"Wanted by police"

I'm exhausted, so this probably won't read with as much impact as how the events actually unfolded…

Today has got to be one of the most fucked up days on the pharm on record. Possibly even weirder than the OxyContin bust day.

The two main highlights were the evil woman and the transgendered dude trying to pass a phony Duragesic script. Then there was the woman who was illiterate.

Evil Woman (EW) entered the pharmacy and made herself known to me first by shouting at me from halfway down the aisle. These aisles are about 150 feet long, so she was a good 75 feet away. And she was shouting. That was our first interaction. That got me mentally labeling her as Garden Variety Harmless Eccentric. (GVHE*)

After consulting with some techs about where to find the item of interest (wasn't in my normal store), I sent the lead tech out to help her. She does so, and within 15 seconds, EW's got her off to do some shopping for her while she gets a couple of other things. OK, that's a little weird, but no big deal, we were in the middle of a 5 minute breather.

This woman drops a basketful of shit on the counter, and announces very loudly that she would like to return an item. No receipt, of course. I page the manager since I couldn't be arsed to know the policies regarding returns without receipts. The manager handles the transaction personally, and she's heckling him the entire time. Just a stream of low-impact derogatory comments, and insinuations that he's ripping her off because she spent "much more money than that on this item" and "I spend a lot of money here and in this pharmacy so what the hell is wrong with you!" I'm starting to get a little irritated, since I don't like people who treat others poorly. EW has now elevated herself from GVHE to RPWEI — Rude Person With Entitlement Issues.

EW starts in asking me if I can ring out her script. I tell her that no, I can't, not until the return is complete. Anyway, the manager is soon done, and wisely, he's kept his mouth shut the whole time. (Really there's no better way to deal with this sort of thing, since as soon as you engage it in any way, you're officially fuckedtrapped.)

He scoots, and she starts heckling me now about how goddammit we're not supposed to fill any prescriptions unless she asks for them. (She had two waiting, and she was only expecting one.) Whatever. This woman is irritating but she hasn't quite perfected the art of being rude, since I'm largely ignoring her and she's letting me get away with it. Unrefined evil. Quasi-evil. The Diet Coke of evil, if you will.

She wanders off — finally — and someone thinks to look at her profile. Liar. She's been coming to the pharmacy for a grand total of two weeks. Even better, in big bold letters in the comments section: "Wanted by police!!!"

Fantastic. I was just happy she was gone.

Not five minutes later, this other person walks in. I noticed her right away. She was tall with dark hair. Really tall. Didn't think much of it until I walked over to wait on her.

Wait a second, this isn't a woman. It's a man, baby! A man with full D cups, makeup, mascara, and possibly a wig. And tall. I'm about 6'1, and I'm standing on a 4" ledge, yet he's nearly looking me in the eye. He hands me a script for Duragesic ("no substitution"), and I tell him that we probably don't have it. He giggles and starts making out with this black dude who's shorter than he. I go check The Book, my mind still boggling at what is transpiring in front of me.

We don't have it, so I send them on their merry way, still trying to wrap my brain around it. (I didn't finally settle the Male/Female debate until I handed the script back to him and saw the size and musculature of his hands.) Something stuck in my craw about the prescription, but I was so caught up in the Transgender Experience that I didn't think about it until later. It was a fake prescription. Not a terribly good fake, but I didn't notice because I was distracted. Clever little misdirection they've got going on there.

We get a PharmAlert about an hour later flagging all scripts by this particular nurse practitioner, and this was a script that she had supposedly written.

The last person of note was a new one for me. I've seen fake prescriptions, transgendered people — though never the two combined — other RPWEIs, and myriad other oddities. This last one made me stop dead in my tracks.

I had dealt with this woman earlier in the day, and she had tried my patience then. I was on my way out for the night, and was already five minutes late. (Five minutes is a long time when you've spent hours numbering in the double digits in the same little 10×20 space.) She was trying my patience yet again. Just so bloody needy. Asking trivial questions. I thought maybe she had forgotten her reading glasses at home or something. Finally she looks at me when she's all done and says "Thank you so much for your help and not getting upset with me. I can't read or write."

…

Talk about feeling like an asshole. Whether she was just being nice or not, I don't know. Nor does it matter — I still felt like a complete jerk.

I've never come across someone (that I know of) that can't read or write. Not in this country, anyway. I'm going to be more careful how I deal with needy people from now on, I think.

* I tend to like GVHEs. They're the most interesting people we deal with on a day-to-day basis.

[tags]Medicine, pharmacy, gender dysphoria, WTF[/tags]

Dextromethorphan and a productive cough

I'm sure this is pretty trivial, but I honestly don't know the answer. Or if it even matters.

Problem: Person presents with chest congestion and a productive cough. You prescribe clarithromycin 500mg bid for an upper respiratory infection, and now they'd like something for their chest symptoms.

I would typically recommend an expectorant — either plain Robitussin or Mucinex, depending on their financial situation — and instruct them to drink plenty of fluids. Is it better to keep them away from DXM-containing products? Will they get better more quickly if you don't suppress the cough? It's my experience that guaifenesin quiets a productive cough somewhat anyway, but not as much as with DXM. Are they better off doing some coughing? Assuming, of course, that they aren't hacking their lungs out.

Does it matter one way or the other?

Mandatory tablet splitting

I came across my first instance of an insurance company requiring a patient to split tablets about a month ago. One of our regulars has recently switched to a new doctor, and the doctor is adjusting doses on his various therapies. In any case, the doc prescribed citalopram 20mg qd #30, but the insurer (UnitedHealth for the win!) would only pay for citalopram 40 ½ tab qd #15.

What the hell is with that? You're going to make a guy with acid reflux, anxiety, depression, hypertension, hyperlipidemia, BPH, and T2DM split his fricken tablets?? Are you kidding me? This guy can barely remember all the medical conditions he has, nevermind what pills he takes at what time for which condition. (There's about 15 meds in all that he takes on a daily basis.)

I felt awful. I called UnitedHealth to no avail. I tried doing a prior auth — yeah, I do that sometimes when insurance companies let their little algorithms run wild without human supervision — nothing.

So now this guy has to remember to split his tablets as well when he's lucky he can get out of bed and tie his shoes in the morning. What assholes. This guy is NOT going to remember to do this right, and there's nothing I can do about it.

What about the money lost through patient non-compliance? I suppose that's not so easily measured when compared to a guaranteed savings of ~$5 per fill by instituting mandatory tablet splitting, so fuck it. We'll deal with the excessive cost of less-than-optimal therapeutic outcomes later.

(I'm conflicted about the idea behind splitting tablets for people since it destroys the tablet's integrity, and can confuse people when they open a bottle and see a bunch of little half tabs staring back at them. I would have asked anyway, but I was so pissed off at UnitedHealth when I got off the phone that it didn't occur to me.)

[tags]Medicine, pharmacy, HMOs, UnitedHealth, tablet splitting[/tags]

Open- vs close-ended questions and the problem of time

I was conversing with Dr. Dino the other day, and we were discussing OTC products, and which ones I recommended. Now, pharmacists don't diagnose. Most of them don't want to, and many of them will tell you that. (This is one reason reading statements like "Pharmacists are just people who didn't get into medical school" really gets my goat, but that's a rant best explored another time.)

We got to talking about how I asked people about their symptoms, and we discussed how I asked nothing but close-ended questions. And this is quite true. Intentionally. In pharmacy school (like medical school, presumably) we are taught to ask open-ended questions. This is great in principle, but pharmacists can't stand and have a 15 minute conversation with someone about the etiology of their sore throat and chest congestion. Prescriptions need to be filled, phones are ringing, and goddammit Mrs. Smith is going to have a stroke if you don't get her triamcinolone cream out in the next 46 seconds.

So I very much have a flowchart mentality when dealing with minor complaints. My advice is usually ended with "If it doesn't get better in X number of days, you'll want to see your doctor." (Where X is adjusted anywhere between 3 and 7 days depending on the type of complaint.) After all, the first law states:

The Art of Medicine consists of amusing the patient while nature takes its course.

I like to think I do my small part in keeping the common colds and poison ivy and other trivial maladies of the ER/doctor's office/clinic while nature runs its course.

It's easy to have a flowchart mentality. I'll just have to remember later — when it's my job to diagnose — that I need to be more open-ended. In the pharmacy, however, the opposite is mostly true, though there are certainly times when it's better to be more involved. Good judgement always applies.

[tags]Medicine, pharmacy[/tags]

Insulin lispro and aspart… interchangeable?

What you say??

Medscape has an Ask Marilyn type of thing, and this one was a head-scratcher:

What is the relationship between NovoLog and Humalog? Molecular structure aside, can they be directly substituted for each other?

I don't know who's asking the question, but I think it'd almost have to be a prescriber, or someone who supervises prescribing physicians. Especially given the answer:

Any differences in pharmacokinetic parameters are unlikely to be clinically relevant, and as such, these 2 agents may be interchanged. However, it is important to keep in mind that the pharmacokinetics and clinical response to all insulin products can vary between individuals due to a variety of factors. Individual patients switched from 1 agent to the other should be especially cautious about monitoring their blood glucose initially after the change.

Emphasis mine.

I hope no pharmacists out in the real world think to themselves "Gee, I'm out of NovoLog, so I'll just substitute Humalog." In this context, a disclaimer would have been nice, don't you think, Mario?

For the non-endocrine types, lispo and aspart swap a pair of amino acids to make insulin adhere to itself less, which results in a smoother pharmacokinetic profile. Patients tend to like it better than NPH. It is, unfortunately, much more expensive.

[tags]Medicine, pharmacy, insulin, diabetes[/tags]

How Sepracor could make a buttload of money

In 2008, CFC inhalers are going away, a topic I've covered extensively here and here. That leaves Sepracor in a position to make themselves quite a lot of money if they're willing to do one thing out of the ordinary: price the Xopenex HFA MDI at or below the same price as the other HFA albuterol products. This would set up the PBMs to be receptive to making the product a Tier 2 copay, like most of the racemic albuterol HFA formulations.*

Then send out the drug reps.

In theory, levalbuterol almost sells itself. At least they won't have to resort to underhanded marketing tactics quite as much.

Will they do it? I don't know. Probably not. That would require doing things differently — like lowering the price right off the bat — and I think we all know how much Big Pharma likes to do things Their Way. Risk is, well, risky.

If I were captain of the ship, though, I'd roll the dice. The inhaler market is huge — and only going to get more lucrative once CFCs disappear — and right now, Sepracor is not positioned to be anything more than a niche player when they could easily have most of the pie.

* Cursory research indicates that some PBMs have the Xopenex HFA MDI at Tier 2 already, but most seem to require a Prior Authorization.

[tags]Medicine, pharmacy, Asthma, Sepracor, albuterol, Xopenex[/tags]

"What's this made out of? Gold?"

How many times have you heard this phrase?

No, my fabulous pharmacy friends, these items are often considerably MORE expensive than gold… we're talking Americium expensive.

For comparison, the price of Ridaura — a gold salt in capsule form — is $295.79 for 60 caps.*

In no particular order:

1. Zyvox (linezolid): $1,546.78 for 20 tablets.
2. Cocaine HCl 135mg: $1,144.80 for 100 tablets
3. 1L of normal saline: $100**
4. Casodex (bicalutamide): $519.76 for 30 tablets.
5. Enbrel (etanercept): $7,500/ounce.
6. Lamisil (terbinafine): $435.84 for 30 tablets.
7. OxyContin 80mg: $662.31 for 90 tablets. (Street value is approximately $7,200 for these same 90 tabs).
8. Aldara (imiquimod) cream: $268.38 for 12×1 gram packets.
9. Vancocin: $651.85 for 20 pulvules
10. Iressa (gefitinib): $2,127.35 for 30 tablets
11. Gleevec (imatinib): $3,563.26 for 30 tablets.

Got anything to add?

* All prices are AWP.
** Except this one.

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