The Ole' Apothecary

 Whenever Richard Corey went downtown,

We people on the pavement looked at him . . .   ---E.A. Robinson

Monday, monday, can't trust that day!     --The Mamas and the Papas

By MONDAY!  MONDAY? Fat chance, eh? Did I hear something about a sphere of snow and the likelihood of it staying frozen in Hades?

About six weeks ago, the Congress mandated that Medicaid prescriptions be written on tamper-proof forms in about six weeks. The deadline is Monday, 1 October.  If there is any evidence that  the Congress doesn't relate to the people it is supposed to serve, this is some of it.  Since the enactment of this legislation, I have seen plenty of copy representing much head-scratching over this deal.  Is CMS going to send out Paper Police on Monday to start spot audits? 

 The rest of this post is for you. Go ahead, make my day in the comments. What do you think of this? What are you going to do about it? 

My Dad hates Saturday mail. He hates it because it is sometimes perpetrated by those who want to drop a hot problem in his lap and not have to talk about it until Monday, and he has to stew about it until Monday with no place to go for satisfaction. Well, I think that's what the Food and Drug Administration just did with its very-late Friday announcement on banning unapproved hydrocodone cough syrups. It knew there would be a lot of questions, so it whispered the move to us. I was online last night, and saw nothing about it. Was it posted at midnight? I'd like to telephone the FDA just to make their unmanned phone buzz on a Saturday, so they'll know I'm on to their tactic of using the weekend to obtund national reaction to this move.  Tussionex drinkers would probably be the first to call them. 

The FDA announcement does make clear the answer to the big question I had in my mind when I started reading: Tussionex stays.  It is one of seven FDA-approved hydrocodone-containing antitussives (see http://www.fda.gov/cder/drug/unapproved_drugs/hydrocodone_qa.htm).  The action has been taken apparently because of confusion, lack of proper product labeling, and, ostensibly, to limit the availability of one of the Nation's most abused prescription drugs, hydrocodone. 

Now, I have a question for another federal agency, the U.S. Postal Service. How come you decided not to discontinue Saturday mail? My Dad, and I, would have been as pleased as punch if you had.  

There are supposed to be three kinds of people: people who make things happen, people who watch things happen, and people who wonder what happened. Judging from the way pharmacy legislation is negotiated, I'd say that we pharmacists fall into that third category. We turn around, and find ourselves fettered by one more mindless, oppressive regulation, a regulation we end up living with because we were silent. Well, here comes another potential attempt to ignore our professionalism and add to our status as toadies for the administrators: "they" may be about to make us account for dextromethorphan (DXM) products the same way we do pseudoephedrine products!

DXM is an over-the-counter cough suppressant that has been available on the U.S. market for more than half a century. It can be considered an opiate derivative, but its specific chemistry prevents its being abused as an opiate, i.e., it is not supposed to have opiate-addictive properties. But, in large doses, it can be a euphoriant. OK, we agree that there is DXM abuse, and it is widespread among teenagers. According to Drug Topics, the "concerned parents'" Web sites have already formed, and some national drug abuse centers are weighing in on the issue. But, what is the first action that these folks want to take? Regulatory action. What do they want to regulate? Why, the easy thing, the feel-good thing: DXM sales! Drug Topics reports that Senator Joseph Biden is about to introduce federal legislation restricting DXM sales by the age of the purchaser. Do you smell a new pharmacy requirement for these sales? I do. Let's stop it!

Keep writing to Senator Biden at http://biden.senate.gov/contact/index.cfm to express your opposition to any pharmacy involvement in this restriction. (if you are not from Delaware, do not expect a reply; if you are from Delaware, lay into him particularly hard!) I would also suggest to the senator, and also state legislators and regulators, that if DXM, or PSE, or even chocolate milk, is deemed so abusable that they want to restrict its sales, then they ought to do so by making it Rx-only and a scheduled controlled substance! If they want pharmacists to deal with these drugs, then they should officially enroll them in the clinical armamentarium of therapeutic substances. But, tell them, no more police work, no more bean counting, for pharmacies!

I have sent the following letter to my own senators and representative in Congress:

Dear Rep. Conaway, Senator Hutchison, and Senator Cornyn,

As a licensed pharmacist, I am writing to you in opposition to legislation that may be introduced by Senator Joseph Biden, to place an age restriction on the sale of dextromethorphan (DXM) products in the U.S. by requiring pharmacies to police these sales.

DXM apparently has an abuse track record, and may need sales regulations, but please oppose any attempt to force the enforcement duty on PHARMACY personnel. Give this duty to the people who already check IDs for tobacco or alcohol purchases.

We pharmacy professionals have already been saddled with the duty of pseudoephedrine (PSE) sales policing in Texas. Neither of these actions (the actual PSE law and the possible DXM law) involves the clinical practice of pharmacy. There is no patient counseling involved. It is just a huge amount of busy work that further strains the tremendously overtaxed, exacting task of the practice of pharmacy. PSE was forced upon us, but we cannot afford any further attempts at solving OTC drug abuse problems by giving pharmacy more police work. If ANY product is so abusable that its sales must be restricted, it deserves to be made a prescription-only controlled substance. Do that, but please stop these ignorant makework schemes in pharmacy practice.

I'll confess fully: I am an "old" apothecary. No, I'm not talking about senility; I'm as strong and as alert as at any time in my life (weightlifting and regular cardiovascular exercise are essential, and I am the only person in my department with good enough hearing to hear the phone ring) . It's just that, after 31 years of practice, I have seen a great spectrum of change in pharmacy get flickered across my screen. Drugs have gone from being pharmacognostic to being biological.  My first boss got his pharmacist license by virtue of apprenticeship only, in 1948; my current bosses are practicing continuous professional development  (CPD). The logo of the profession should be changed, from the mortar and the pestle to the structural formula of a molecule (how about the DNA sequence of the gene for heparin-induced thrombocytopenia?).  I gained admission to pharmacy school in 1973 on the strength of an application, transcript, fee, and a postage stamp (no interview; I didn't even pick up the telephone!); today's pharmacy applicants go through a challenge experience worthy of contention for any rigorous clinical spot, including medicine. 

And so, for the twenty-teenth time, I say, you 21st-century pharmacy graduates may be on a collision course with reality. I am quite curious: what do you want to do in pharmacy? I suppose my real question is, why aren't you avoiding retail like the plague, and all flocking en masse to institutional practice, where your hard-honed skills can best be actualized? From what I can see, the paradigm of community pharmacy practice has not changed very much at all in my time, while the academic training for the job has been revolutionized.  After all you've been through, how much of a sign-on bonus would keep you glued permanently to an oar as a galley slave for the prescription mills? 

I recall one 2003 graduate whose entire interview theme at my hospital was "my bonus term at Big Chain Pharmacy is expiring, and I want to get out and do what I went to school for."  Does this mean that, in 2006, when "the three years were up," that there was a gigantic exodus of '03 grads from retail to hospital?  

 The PharmLand blogs tell me that you guys are persevering in that for-profit, ambulatory care environment, but are you thriving there? Is this what you had in mind for your mind?  Or, is there talk of your posting a shingle, "Carla Clinical, Pharm.D., Medication Therapy Management" and successfully taking profits of your own with your NPI?  I was in retail for 13 years, ending in 1993, and I cannot see how the major chains will allow you to practice pharmacy as you are now supposed to be doing, and want to be doing. 

According to James G. Frazer's The Golden Bough, a classic discussion of religion and folklore, it was not good to be treated like a king. Because their persons were sacred, the kings of old were often placed under severe limitations, such as regards where they could go or what they could eat. The owners of the Doubletree Hotel chain must have taken a page from Frazer when they designed their hospitality paradigm. Yes, I was feted like royalty. But, who wants that? Read on.

I just returned from a weekend continuing education conference that was held at a Doubletree property. This year, for the first time, I was able to get a room reservation on site. I had never been a guest at one of these hotels. Beforehand, I was delighted. Afterwards, I was delighted to check out! In the name of luxury, hotels such as these are self-contained and massive. So massive, in fact, that there were no elevators on the side of the building I was in. I had to walk down the corridor of an outdoor atrium to get to the nearest lift. Then, unlike more user-friendly lodging, the Doubletree wants all the revenue to itself, and, like the movie theater that prohibits "imported" snacks, has no solid-food snack vending machines, only soda machines. The only sources of victuals in the castle are room service (17% service charge!) and a haughty restaurant near the lobby, such that casual dining is discouraged. Come on, I just wanted a Honey Bun with my Diet Coke. No way you're getting off cheap at the Imperial Doubletree, Apothecary baby! No driving to 7-11, either. The hotel was located on a moat of heavy traffic requiring sophisticated navigation of frontage roads. And, to get in and out, I had to drive a spiral up and down an elevated parking garage. On the last day, though, I did a Count of Monte Cristo, and escaped to Fuddruckers for an Inferno burger. Yum. But, it was a long walk to get there, really hard-won peasant food for this "King For A Day."

Doubletree, you ought to listen to Dave Ramsey. Haven't you heard that the paid-up home mortgage has replaced the BMW as the status symbol of choice? I guess that, to you, a status symbol is convenience, and you'd rather charge through the nose for inconvenience, and represent that as sumptuous living. I'd represent it as a gun in the ribs and your palm out. Please join the real world. Treat others as you would want to be treated. Bet the owner wouldn't want to suffer the slings and arrows of his own marketing scheme. Hey, Hilton, I work for a living. Treat me like a working man instead of a king, and I might come back to you.

He sauntered in through our mahogany-like front door, the epitome of "the doctor," carrying the classic leather doctor bag, and I felt better already. It was one of a number of doctor house calls I experienced as a child. The touch of this gentle man with his stethoscope, wooden tongue depressors, and abdominal palpation were half the battle towards a cure for just about anything. And later, my mother would bring home this amber glass bottle with my name typed on it. There was no drug name typed on it, but I learned that the liquid was Phenergan with Codeine cough syrup. To that little boy of long ago, it was as if this medicine was ordained to be on my bedside table by God, the patriarchs, Moses, David, and Solomon . With the trusted sources involved, it just had to work, and, well, it always did.

Since then, however, I've wondered. Over my years as a pharmacist, I've seen medications demoted from the divine treasures of my childhood to mundane commerce of the present day. They are advertised in the media almost like beer. New products seem to arrive on the scene in time to replace old products whose patent life is over, or with just enough of a molecular modification to deserve a new patent (a recent one: how about Nuvigil, iisomeric successor to Provigil?) Some products are in the clinical area one day, and are over-the-counter the next day (look at Plan B; in Maine, there was a huge collaborative practice system erected for it; then, POOF--who cares? It's OTC!) There was a time when controlled substances could not be advertised in pharmacy ads, but they are now hawked prominently on television in the form of prescription sedative-hypnotics.

But what really has me re-thinking the value of my stock in trade is a continuing-education presentation I attended this week. One of the speakers compared the major international studies on antihypertensive therapy. With each decade's study, the therapeutic plans went from lists to algorithms to colored algorithms, but seemed to offer no optimal pharmacotherapeutic answer for the problem of high blood pressure except the cheapest and the most obvious: lifestyle changes. So, the end of the lists and algorithms just had me wondering: with all we do in pharmacy, are we dealing with useful substances at all? Do drugs, in fact, work?

The blood pressure deal was, for me, the latest blast of the approach to drugs that we as pharmacists see all the time: trial and error. If medicine is becoming evidence-based, please tell me where you see evidence of the use of evidence! I wonder about this especially when we see people on a dozen medications. Whatever happened to the notion, briefly stated in a non-medical piece I once read, that while there are many diseases, there is only one health? Why cannot our goal be to identify the source of that one health, and arrange for its generalized victory?

The book of Ecclesiastes talks about all being vanity, "miserable business." Perhaps medicine was destined to be what Coolidge said: "The business of America is business." Only through the eyes of a child reaching for help from a kindly old house-calling doctor was there ever a drug that worked. Otherwise, drugs are only sold.

You've seen the ad: you get your cholesterol from your body and also from Aunt Tillie. Nature and nurture. But, I sense that our 21st-century ills come mostly from nurture. The bad food. The lack of locomotion. The substances of abuse (alcohol, tobacco, and both licit and illicit pharmacodynamics). Yet, what do you see when your patients approach your counter? I think that, very often, you see obese, underexerted, smoking, drinking meth mouths, and the doctors are writing them prescriptions: prescriptions for hypertension, prescriptions for hypercholesterolemia, prescriptions for anxiety and mood disorders. Yes, they are sick. Yes, they have pathology. But, from what root cause? Why is the root cause of their illness cluster--their collection of bad habits---being tolerated?

I have just invited a cacophony of roaring protests, and I already hear the cries of healthcare rationing, discrimination, social engineering, and also a just plain "None of your business!" Ah, but as a taxpayer, an insurance premium payer, and most important, as a healthcare professional, I have to try to make it my business. I have to strive to be part of the solutions, and not part of the problems, of disease. To be otherwise is to be nothing more than the Pyxis machine section of the store, pills popping out of my hands to do no more than fill the rice bowls of the drug makers, insurers, and prescribers.

To rephrase the $64 billion healthcare question, could rehabilitation become part of medication therapy management (MTM)? Instead of continuing to allow the throwing of Vytorin, Toprol, and Cymbalta at the problems, why can't we affix our National Provider Identifiers to requests for dietetic or controlled-drug or tobacco interventions? Otherwise, we risk running into the accusation of being partners in crime.

Drug Topics recently described pharmacists as "the new gatekeepers" of drugs. But, with our current position in the healthcare pecking order, the strength of that gate is laughable. Thus far in the history of the pharmacy profession, we are supported only in the dispensing, and not in the controlling. Still, the federal act that created MTM reimbursement strongly hints at our arrival as learned intermediaries in the matter of pharmacotherapy. We are on a collision course with some of the poor lifestyles that are nothing more than excuses for the eating of expensive drugs. And, no, I shall not bite my tongue.

I received an interesting pharmacist recruitment postcard in today's mail. It was from Humana Military Healthcare Services, which is looking to fill civilian Air Force pharmacist positions in Mississippi, Alabama, and Texas. From the sound of it, Humana is contracting for civilian pharmacists for the U.S. Air Force; that was interesting enough. But, what really caught my attention was the opening line about this company having " . . . excellent upcoming positions avaiable for registered and clinical pharmacists . . ." Once I read that, I wanted to raise my mental hand in this postcard classroom and ask, "Hey, wait a millisecond: what about that  pharmacy classroom pep talk we once heard about all pharmacists being clinical pharmacists? And, legally, aren't all clinical pharmacists also registered (licensed) pharmacists?  Well, in the world of the emerging caste system among us, some pharmacists might be more equal than others.  The Humana postcard didn't contain an actual "R.Ph. vs. Pharm.D." dichotomy, but the implication is there, especially in the added qualification, "additional experience/certification may be required for clinical positions."

 Somewhere on a human resources desk, a rule has been formed: there are now two kinds of pharmacists---dispensers and clinicians. It is possible that a recent pharmacy graduate, holding the Doctor of Pharmacy degree, could have his or her clinical training diluted by years of rusticating with the average community pharmacy chain (I apologize to those few exceptionally ambitious, assertive retail pharmacists reading this), and might have to catch up to qualify for a position involving, let's say, the preparation of pharmaceutical care plans, consulting on the building of total parenteral nutrition (TPN) orders, or practicing medication therapy management.  There are some clinical skills required of dispensers, such a recognizing overdoses, drug interactions, or adverse drug reactions, but the skills are hard to hone in retail practice and, unless exposed by a deficiency in them (such as by a pharmacy board disciplinary action or a civil action),  go unrecognized. 

How do we make the old pharmacy school cheering section's message a reality? How can we ensure that every future pharmacist gets to practice the pharmacy profession instead of keyboarding and inventory control? Individual initiative? There is, or was, a pharmacist news column named 'Tween scripts; dispensing activities crowd out real cogitation. Institutional practice? It is a possible venue for all of us, but many of us are lured away from it by the prospects for higher salary, bonuses, and other retail mammon.  Independent practice? If you believe the American College of Clinical Pharmacy, 165,000 of us are going to have to do that by 2020 to fill the need. If one says, "Let the chips fall where they may," then keep watching, because those chips are falling into place as we speak. But, it might be more prudent for us to chart our profession's future by method instead of madness, and  spend time shopping for the best outlets for our training and talent.