Friday, December 2, 2011

Fill At One Pharmacy


I feel that pharmacists do not stress the importance of filling all of a customer's medications at a single pharmacy or at within the same pharmaceutical chain nearly enough. The importance is not my attempt to increase our overall script count, but customers benefit from filling all their medications with the same pharmacy.

With all the different incentives at different pharmacies such as Walmart’s $4 generic list and Rite Aid’s fifteen-minute guarantee, a handful of customers spread their prescriptions all over the place. Just the other day I sold two prescriptions to a customer and she asked us to transfer her remaining three prescriptions to a cheaper pharmacy. I am glad she found a cheaper pharmacy especially in these rough economic times, but she is also doing herself a disservice.

When a customer fills all of their medications at a single pharmacy that customer’s profile reflects all current and past prescriptions. At a single pharmacy the pharmacist can keep tabs on the customer and more importantly have his or her prescription history readily available. With the prescription history the pharmacist checks any new prescriptions against current medications for any sort of drug interaction. Drug interactions may go unnoticed if the customer fills at different pharmacies especially if the customer also visits more than one doctor.

Pharmacy staff also asks about any sort of allergies to any medications for a reason. Allergies are sometimes over looked by some doctors or in some instances, such as a visit to the emergency room, the customer may not remember which drugs he or she is allergic to in the heat of the moment. In these cases the doctors and customer, aware or not, rely on the pharmacist as the last line of defense before the customer receives a potentially life-threatening medication.

My pharmacist has made plenty of calls to doctors’ offices to verify prescriptions and request a change in medication due to interaction. Without all the available information I would hate to imagine what may happen.

Perspective of the Inexperienced


A little while ago I ran in to a girl who had never filled a prescription at a pharmacy before. Trying to remember my outlook on pharmacy before I joined the field over a year and a half ago, I spent some time talking to her just to hear her perspective on pharmacy and what she believed goes on behind the counter.

She surprised me by claiming she does not trust pharmacists. Not that she does not trust a pharmacist will fill a prescription correctly, but that a pharmacist would not be able to guess a diagnosis based on symptoms. No, she believes a pharmacist’s job is to fill the prescriptions written by the doctor and just make sure the correct drug has been dispensed and whether she has any questions.

Based on my experience in the pharmacy I began to believe customers overused the pharmacist and sought consultation as a means to avoid a trip to the doctor. However, I never expected someone would hold pharmacists in such lower regard than medical doctors.

When I inquired further about pharmacy she revealed to me that she does not have a clue what goes on behind the counter. Her best guess was prefilled prescriptions and the pharmacy staff merely had to find the correct medication from the shelf. That guess definitely explained her expectation of a prescription filled in five to ten minutes during rush hour. In fact, her expectation is starting to sound a lot similar to other customer’s expectations when they drop off a prescription.

If only they knew.



Over-Prescribed Antibiotics


Drug resistant bacteria may pose a serious threat in the not too distant future due to the overly prescribed use of antibiotics.

Since the inception of sulfa antibiotics in 1932 and more notably the mass production of penicillin in 1942, the use of antibiotics to treat and prevent bacterial infection has skyrocketed. These antibiotics continually prove to be a valuable asset to fighting illness, but scientists and doctors are becoming increasingly aware of the great potential risk in using the medications.

As Western medicine developed the cultural mentality shifted from preventative medicine and build the immune system to trying to find the next best drug. The repeated use of these drugs actually destroys people’s immune system and when a new strain of drug resistant bacteria arises the immune system becomes helpless and unable to defend itself.

Hospitals suffer from rampant spread of drug resistant bacteria and in an increasing number of cases infections remain unaffected by even our strongest antibiotic created thus far.

In terms of retail pharmacy I fill plenty of antibiotics every day from azithromyacin to amoxicillin and doxycycline among plenty of others. Majority of the antibiotic prescriptions treat customers who suffer minor cold and flu but wish to stop the bug in its track. A handful of customers have antibiotic prescriptions on file with refills so they can call in and have their antibiotic filled at the onset of illness. This self diagnosis does a disservice to the customer as in some cases an infection may not be present and with the constant use of antibiotics the immune system becomes more prone to illness.

However, antibiotics do help in cases where they are necessary and if customers continually take antibiotics doctors and pharmacists must ensure that the customers understand the importance in taking the medication properly to avoid the evolution of drug resistant bacteria. When a customer picks up an antibiotic I must stress above all else, finish the entire duration of the antibiotic. Even if the customer feels markedly improved after a couple of days the bacteria may not have been completely eradicated from the system. The bacteria remaining may then evolve and become resistant to that antibiotic next time around.

Prescription Expiration


Prescriptions expire. The statement can not be repeated enough. Prescriptions expire. Too frequently prescriptions come in to the pharmacy past the expiration date and the pharmacy must turn the prescription down.

The expiration I refer to pertains to the prescription hard copy itself and not the expiration of the dispensed drug.

How long a prescription lasts depends upon the medication prescribed. Prescriptions for medication not listed as a controlled substance last one year from the date written by the doctor. If refills still remain on the prescription they are lost and the pharmacy requires a new script from the doctor – no exceptions.

A common misconception occurs when a doctor writes for PRN (abbreviation for the Latin Pro Re Nata – “as needed”) refills. PRN means the customer may fill the prescription as many times as they feel necessary within the prescription’s expiration.

Scheduled III through V controlled substance prescriptions expire after six months from the date written. Scheduled medications have a shorter expiration date to force customers back in to the office and the prescribed medication may be better monitored.

Scheduled II control substances have the shortest expiration with twenty-one days from the earliest allowed fill date. The earliest allowed filled date may differ from the date written by the doctor. If the doctor sees a patient and decides to prescribe three months worth of the medication, but the patient’s insurance will only cover one month at a time, the doctor may write three different prescriptions to save the patient the copay of visiting the office each month. In these cases the doctor may write an earliest dispense date and no matter what date the doctor wrote the prescription the patient can not fill that prescription before the designated date. If an earliest release date is written the twenty-one day expiration begins on that date and not the date written.

Controlled Substances


State and federal law control the distribution and use of particular substances. The federal law, the Controlled Substances Act (CSA) of1970, originally defined controlled substances. Since 1970, roughly 160 substances have been added, removed, or transferred within categories. (Drug Enforcement Administration, n.d.)  The substances currently listed as controlled fall in to one of five possible categories known as schedules.

Schedule I

  • High potential for abuse
  • Considered to have no current medical use
  • No substance may be prescribed, administered, or dispensed.
  • Examples would be marijuana, heroin, and lysergic acid diethylamide (LSD) (Drug Schedule, n.d., Drug Enforcement Administration, n.d.)


Schedule II

  • High potential for abuse that may lead to severe mental or physical dependence
  • Generally consists of strong narcotics and stimulants
  • Examples include morphine, hydromorphone, amphetamine salts (Adderall®), and cocaine (Drug Schedule, n.d., Drug Enforcement Administration, n.d.)


Schedule III

  • Less potential for abuse than schedules I or II
  • May cause low to moderate physical dependence but possibility of high mental dependence.
  • Examples include hydrocodone (Norco®/Vicodin®/Lortab®) less than 15 mg and no more than 90 mg of codeine per dose unit such as Tylenol #3® (Drug Schedule, n.d., Drug Enforcement Administration, n.d.)


Schedule IV

  • Low potential for abuse compared to schedule III
  • Examples include alprazolam (Xanax®), diazepam (Valium®), and temazepam (Restoril®) (Drug Schedule, n.d., Drug Enforcement Administration, n.d.)


Schedule V

  • Lowest potential for abuse
  • Include mostly preparations containing limited quantities of certain narcotics
  • Examples include Robitussin AC® and Phenergan with Codeine® (Drug Schedule, n.d., Drug Enforcement Administration, n.d.)


Due to the high risk of dependence, customers on long-term use of these medications should be monitored. These medications should not be stopped abruptly and should instead be waned off the medicine.

Customers should check their individual state laws to determine what other regulations may be on controlled medications. Controlled medications may only be transferred from one pharmacy to another unless the two pharmacies are centrally linked (Control Substance e-Rx, n.d.), e.g. a Walgreens in one part of the state can transfer a controlled medication electronically as long as refills remain on the medication and it is not too soon since the previous fill. It may vary between states, but generally controlled medication can not be filled more than two or three days before the previous dose runs out.

References
Commonly Abused Drugs. (n.d.). drugabuse.gov. Retrieved December 1, 2011, from http://www.drugabuse.gov/DrugPages/DrugsofAbuse.html
Control Substance e-Rx FAQs. (n.d.). ncbop.org. Retrieved December 1, 2011, from www.ncbop.org/faqs/Pharmacist/ControlledSubstanceE-RXFAQsApr2010.pdf
Drug Enforcement Administration. (n.d.). DEA Diversion Control - Controlled Substance Schedules. DEA Diversion Control Program :: Welcome ::. Retrieved December 2, 2011, from http://www.deadiversion.usdoj.gov/schedules/index.html
Drug Schedule. (n.d.). Addictions.org - Recovery for Drug or Alcohol Addiction and More. Retrieved December 2, 2011, from http://www.addictions.org/schedules.html
Food and Drug Administration. (2009, June 11). Controlled Substances Act. U S Food and Drug Administration. Retrieved December 2, 2011, from
                  http://www.fda.gov/regulatoryinformation/legislation/ucm148726.htm

Generic Medications


On the flip side of brand name medications exist what are referred to as generic medications. Generic medications often receive a bad reputation due to fears of being much lower in quality and less effective (Stroppler, 2009).

Generics must perform similar to the brand in the body

  • The U.S. Food and Drug Administration (FDA) tests generic medications just as vigorously as brand medications (Food and Drug, 2009)
  • Generics are required by law to contain the same active ingredients as the brands they copy (Consumer Reports, n.d. Food and Drug, 2009)
  • Generics must be administered in to the system exactly the same and as efficiently as the brand names

 Where generics may differ could be something such as the size, shape, or inactive ingredients, e.g. color dye and bonding agents. However, as mentioned before generics must meet certain standards in regards to identity, strength, quality, purity, and potency.

Generic drug costs

Once the patent ends on a brand medication generic manufacturers may produce generic equivalents. Brand manufacturers suffered the steep investment costs innovating the drug so generic manufacturers do not have to go through the same. Without the development cost, generic manufacturers may sell their product at a much lower price (Generic Drugs, n.d.).

With the significantly lower generic medication price some pharmacies offer a deal on generics at low cost. Generic medications that fall under a particular list cost $4 for a thirty-day supply at Walmart, Target, and Kroger. No $4 list, but CVS offers their Health Savings Pass and Walgreens their Prescription Savings Club, each charging $12 for a ninety-day supply on certain generics after an initial annual fee.

Some manufacturers produce both the brand and generic

The brand name Xyzal allergy tablet and its genericLevocetirizine are available as the exact same pill. Similarly, Concerta andits generic Methylphenidate ER are also identical tablets. In fact, ALZA Corporation produces Concerta tablets and supplies them to Watson to be sold as a generic.

References

Reports Best Buy Drugs. (n.d.). Generic Drugs: The Same Medicine for Less Money. Consumer 
             Reports Health. Retrieved November 30, 2011, from 
             www.consumerreports.org/health/resources/pdf/best-buy-drugs/money-saving-
             guides/english/GenericDrugs-FINAL.pdf

Generic Drugs: Information, Cost, and Types. (n.d.). WebMD - Better information. Better health.
              Retrieved December 1, 2011, from http://www.webmd.com/a-to-z-guides/questions-
              about-generic-drugs-answered

Generic drug definition. (2004, June 6). MedicineNet. Retrieved November 30, 2011, from 
             www.medterms.com/script/main/art.asp?articlekey=33073

Monson, K., & Schoenstadt, A. (2011, May 17). Generic Concerta. ADHD Home Page. Retrieved 
             December 1, 2011, from http://adhd.emedtv.com/concerta/generic-concerta.html

Monson, K., & Schoenstadt, A. (2011, November 28). Generic Xyzal. Allergies Home Page
             Retrieved December 1, 2011, from http://allergies.emedtv.com/xyzal/generic-xyzal.html

Stoppler,M.D., M. (2009, September 28). Generic Drugs, Are They as Good as Brand Name?. 
             MedicineNet. Retrieved December 2, 2011, from 
             www.medicinenet.com/script/main/art.asp?articlekey=46204

Food and Drug Administration. (2009, October 13). Facts and Myths About Generic Drugs. U S 
             Food and Drug Administration Home Page. Retrieved November 30, 2011, from
             http://www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/
             understandinggenericdrugs/ucm167991.htm

Brand Name Medications


The age old debate that continues to rage to this day and most likely will continue for quite some time: brand vs. generic medication. Brand name medications take the spot light in this post as I go over some of the key talking points concerning brand name.

The Price

Multiple variables factor in to the high price of brand name medications.

  • Research and development (Kaiser, 2011)
    • Manufacturers try to regain some of the cost that goes in to both successful and unsuccessful drugs

  • Advertising and marketing (Kaiser, 2011)
    • Manufacturers invest heavily in to advertising new and expensive drugs to doctors and patients

  • Patent protection (Kaiser, 2011)
    • New medications may be patented for up to twenty years giving exclusive right to the manufacturers to sell the drug.


In a perfect example, Pfizer has moved to extremes to protect one of their most profitable drugs, Lipitor. Pfizer will pump millions of dollars in to marketing Lipitor further in an attempt to undermine the recently released generic.

But the brand is safer and better than generic right?

Not necessarily. Have you tried looking for brand name Tylenol®, Benadryl®, Motrin®, Rolaids®, Simply Sleep®, or St. Joseph’s® aspirin on the shelves in the past year? The mentioned brand names have been hard to find because McNeil PPC, Inc. recalled the medications and pulled them off theshelves.


However, do not allow the fault of one manufacturer completely discredit the rest. I mention this particular manufacturer simply to prove the point that just because you buy brand does not mean you are buying the best quality.


References
Associated Press. (2010, January 21). Tylenol recall expanded to Motrin, Benadryl, more. News, Travel, Weather, Entertainment, Sports, Technology, U.S. & World - USATODAY.com. Retrieved December 1, 2011, from http://www.usatoday.com/money/industries/health/2010-01-15-tylenol-recall-expands_N.htm
DeNoon, D. (2010, January 15). Tylenol, Motrin, Benadryl, Aspirin, Rolaids Recall. WebMD - Better information. Better health.. Retrieved December 2, 2011, from http://www.webmd.com/pain-management/news/20100115/tylenol-motrin-benedryl-rolaids-aspirin-recall
Johnson, L. A., & Press, A. (2011, November 30). Lipitor will be far cheaper as patent expires. News, Travel, Weather, Entertainment, Sports, Technology, U.S. & World. Retrieved December 1, 2011, from http://www.usatoday.com/money/industries/health/treatments/story/2011-11-29/Pfizer-maneuvers-to-protect-Lipitor-from-generics/51475288/1
McNeil PPC, Inc.. (2010, October 8). MCNEIL PRODUCT RECALL. MCNEIL PRODUCT RECALL. Retrieved December 1, 2011, from http://www.mcneilproductrecall.com/
The Kaiser Family Foundation. (February 2010). Prescription Drug Costs: Issue Modules, Background 

                 Brief - KaiserEDU.org, Health Policy Education from the Henry J. Kaiser Family Foundation. 

                 KaiserEDU.org. Retrieved December 1, 2011, from http://www.kaiseredu.org/Issue-

                 Modules/Prescription-Drug-Costs/Background-Brief.aspx