I Hope This Patient is Okay…



So, I have an interesting story from today. It’s one that worries me, but also makes me shake my head.

I had a woman call me, asking if I could give her a few pills to tide her over until Monday when she can call the doctor for more refills. I ask her name and find that she hasn’t been to our pharmacy for over a year. I ask what she’s looking for and she tells me it’s a heart medication that is for 40mg. I notice there is a very old script for furosemide, so I ask if that’s what she’s looking for, she says no and that it starts with a “car” sound. I ask her if it’s carvedilol, and she says yes. The most recent script is for a low strength. I ask if she’s gotten it filled since the previous time she was here. She tells me her cardiologist has been directly dispensing it from his office. (I wasn’t aware they did this for things other than controls or samples of brand name medications, but I didn’t question it.)

She states she really needs it because she’s out of town and very far away from home. I tell her that there’s not much I can do, since the dose she’s asking for is not on record with us. I also tell her that since she hasn’t been to our pharmacy in so long, I don’t fell comfortable providing the medication. She suddenly tells me she has retained 15 pounds worth of fluid in the past few days and her skin is yellowing. I tell her that’s quite serious and that she should be seen right away. She starts asking what she should do, since she’s worried about her condition. I tell her that the best option is to head to the ER. I told her that even if we did have a current prescription on file, I’d still suggest going to the ER because she could be going into congestive heart failure. She tells me she doesn’t want to because “the ER sucks big time”. I tell her that even though ERs are usually a pain, this situation requires action be taken soon. She continues to tell me I should just give her the medication. I again tell her no. She asks what will happen if she doesn’t go to the ER. I tell her that she could possibly go into heart failure, which has very poor outcomes when left untreated.

“Oh well. I guess that will have to do. I don’t have time to go to the ER.” –Click–

I did try to call her back right after she hung up, thinking maybe I could calm her down and get her to see my reasoning. Her number on file was invalid. I don’t know what else I could have done. I will gladly give people a few pills for a maintenance medication if they run out on the weekend or the prescriber hasn’t replied to our refill request by Friday evening. Seeing as how this woman had not been to our pharmacy in so long and how the dose she claims to take didn’t match up with the one she used to take, I didn’t feel comfortable giving her any. In all honesty, she probably needs some IV diuretics and a few diagnostic tests. The way she described herself is not something that should be left alone. I am worried that she will start experiencing organ failure, especially considering the jaundiced skin.

It’s people like her that make me both sad and confused. If she’s seeing a cardiologist, then she obviously has heart problems. I am sure he explained to her the difference between emergent and non-emergent problems. Most do. For her to refuse to go to the ER like that is very stubborn. It’s sad because she doesn’t seem to understand the gravity of her situation, but it’s also frustrating. People need to be more involved in their own health care. If you see your skin suddenly turn yellow, that means your liver is probably not doing so well. It’s not something you wait around to see if it gets better. If you gain more than 10 pounds in a day or two, that is water weight. It takes a lot longer to gain weight due to fat accumulation. Lots of water weight usually indicates your heart isn’t working right. It is also not something to be taken lightly. Both require at least a call in to the doctor. He will probably either have you come in to the office that day or go to the hospital. Regardless, a physician should be involved as soon as the symptoms start.

-Sigh- I hope that woman is okay. =(


Image courtesy of http://i127.photobucket.com/albums/p124/roscoe81/ChronicHeartFailure.jpg

Computers Make the Pharmacy World Go ‘Round



So, the biggest issue our pharmacy has been dealing lately is a slew of computer problems. Almost every day since the new store opened, we have been unable to use any of the computers in our pharmacy for a good portion of the day. Several times, they have crashed in the evening and stayed down until after we closed. Our pharmacy is open for 11 & 1/2 hours a day during the weeks; there were a couple days where we couldn’t use our computers for 6 of those hours. Trying to do 11 & 1/2 hours’ worth of work in about 5 hours is not fun. I have felt like the figure in the animation above many days. Both my partner and I have had to come in before the pharmacy opens our our days off to clean up what couldn’t be finished the previous night. It has been quite exhausting.

Luckily, our patients have been so understanding throughout this whole thing. I find it interesting the difference between how my partner and I have been handling this. If a person comes in with a script and our computers are down, I give him/her enough for a day or two without hesitation. The only exception for me is narcotics but I do my best to find those patients the closest pharmacy to us that can fill it. But, as far as benzos and hydrocodone goes, I’ll even give a few of them. I just always make sure to mark down if they got any and subtract it from the balance on the script. My partner, on the other hand, has been completely turning people away, even those with non-controlled scripts. I don’t understand why. I feel getting a patient started on an antibiotic or making sure a person doesn’t lapse in his/her Coumadin therapy is important. Our computers being down shouldn’t affect this. I am still going to practice pharmacy without them, and I am still going to put patient care first. I guess not all pharmacists feel the same, though.

I am hoping that our computer issues have finally been resolved. Yesterday was the first day they stayed up all day. Maybe it’s a good omen! =) I hope everyone’s days are going well and that your pharmacies are filled with working computers!


Image courtesy of http://i1170.photobucket.com/albums/r539/Betelgeuse3x/Useful%20gifs/Computerfrustration_zpsfce93557.gif

Tighter Control on Vicodin?

A widely prescribed painkiller


So, before reading this blog post, take a peek at this article:  http://www.latimes.com/news/local/la-me-0126-vicodin-20130126,0,4066484.story

I’m not going to comment on whether or not this is a good move because, truthfully, there’s a lot to be said for both sides of the coin. There would be patients–legitimate pain patients–who would suffer from this being approved. But, there would also be a lot less abuse (or so we would hope). Regardless, I’m not going to comment on whether this is good or bad. I can tell you one thing, though:  this would make life in a big chain retail pharmacy a nightmare. Can you imagine having to be the only one allowed to count out every hydrocodone-based prescription? I don’t know where we would store it all to be honest. But, I digress.

The real thing that should be focused on here is how we, as a health care community, look at “chronic pain”. There are so many chronic pain sufferers out there, and each is different. My thoughts are that instead of reclassifying the most commonly prescribed medication in the US, we should reclassify how it is prescribed. No primary care physician should be the main person writing for a chronic pain medication. Chronic pain patients should be going to a pain specialist. This should be required. This is not only to insure the prescribing is done correctly, but to help the patients find the best possible relief. Now, I’m not saying there aren’t pain doctors out there that give out narcs like candy, but they are better equipped to be writing for these patients. I feel like writing for chronic heavy duty narcotics is out of a primary care physician’s realm of practice. Primary doctors are too quick to write a chronic lower back pain patient a script for Percocet many times. Shouldn’t they be trying out other options, such as Cymbalta or gabapentin first before going to a potent opioid medication? I think people should exhaust all other options first before starting with meds like that, including things like acupuncture and physical therapy. It’s very difficult to get off opioids once you’ve been taking them for a while. You can always go forward if it’s not working, but it’s hard to go back.

The other thing that makes the world of opioids so tough is the lack of communication between physicians, sometimes due to the patient not telling the whole truth. We had a patient who is taking both Suboxone and Percocet on a daily basis. She stopped coming to our pharmacy because we questioned why she was on both and asked if we could contact her physicians about therapy modification. There is no reason she should be on both. I wonder if her two doctors know that she is on both medications. How it ever went through her insurance is beyond me. Usually, that kind of interaction requires a prior authorization, so either one of the doctors did the prior authorization without thinking or the insurance let a major drug interaction slip by. Whichever it is, it truly points to a problem with the way this nation treats chronic pain and opioid dependence/addiction.

It really saddens me. I wish that the FDA would focus on where pain killer abuse starts instead of where it ends. We need to be proactive about health care, not reactive. If we can prevent opioid misuse by better regulating how and by whom the medications are prescribed, then we won’t need to restrict them in the pharmacy as much. But, that’s just me, a lowly pharmacist who receives multiple 7 to 10 day early fill authorizations from the same primary doctors every few weeks. Who am I to argue?


Image courtesy of http://www.latimes.com/news/local/la-me-0126-vicodin-20130126,0,4066484.story

Out of Control



Hello everyone! Long time, no post. I had been in the midst of moving my pharmacy. It took lots of planning, cooperation, and teamwork, but it went smoothly and now I can relax again. I will probably go on another hiatus in the upcoming months to study for a law exam. I am in the process of transferring my license to another state, and as soon as I get my authorization to test, I’m going to go back into student mode and study my buns off. But, for now, I am going to return to regular blogging. =)

So, today’s story is one I encountered a few days ago. It was the end of the night, and we were getting ready to close. A woman comes in, and one of my techs goes over to help her. She had some medications to pick up and she had requested print outs of last year’s medications for both her and her husband over the weekend. The policy at our store (in compliance with HIPAA) is that the person for whom the print out is for must be present to receive it. They also have to show ID proving they are who they say they are. The only exceptions are 1.) parents may pick up for children aged 17 & under and 2.) people who have power of attorney over another person may pick up for that individual (in which case, we ask them to bring in the POA paperwork once as proof and we mark it in our system). If the individual is not present and does not fall under one of the exceptions, we are required to mail it in our super spiffy confidential envelopes. All of our techs have been informed of this, but our newest tech dropped the ball and told this women she’d be able to pick up both hers and her husband’s.

Not surprisingly, the woman was upset. I apologized, as it was the fault of our technician’s. As sorry as I was, though, I was not about to break our HIPAA abiding policy. It’s there for the protection of everyone’s privacy and is a good policy. I offered to have it mailed first thing in the morning, letting her know I would personally ensure it got mailed. The woman kept ranting (again, not surprisingly), and I kept apologizing. Up to this point, this is a normal upset patient scenario and one I’ve dealt with several times. I take the brunt of the anger and apologize for a tech’s mistake. Usually, they either calm down after yelling a bit or storm off. This is where things got interesting and where the patient turned from angry to out of control.

She asked to speak with my manager. My manager happened to be standing not far away when the situation started, so I called her over. She also knows this print out policy, as she used to be a tech before becoming a manager. She attempted to intervene and calm the lady down. She offered her a gift card for her trouble (yay, retail store policies of feeding negative behavior!). The lady refused the offer and started to yell louder. She turned back to me, walked towards me, and got right in my face (we’re talking less than six inches from me). She started banging on our counter, and I became scared she would get physical with me and grab me by the collar of my jacket. Her yelling also started to scare the other patients in the pharmacy area. A good ten minutes go by, and this woman has not calmed down (she was actually yelling more) nor accepted any form of apology, telling us instead that we weren’t sorry. She’s still banging on our counters and is now pacing the length of the pharmacy. She kept returning to get as close to me as possible (at this point, I had stepped back a bit so she couldn’t grab me). Those shopping up front could hear her across the store and suggested to the girl working up there that she call the police. Just as my manager decides it may be a good idea to call the police, the woman finished her rant and left, continuing to yell all the way out the doors.

This was one of the few times I was actually scared of a patient. At first, I felt really bad for her. She was misinformed and had every right to be upset and angry with us. But, there is a point that most people reach when they’re yelling where they realize their carrying on won’t fix anything, so they either calm down or leave. I have never had anyone get right in my face like that before. She is one patient I hope never returns and transfers everything elsewhere. Being outright abusive to our staff is uncalled for and does not fix things. You have the right to be angry; you don’t have the right to be out of control like that. When you start scaring other patients and customers to the point where they tell our employees to call the police, that’s when you’ve gone overboard and need to stop. In the end, I still didn’t break HIPAA, and she still left without her husband’s print out. I did mail it the next morning, and it should be at their house by now. But, man…what an experience that night was.

The ironic part of this whole thing is that her husband’s print out contained five items from all of last year. She was out of control over a piece of paper with five items on it. *shakes head*


Image courtesy of http://i147.photobucket.com/albums/r290/ero_sennin37/angry.jpg

Pills, Thrills and Methadone Spills: A Book by @MrDispenser

Hey everyone! I apologize for my inactivity as of late. I’ve been busy, as our pharmacy is getting ready to move to a new location, and I am in the process of making a large geographical move. I am stopping by to tell you all that you should check out Mr. Dispenser’s new book that was recently released for Kindle: Pills, Thrills and Methadone Spills. It’s full of good pharmacy humor that anyone can appreciate regardless of whether they work in a pharmacy or not. It should be available in print soon. 5% of sales are going to Pharmacist Support Charity, so it’s not only worthwhile to read, but it’s going to a good cause as well. You can purchase the Kindle edition here. I hope you’re all doing well! Hopefully, I’ll be back to blogging soon. Happy New Year everyone!


Guest Post from Mr. Dispenser: The Back of It

Thank you, Mr. Dispenser for this great guest post! It’s about how prescriptions are paid for in England, geared towards the US audience. It’s quite enlightening and very interesting. I hope you guys enjoy it. If you get a minute, you should check out his blog. He’s a great writer that I always enjoy reading. My US counterpart can be found on his page.


The Back of It

In England, the majority of people get free prescriptions if they qualify through 13 categories. Although, I really wish patients would stop asking me what they should tick on the back of their prescription!



The categories are:

A] Under 16 years of age

It makes me chuckle when people tick income support on their babies’ prescription. The parents fill in the prescription but writes down her exemption instead of the child’s.

B] 16, 17, 18 AND in full time education

If you leave school at 16 and get a job, then you pay. Students start university at 18 years of age and get quite upset when they hit 19 and realise that they have to pay. I have seen students blatantly lie about their age even though it is printed on the prescription.

C] Over 60

The people who use the most medicines get free drugs too. The pharmacy staff sometimes fill out the back of the prescription for people who are exempt by age, when we receive the prescription from the doctors. Sometimes, they tick over 60 when they patient is not. One day, I will get a slap when handing out a prescription for an insecure 55 year old lady

There is no requirement for someone over 60 to sign the back of their prescription if it is a printed prescription as it’s obvious from the date of birth that they will be exempt. Depending on how grumpy the person is, I do or do not make them sign.

Sometimes you may ask someone to pay and they say that they are over 60 and it’s confirmed by looking at the prescription properly. If you apologise and say that they look good for their age, then you will get brownie points.

D Maternity exemption

Once you get pregnant and up to the child’s first birthday, your prescriptions are free. Sometimes, ladies will ask me if I want to see their exemption card but I say that I can see their evidence. This is either a big bump or a baby.

Sometimes, this is ticked by a man with medical exemption by accident which causes much hilarity and embarrassment for the man.


E] Medical Exemption

People with certain conditions get free prescriptions. These include epilepsy, diabetes and under active thyroid. Recently cancer was added to the list which is excellent. However, my Auntie was over the moon when she got diabetes as she now has free prescriptions for life.

F] Pre-payment certificate

If you do pay for your prescription, then it can get costly. Each item costs £7.65. If you need more than 4 items in 3 months or 14 items in 12 months, then a three or twelve month pre-payment is a good option. They cost £29.10 and £104 respectively. Then you can get as many prescriptions as you want.

Unfortunately, some people don’t believe that it is a good offer. I once wasted 5mins of my life explaining the benefits of a pre-payment complete with calculations and my working out and they couldn’t be bothered. I’m more upset about having to do some calculations.

G] War pension

Former soldiers are also entitled to free prescriptions.

L] HC2

People on low incomes can apply for a HC2 certificate. This is normally but not exclusively used by students once they turn 19. It normally depends on how much savings they have, whether they work and how much their parents earn.

X] Free of charge contraceptives  

All women get free contraceptives on prescription. Some women who have another non-contraceptive item on the prescription, sometimes conveniently forget to pay for that item and just tick X. These women get chased after by overweight pharmacists.

H] Income support

This is the most common benefit that is ticked on the back of the prescription. This is also the default option when people don’t know what to tick. Some people who can’t speak English just say ‘H’ when asked what they tick. It is also normally ticked by people in expensive cars who have just come back from holidaying abroad

K] Jobseekers allowance

This is another benefit that is given to some people. It is normally ticked by people in McDonalds uniform and taxi drivers


M] Tax credits

Another benefit that is generally claimed by people who work part-time or have a partner that does. Some pharmacy staff claim this. There is sometimes the awkward situation when they don’t want to accept any more hours at work as it will affect their tax credits.

S] pension credit guarantee credit

I have never seen anybody tick this option

Prescription Charge

The prescription charge is a contribution to the NHS. It is not a payment to the pharmacist. It bears no relationship to the cost of the medication. It is currently £7.65.The quantity of each item is irrelevant.

There are some anomalies. A pair of hosiery stockings carry two prescription charges. If you are prescribed the same drugs in different strengths is only one charge. A drug prescribed in two different formulations is two charges.

False exemptions

There is a great opportunity for patients to tick anything on the prescription. At the end of the month, all the prescriptions get sent off to The National Health Service Business Services Authority for payment. Less than 1% of the exemptions are checked by them. So it is highly likely that you will not get caught unfortunately.

There is an ‘evidence not ticked box’ on the back of the prescription for the pharmacy to tick if the patient has not provided any evidence. Pharmacy contractors are in no way responsible for the accuracy of a patient’s declaration; this remains the responsibility of the patient. Patients found to have wrongly claimed help from the NHS with the cost of their NHS prescriptions will face a penalty charge and in some cases prosecution.

If the patient does not tick anything on the back of their prescription and it gets sent off, then £7.65 is taken off the pharmacy. It is in the pharmacies best interest to ensure that the back of the prescription gets filled in.


Mr Dispenser

My blog can be found here

Pictures Are Worth a Thousand Words


So, I realized something today. I realized how much I’ve become a part of some of my patients’ lives. I know that a pharmacist is a familiar face many people see; however, forming a bond with a patient is something special and doesn’t happen with just any patient and any pharmacist.

Today, I had a woman share pictures of her grandson’s graduation from college. She had them in a cute photo album and everything. I didn’t think anything of it until she told me she has been carrying it with her the past few times she came to the pharmacy, hoping it would be my day to work. I suddenly felt very prominent in this woman’s life and not just in a healthcare professional way. It made me smile to know that she has connected with me in such a way. It ultimately benefits her and will make the quality of healthcare she receives from me even better. I’m not saying I will treat her better than other patients, but that she will be more receptive to what I advise her to do. She will be more open to patient education that is important to share with her. And, that is a great thing.

After that, I realized that there are several other people who have made similar, more personal connections with me. I feel very privileged to be able to experience such wonderful things. Days like these  make me enjoy my job and profession even more than I already do. =)

So, what personal connections have you guys made with your patients? Patients, what personal connections have you made with your healthcare professionals? I would love to hear.


Image courtesy of http://i736.photobucket.com/albums/xx10/CindyGee13/photography1.jpg