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


Puffy Eyes


So, I had an interesting phone call today. A woman who isn’t a patient of ours called to ask about her eyes. She told me they were red, puffy, and almost swollen shut. I asked if both side were equally swollen, and she told me they were. She also told me the few medications she was on, but stated that she had been on them for a while. At this point, I had come to the conclusion that is was either really bad seasonal allergies or that she had consume or used something that she was allergic to without knowing it.

I asked if she had eaten anything out of the ordinary or new recently and if she had switched soaps or detergents in her house. She answered no. I started telling her that she should take some diphenhydramine and call her doctor first thing in the morning. She interrupted me, asking if there were any interactions with that and her other medications. I told her no, and she replied back to me:  “Well, that’s good. I just wanted to make sure, since these medications are all sort of new to me.” Whoa. Back up. Rewind. Didn’t she just tell me she had been on them for a while? I asked her when she began taking the medications. She told me she started them a week ago. *facepalm*

So now, the tables have turned. Now, I’m leaning more towards a drug allergy being the cause of this. But, the question is, which one is causing the problem? She started each of them on the same day. I told her this and let her know the only way to know for sure which drug would be the cause is to discontinue all of them and restart each individually. Again, I told her to take the diphenhydramine and call the doctor first thing in the morning. I also told her if she experienced any throat tightening or trouble breathing to go to the emergency department of the nearest hospital. She agreed to do so if needed, thanked me, and hung up.

The take home point of this story is to always ask questions. Lots of questions. Ask the same thing in different ways. Use open-ended questions (when did you start these medications vs. have you been taking these medications for a while). It’s important for us to ask these questions and get to the root cause of why the patient is speaking with us. It’s how we screen them and determine what action needs to be taken next, whether it be self-treatment, a call to the doctor, or even a hospital visit. Never be afraid to ask the same thing again if you need to. When patients seek out your help and advice, they usually don’t mind the questions. Most times, they appreciate how much effort we put in to helping them. This is one of our duties to our patients. It falls under the “Do No Harm” portion of the Hippocratic and/or Pharmacist’s Oaths. And, it can make all the difference in a person’s life.


Image courtesy of http://i33.photobucket.com/albums/d76/xx_Emmeh_xx/eyeball.jpg

Routes of Administration


Today, I ran into an issue that should be shared with all patients. I saw one of my favorite wife/husband patient combinations during my shift. I met them not long after starting at my current pharmacy, and I was able to help them save some money on prescriptions. They have sought me out for advice ever since.

Today, they came into the pharmacy to return a steroid cream. I asked them why, and the wife responded that the list of side effects on the medication guide scared her. She said she had decided not to use it. I asked her if she has discussed not using it with her physician, and she told me she had not. So, I started to go through the medication guide with her sentence by sentence to see what was the most troubling for her.

After some explanation, I realized the side effect she was most worried about was the immunosuppressant effect steroids can have. I explained to her that this adverse reaction was not one that should concern her too much. I told her that this effect happens after months of therapy and is more likely to occur with oral steroids. She calmed down immensely afterwards. She ended up taking the medication back home with her. I encouraged her to call or come back if she had more questions.

I have come across this situation a few times before. A patient has a non-oral therapy. They decide to read the warnings and other patient information, and they come across side effects that are mainly related to the oral form of the drug. It scares them, and they stop taking it. Once they realize there is no reason to worry about side effects A and B, though, they calm down and become more adherent.

One thing patients need to realize is that the medication guides that print out with the prescription labels at the pharmacy are required to include everything under the sun for that drug. It will include the side effects for the oral form, as well as other routes of administration (topical, rectal, vaginal, etc). So if you are picking up a prescription for a non-oral medication and are concerned or unsure, ask the pharmacist which side effects are the ones most likely to happen while you’re on it. Try not to scare yourself out of using the medication before you ever use it. As a general rule with many medications, you will probably never experience most of the side effects listed on the medication guide, especially if the prescription is for something non-oral. They are there to tell you all the possibilities for every person who might ever use the medication, not to forecast what will definitely happen when you use it.


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Verifying Identity


Today’s story is a quick one, but definitely it stood out from the masses!

We had a patient come to pick up his prescription around dinner time. The technician who was ringing register followed the proper pick up procedures, which include verifying either the patient’s date of birth or address before allowing them to take it home. The patient was very rude when he answered the question, shouting his date of birth as loud as possible, then asking in a very demeaning tone, “Is that loud enough for you, buddy?” He proceeded to say he would report him to the state police for a violation of privacy if he was ever asked for his personal information again. The technician tried to explain that the only reason he was asking was to make sure he had the correct prescription for the right person in his hands. The patient arrogantly replied, “I am the only one with that last name who’s a patient here.” (That statement isn’t true, but he wouldn’t know that because of HIPAA.) He then muttered something about a conspiracy, purchased his prescription, and left.

My internal thought process was, “What a rude [insert expletive here]!” It makes sense to have some sort of verification process to pick up prescriptions. Every pharmacy is slightly different, but most ask for the name of the patient and a second identifier. If he didn’t want to announce his information, all he had to do was provide us with photo identification. We have several people that don’t like to say these things out loud, and it’s perfectly understandable. Why should they have to say their personal information out loud? We don’t ask questions if they provide photo ID, and truthfully, I prefer when people go that route because I can verify multiple identifiers quickly and efficiently. This man’s rude behavior was quite uncalled for, especially considering there was no one in the pharmacy area and the technician was using his “inside voice”.

Out of curiosity, does anyone else have similar stories to share? I’ve run into this situation a few times in the past, but never have I seen someone get so angry about it.


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Mixing Flavors


We all remember how some of the liquid medications that we had to take as children tasted. There was yummy, bubble gum amoxicillin. There was disgusting, bitter Augmentin that we could barely tolerate enough to swallow. There was sweet, grape Dimetapp that soothed a sore throat and quieted a cough. Those are just a few I personally remember be given as a small child when head colds, strep throat, and walking pneumonia came my way. Unfortunately for me, the flavor of the medication was what it was. I just had to deal with it if it was nasty. Today, there is the option to flavor liquid medications if the original flavor is yucky. The brand of flavoring drops we use at my pharmacy is FLAVORx. I feel it works pretty well, and it’s a reasonable price ($2.99 USD per prescription). Having personally taste tested many of my “creations”, I feel comfortable telling my patients which flavor is their best bet to cover up the “yuckiness”.

There are some people, though, that cannot afford the service very easily. We have a high welfare population in my area, so I try to tell these people other ways to diminish the bad flavors. I also offer to flavor it at any time if they find it just too difficult to swallow it as is. The one thing I always tell people is to have a “chaser” ready for the really bad tasting things (Augmentin, Cleocin, etc). I also tell them to try sucking on an ice cube or ice pop for a few minutes prior to administration to help dull the taste buds. I always recommend keeping things in the fridge for the medications that don’t have specific storage requirements (azithromycin, prednisolone, etc). Most people find a combination of factors that works, and if they don’t, they come back in a day or two to ask for the flavoring service.

My story today is about a mother who was picking up some liquid allergy medication for her daughter. She asked me if it was okay to put it in the fridge. I told her that was fine and would help improve taste. She commented that taste isn’t a problem since they always mix the medication with whatever beverage she is having at the time of administration. She began listing off every drink you could think of–soda, milk, juice, tea…you get the picture. I asked her if someone had told her it was okay to do this with the medication. She said she came up with the idea by herself. Instead of going through each drink to see if it was okay to mix the medication in them, I asked her to refrain from doing this because I was unaware if it had any negative implications. She seemed confused, so I explained there are some medications that if mixed with or taken at the same time as some beverages could essentially be made inactive in the body. She nodded, and asked for tips on how to make the taste less bitter. I gave her my normal spiel, and she thanked me. She ended up coming back later to ask for the flavoring service just to make sure it was palatable enough.

My advice here for my readers is to never mix liquid medications with other beverages without contacting a healthcare professional (preferably a pharmacist) first. You want to make sure the drug is as effective as possible when taking it. Whether it be by finding something that is acceptable to mix it with or by flavoring the medication itself, we can help you figure out a way to make it less yucky.


Image courtesy of http://flavorx.com/wp-content/uploads/2011/09/classic_flavoring_set.jpg

Mistakes and How to Fix Them


Today’s theme is going to be centered around fixing mistakes. I ran into several errors today. Though they weren’t faults of the pharmacy, the situations still needed to be handled appropriately. So, here’s a handy, dandy guide to fixing prescription problems.

Step One:
Determine the cause of the error. Find out what went wrong and, if possible, who was at fault. This not only helps you to figure out the best way to resolve the issue, but it will also help you explain the situation to the patient. The root cause may or may not be in the pharmacy. It’s always possible the wrong medication was called in or (for us United States folks) the insurance was billed incorrectly.

Step Two:
Resolve the issue. Do whatever is necessary to make things right. If you need to call the prescriber’s office, do it. If the insurance needs to be contacted, do it. If you need to admit to yourself that you messed up, DO IT! Whatever it is that needs to be done, take the proper steps to effectively and efficiently resolve the problem. Every issue is different, so handle each individually.

Step Three:
Explain the situation to the patient every step of the way, and apologize for the hassle. Face it, pharmacists and pharmacy techs, we are the healthcare professionals seen most frequently by the community. When something goes wrong with a prescription, it is understandable that people get upset with us. They don’t care who made the mistake; they just want it fixed. And, we are almost always the ones in charge of fixing it! When we apologize for the error (even if it’s not our fault), people tend to calm down or, at least, stop getting more upset. This ultimately leads to building good professional relationships with our patients.

Step Four (optional):
If the error is the pharmacy’s fault, compensate the patient in some way. At my pharmacy when something is a fault of ours, we refund the price of the incorrect prescription (if paid for) and charge them nothing for the corrected one. This tends to work out best for us and shows our patients that we value their safety over our profits.

Step Five:
Apologize one last time before they leave, and wish them a good day. Truthfully, this is just plain courtesy.

So, that about sums up the basics on how to handle prescription problems properly. If you feel I left anything out, let me know!


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Keep Out of the Reach of Children


I have found that one of the things I do while it’s not too busy at work take note of how parents handle their children’s antics. Not to pick on them or snicker. Just out of curiosity, since every parent handles it differently. But, today, I couldn’t help but shake my head and chuckle.

Meet the “parent of the year”…

The mother had just picked up her albuterol inhaler right after we opened. Later on, we get a phone call from her asking for a refill. We ask why she needs it refilled again on the same day. Her answer is as follows:

“Well, I let my son play with it because his squirt gun broke. Now, it’s all gone.”

It was so difficult to keep a calm, serious sounding demeanor because I wanted to laugh so hard. I have never heard something so ridiculous. She then asked if we could get an override from the insurance for a new one. Her insurance didn’t allow for lost/spilled medication overrides, so we offered her an in-store discount. Even so, the price was still $30, which she couldn’t afford. She said she’d get it filled again when she had the money.

After the phone call ended, I burst out laughing. Why on earth would you willingly allow your child to play with your medication?? Not only will that leave you without medication, but more importantly that could be dangerous to your child! It’s just an all around bad situation, which should have never happened.

*shakes head*

Moral of the story — There is a reason all medications say keep out of the reach of children on them.


Image courtesy of http://i29.photobucket.com/albums/c267/Drennon1/inhaler.png