how we might otherwise perceive it as children - to have access to government sponsored education. True, there exists tremendous disparities in the quality of these institutions across the US, but a foundational principle underlines our culture: access to education is a right, and legislation for educational reform is applauded and valued.

When our educational system falls short of its goals, we swiftly act to correct the imbalance. But when it also demonstrates discrimination and ignorance, I, and I'm sure many other individuals, become a bit frightened and outraged. Such was the case when I read over an article (http://www.childrenwithdiabetes.com/d_0n_401.htm) concerning a blatant demonstration of stupidity at middle school in Missouri. A diabetic child, taking a glucose tablet to maintain proper glycemic control, shared them with friends. A teacher, noticing the incident, took possession of the later alleged "drug", and subsequently, after much-ado with the principal and superintendent, culminated in the diabetic child's six-day suspension after sharing OTC medication. Not only that, but the child had a permanent record placed in his file stating the illicit incident and was targeted as a candidate for a drug abstinence program.
This occurred despite letters from the state's diabetes' advocacy group, numerous medical professionals, and the manufacturers of the glucose tablets attesting to the fact that the sugar discs were no more a drug than the candy teacher's handed out for turning in homework. Evidently, to all the teachers and professionals within the district, the tablets were still drugs.

For upcoming medical professionals like myself and already tenured individuals, this demonstrates a unique challenge we must recognize. Not only must we educate individuals with particular disease states on how to manage their conditions, but we must also fervently educate the community at-large. When we all help in creating an environment that nurtures health and wellness, we all benefit...and we can avoid an educational system that demonstrates an exorbitant level of stupidity.

Thursday, March 5, 2009

Assuming: It makes a You-Know-What Out of Me and You

I learned yesterday to never make assumptions, and I learned it the hard way. So maybe the rest of the pharmaceutical world can profit from my stupidity and avoid the same blunder.
Patient comes to pharmacy to pick up their medications. Patient is with 10 year old son. The medication is for prenatal vitamins. The pharmacy you work for puts a "Mandatory Consultation" advisory on the medication. You can't sell the medication until the pharmacist talks with the patient about their prenatal vitamins.
So, you tell the pharmacist that they need to consult with the patient. Meanwhile the patient is waiting, eagerly, to get on with their day. You don't want to inconvenience the patient anymore, and the pharmacist seems busy. So, pharmacist asks you to ask the patient if they're pregnant, nursing, or attempting to have a child.
You go back to the patient to ask these routine questions because these "Mandatory Consultation" blocks happen all the time. But - SCREEEEEEEEEEEEECH , STOP! WoW- Back the Car Up....not such a good idea. Can we go back in time at this point?
The patient looks at you with a flushed face...the 10 year old kid looks a bit bewildered and puzzled. Mom snaps at child "Go sit down", avoids looking at you, and walks over to the pharmacist.
"This is not how I wanted my son to find out" she quips. Pharmacist apologizes, updates health information. I look like a big, yep, you know what, feel about 2 inches tall, and want to curl up, out of sight, in the back of the pharmacy and not face the world for the rest of my shift.

Moral of the story: never assume your inconveniencing a patient by having them step over, by themselves, to the pharmacist to talk about their medication - even if it's just for a multivitamin.

Prescription Drugs For Less: Part Two

Continuing on the note of soothing the financial difficulties of
prescription drugs, here are some more questions to ask your healthcare
professionals or to investigate yourself.

1. "Are there rebate programs for my particular medication?"
Amazingly, many prescription companies have reimbursement programs setup to help defray the costs of your out-of-pocket expense. You should know that in most circumstances, individuals covered by Medicaid or Medicare
are NOT eligible for these programs.
In order to find drug vouchers, you can
-ask your prescriber if they have any available in their office,
-look online using a search engine like "Google" using search terms
like, "chantix discount card" or "provigil voucher",
-ask your pharmacy if they have any coupons available
-contact the manufacturer of the medication via email, phone, or snail mail

Among some of the medications I've seen discount cards used for:
- Chantix
- Vyvanse
- Provigil
- Proair
- Proventil
- Pristiq
- Actonel
- Boniva
- Advair
- Solodyn

You'll see that most of these drugs are all brand name - so even with a
voucher, it may still be cheaper to go "generic" or find a "therapeutic
equivalent", but it's worth inquiring.

2. "How long will I need to be on this medication? What else can I be
doing besides drug therapy?"
If the course of therapy is going to be extensive, don't forget that lifestyle choices can considerably impact the need for many medications. It's been said to me, "For every pill, there's a lifestyle choice it mimics". A study published in the BMJ in 2007 (http://www.bmj.com/cgi/content/abstract/334/7588/299) showed that
lifestyle choices were just as effective as medication in preventing
type II Diabetes in individuals with glucose intolerance. A 2008 study
on sleep and prehypertension discovered that not getting enough
shut-eye, among other lifestyle choices, had tremendous ramifications
that - if remedied - could reduce the need for medications

3. "Does my insurance offer me reduced costs on mail order?"
I'm a firm believer in establishing a great relationship with a
community pharmacist, but if getting your prescriptions through mail
order is cheaper than getting your prescriptions at a retail pharmacy,
it may be the better option. Especially when you intend on being on the
medications for at least a year (since mail order typically delivers a
3-month supply at a time), mail order can dramatically reduce the stress
of picking up your medications every month. However, mail order has it
down falls, so make sure you inquire with your Pharmacy Benefits Manager
- which can be different from your insurer - on what their policies are
for mail order and retail pharmacy payment structures. Usually you'll
need to get two scripts at your doctor visit - one for a week or two of
the medication to fill at a community pharmacy, and the other to send to
the mail order facility with their required documentation.

Mail order isn't a good option if you move frequently or have limited
access to secure mail. If the medication is an anti-depressant, blood
thinner, blood pressure medication, or for a thyroid disorder, your
prescriber may change your dose on a monthly basis. For these kind of
medications, mail order can be extremely confusing. And if you intend
on going on vacation when your supply is running out you'll need to see
if you can get a one-time "override" (just ask your local pharmacy to
call your insurance company to take advantage of this benefit IF your
pharmacy benefits manager provides it).

Tuesday, March 3, 2009

How to Get The Cheapest Prescription Costs: Part One

Gone are the days of lavish insurance benefits and $10 copays. Now,
faced with a disastrous economy, its not atypical to see a patient come
to the pharmacy and pay $100 out of pocket - even after their pharmacy
benefit's manager has pitched in their contribution.

If you're one of those people paying - in more ways than one - for your
health, or if you're a health professional assisting patient's with
their drug therapy, consider the following tips to keep everyone out of
the red. Ask your pharmacist and/or prescriber these questions:

1. "Is there a generic available?"
Generics...Generics...Generics: Ask your prescriber if the medication
they want to prescribe for you is available in "generic". You might
frown at the idea of getting "non-brand" anything. But rest assured:
generic medications are not your ordinary knock-offs. The Federal Drug
Administration (www.fda.gov) oversees all prescription medications in
the US and states the following on their webpage:

"What are generic drugs?
A generic drug is a copy that is the same as a brand-name drug in
dosage, safety, strength, how it is taken, quality, performance and
intended use.

Are generic drugs as safe as brand-name drugs?
Yes. FDA requires that all drugs be safe and effective. Since generics
use the same active ingredients and are shown to work the same way in
the body, they have the same risks and benefits as their brand-name

In order to receive a generic medication when it is available, your
doctor must not indicate "Dispense As Written" on the prescription. If
they do check this box, the pharmacist must dispense exactly what your
doctor writes.

2. "What are these medications, how many days will they last me, and is
this exactly what the prescriber ordered?"
It might seem obvious, but make sure you're getting what you want before
you pay. Pharmacies are very hesitant about taking back medications
that have left their stores, and for good reason: it assures the quality
and safety of all patients who could potentially receive that
medication. If a price seems too high, ask if you received generic,
what quantity you received, how much insurance picked up, and ASK THE
PHARMACIST. Technicians can be very savvy, but they can also be very
incorrect. BEWARE: When a drug is not available because of backorder or
because they're out of stock, I've personally seen pharmacists give
patients brand medications simply because they want to make a sale. If
that pharmacy doesn't have the medication in stock, ask for the pharmacy
to call around and find a store that does have the item or ask them to
order it for you. In most circumstances, you can get exactly what you
want within 1 business day.

An example as of late was Metoprolol Succinate ER. A particular chain pharmacy's supplier,
Ethex, recalled the medication and this reduced the availability of
Metoprolol Succinate (generic for Toprol-XL). HOWEVER, Ethex is not the
only manufacturer of Toprol-Xl; in fact, the brand manufacturer makes an
almost identical generic. That company, Par, supplies other drug
companies with the generic for Toprol. But, because of what seemed to
be for business reasons and the financial interest of the pharmacy chain since
Par is not a preferred supplier and because the pharmacy chain doesn't make as
much off of that particular manufacturer's generic, the chain drug
company was not acting in their patient's best interest to seamlessly
continue the supply of that medication. Instead, they were telling
patients that THEY needed to contact their doctor and ask for a
different, non-extended release form of Metoprolol. Rather than
telling the patient this, pharmacists were sometimes changing the patients over to
the much more costly brand medication and telling their patients - often
unknowing seniors - that the medication costs more now and may look a
little different because the drug is on backorder. Case in point:
always check before you buy and ASK QUESTIONS.

3. "Is it cheaper for me to get three months at a time if my insurance
will allow it, or would it less expensive if I paid without using my
Ask this question when you drop off your prescription to save you and
the pharmacist/technicians valuable time and stress. See if you can get
a 90 day supply of your meds. Oddly enough, sometimes insurance
companies will charge the same copay for a month supply that they would
for three. Also, some medications that are taken weekly, like Vitamin D
50000 Units, can be cheaper for you to purchase out-of-pocket (without
your insurance). In the case of Vitamin D, 12 pills - a three month
supply - is roughly $17 up front. Since many insurance companies have a
mandatory minimum copay ($10 maybe), you might have to pay $10 each
month for three months. That's $30 over the course of 90 days.

4. "Will you price match?"
Chains like Supervalu (Albertson's/Osco) will price match other
companies on your medications even if you don't know the cost at large
chain stores like Walgreens, Walmart, Target, or CVS. They can look
them up online and will gladly - from what I've observed - give you the
best cost because they genuinely care about your physical and financial

5. "Is there a therapeutic equivalent?"
A therapeutic equivalent is different from a generic. Therapeutic
equivalents can achieve the same effect of another medication and help
you reach similar health outcomes (like lowering blood pressure or blood
glucose). For example, Lipitor - the top-selling cholesterol lowering
medication - does not have a generic available yet, but it belongs in a
family of medications called "statins". There is a generic statin
called simvastatin (Zocor) that can be just as a effective as Lipitor.
It may, however, require a higher dosage or perhaps need to be taken
more frequently. Doctor's may prescribe a brand like Lipitor because
they've read some recent study on its efficacy, spoke to a drug rep, or
want to deliver the most effective therapy for their patients. But if
the price of a medication isn't working for you financially, it can
greatly impact your health because of the added economic stress or
feelings of entrapment ("I have no other option...I must take this exact
medication...this price is the burden I have to pay for my poor health
and there is no alternative). These thoughts are not true and, by
dialogging with your pharmacist - your personal medication expert - and
doctor, you can find a medication that will work for you in every aspect.

Sunday, January 18, 2009

Suppositories Don't Amuse Me

Pharmacy professors aren't stand up comedians. There's a reason why
they went into pharmaceuticals. As such, I think I'd like to proclaim a
moratorium on all route-of-administration jokes in any pharmaceutics
class. Pharmacy professors: spare your students and do not rant about
the importance of such statements as: "UNWRAP and insert" or "FOR VAGINAL
use only". Find one discrete class to mention it once, then pick
another specific class about 6 months later and mention again that "BY
MOUTH" or "USE RECTALLY" must be on prescriptions...but don't bother
telling the story about the gentleman who came into the pharmacy to
complain about how bad his suppositories tasted or the woman who's
symptoms were improving, she just "didn't like how the foil wrapper
felt". I chuckled awkwardly the first time, laughed a little the second
time, smiled the third, yawned the fourth... I'm barely through my
second quarter of classes as a first year student, and I don't have
enough fingers to count how many times a joke like that's been used.

Don't get me wrong: humor is great in the classroom. But jokes are
jokes only a few times. After that, the jokes on you.

Monday, January 12, 2009

I'm My Own Worst Patient

Considering I'm going to school to be a pharmacist, it's a bit ironic
that I'm rather "anti-medication" when it comes to myself. The last
time I took an OTC was maybe two weeks ago...a couple of Advil. I think
I did that twice last year. And the script I needed for a nail
infection, well, I refilled it once, took it pretty regularly, and then
my symptoms improved. The remaining refills are still on the Rx.
Perhaps I'll transfer it to Walgreens and cash in on a $25 giftcard like
the rest of America.

More than half of all insured Americans take medications for chronic
health conditions. American children are 3 times more likely to be on
psychotropic medications (for ADHD or depression) than their European
counterparts. And in 2002, the volume of medications dispensed in
America went up 25%. We are an Rx nation. The fact that drug companies
profit off of their consumers (not patients but consumers) is
unsettling. First they instill a psychological sense of dependence on
their medications (when in reality lifestyle modifications could
ameliorate symptoms of many chronic diseases and other treatment options
besides medications are available but much more time consuming).
Second, with this dependence ingrained, they can raise or lower prices
at will with little competition on the market. Consumers are left to
bend and sway at the command of big pharmaceutical companies.

My aversion to OTCs is equal: what a ploy that Tylenol sells a $12
bottle of APAP when the actual pills are pennies a piece. And then they
market the same bottle with "Arthritis relief" for $2 more, but seeing
that the typical consumer knows no difference, it's an automatic source
of profit.