The Ole' Apothecary

So, I joined the vast blogosphere on June 28, 2007, one year ago today. This has certainly been fun. I'm going to delete the whole thing right now--NOT.  Thank you very much, everyone who has commented.  This has been, and shall continue to be, a source of enormous pride, release, and insight for me. I wish I had this pharmacy blog, and the other pharmacy blogs I have read, as reference works when I was starting out; I could have used their collective wisdom, and, who knows, what I have read here might have redirected my career a long time ago.

To the likes of The Angry Pharmacist, The Angriest Pharmacist, Pharmacy Chick, Pharmacy Mike, The Drug Nazi, and the late, great Pharmacy God, I say, thank you for keeping me well informed of the nature of community pharmacy practice in the 21st century, because I left it long before the 20th century ended, and thanks to you, I am able to list the following as non-negotiable conditions for my return:

1) $100 hourly wage
2) daily, uninterrupted, external (i.e., Elvis gets to leave the building) 1-hour meal break 
3) third-party ombudsman pharmacy technicians
4) personal receipt of all MTM reimbursement I file for
5) immunity from frivolous customer complaints
6) limit drive-thru transactions to prescription-related products only
7) in-pharmacy toilet facilities

Give me another year, and I'll probably add to the list.  And, even with these, you'll have a long
wait until I make up my mind. 

On to year two!

I can't help it, but I'm coming back to this. This is the endpoint irritant of disrespect to all community pharmacy professionals, and I do not care about the presumed legalistic virtue of it: the "controlled-drug" status of pseudoephedrine.

Our national government has put this excellent over-the-counter drug, not just in the status of a potential threat to public order, but in the status of a potential threat to homeland security! The federal law governing pseudoephedrine sales is part of the USA Patriot Act. Because of Al Quaeda, you are now, in some semblance, a potential terrorist if you seek relief for a stuffy nose.

Of course, sales of pseudoephedrine (PSE) have been restricted because the drug is a precursor in the manufacture of the illicit and fiercely addictive drug methamphetamine (meth), certainly the scourge of the Nation, but now also the scource of pharmacy operations from purple mountain majesties above the fruited plain and sea to shining sea.

This isn't maudlin sentimentality, but real chagrin. I don't like the idea of a popular, effective, nonprescription medication becoming hard for ordinary, law-abiding, upper respiratorily challenged U.S. residents to get, and also having this happen in the new century. It goes totally against the grain of an Ole' Apothecary who has been the custodian of similar jurisprudence from former times. Why add to it? Have you ever heard of the so-called "exempt narcotics?" They were exempt from narcotic tax, but also exempt from prescription status. In the modern era, they are Schedule V controlled drug products which, in some states, can be bought without a prescription but must be purchased similarly to pseudoephedrine: the purchaser must be at least age 18 with proper ID, and must sign his or her name and address. Examples of these are Robitussin-AC, Tussar-SF, and Novahistine-DH codeine cough syrups, and (before they went off the market), the antidiarrheals Parepectolin (kaolin/pectin plus paregoric) and Donnagel-PG (belladonna alkaloids with paregoric). Folks bought these easily enough, and in early times, they were seldom abused. But, pseudephedrine isn't even directly abusable. Take a handful of Sudafed 12-Hour caplets, and you'll get rather agitated, sweaty, and tachycardic, and your blood pressure will crack the mercury column. So, you won't seek that feeling again.

The problem is with the illicit drug makers and dealers. Prior to the federal and state regulations, these folks were able to obtain PSE by the carload for processing into meth. Surely, the sale of the drug must be monitored: I am in total agreement with that. But, I say, why must the task be thrown to the already strapped, busy, clinical staff in the pharmacy? Front store staff are perfectly capable of checking the IDs of PSE purchasers the same way they do for tobacco, beer, wine, liquor, or firearms ammunition. We need our technicians to help us fill prescriptions without the PSE interference, so we can more efficiently handle our professional duties of drug use evaluation and counseling.

I have occasional sinusitis, so today's PSE post was inspired by my visit to the local fast-food pharmacy for measured relief. I stood in the roped off HIPAA line for a few minutes, then stepped forward with my drivers license in hand, and asked for my Sudafed 12-Hour caplets. The technician-trainee filled out his little booklet slip and had me sign it, and I received my receipt categorizing the sale as "AGE RESTRICTED - LIMIT REACHED." The pharmacy staff all looked pretty tired and nervous, but somebody must still be stuck with this behavior-control scut work, and one needed pair of hands was taken away from the practice of pharmacy and handed over to pure law enforcement.

It may now be a crime to want freedom from rhinorrhea.

Thirty-two years ago today, I walked into a hot, ordinary amphitheater at a local college to start taking the National Association of Boards of Pharmacy Licensure Examination, or NABPLEX, as it was then called. I understand that folks do this on a computer these days, and in air-conditioned comfort. But in 1976, on the first day of a typically humid summer, we of that pharmacy class had to do our work in oppressive air, and that meterological symbolism would turn out to be appropriate. There were tower fans around the room to keep that air moving, but our introduction to the professional era of our lives contained no mercy. Even verbally, there was no rest. As we sat waiting for the proceedings to begin, the crusty old members of the Board of Pharmacy got in a final taunt. They would stop people in the hall and ask the following:

"What's Turlington's Balsam*?"

Typically, there would be no answer, since the name for this vehicle went to the boneyard before we even took our compounding course. To the silence, they rubbed in, "Five years of college, and you don't know what Turlington's Balsam is?"

The rest of the board-exam week came and went. On the last day, I felt shaky and tired. I don't remember it being a bad test. I just remember how tiring it was. I don't think I have been quite as tired since; that is, I cannot recall a combination of hot weather, hard work, and emotional traction that ever came together in just such a way since then. My notice of passing the exam was not issued to me until the first week in August, but the license reads June 21, so, unbenounced to me, I had become a pharmacist when I woke up that morning.

Not because of any particular romance--I was doing my first boss a favor for a friend to fill in part-time---but, I filled my first prescription as a licensed pharmacist at a tiny drug store called Village Drug, in a place that probably was once a village. You could dial (yes, dial; touch tone phones were a few years away) four digits to reach anywhere around town, and I suspect that the human operator had retired just ten years before I arrived. The owner got his pharmacist license in 1948, a few years before a baccalaureate degree would be required to get it. As has been the case for centuries, and would be so for decades more, patients would bring in paper prescriptions, I would stamp out prescription serial numbers four times with a big, metal Bates numbering machine, type a label with a manual typewriter, package the medication, and out the door they would go. There was no counseling required unless it was an obvious thing: drowsiness, orange urine, or, especially, a first course in monomamine oxidase inhibitors (no patient literature was available; I had to underline a package insert to warn them what not to eat or drink with, say, Nardil).
At this same time, I was working full time in the community hospital of a small city. The authors of USP Chapter 797 would soil their pants, because nurses prepared all of their sterile products on the patient floor! It's almost needless to say that there was no TPN service at this little place. I suppose that if someone needed a TPN, they'd be shipped out to a larger city 50 miles down the road. These were the days when you could still have concentrated potassium chloride on the nursing unit. Over the years, Americans in various parts of the country would have to die before this changed.

I just came back from a visit to my native state and the town where I grew up, and near the place where I took that NABPLEX, and all I seemed to feel is that everything seemed so formalized. The many roads that once ran free now had much more definite traffic rules. One familiar street has been made one-way. My old high school hadbeen torn down, and a land-of-Oz emerald palace has replaced it (it looked and felt much more like a corporate headquarters building than a high school; and again, air conditioning? In school?). The same is true with pharmacy; we have added formalities, not done away with them. The bolts have all been tighted, the standards raised, the language made specific, and the fear of, and opportunities for, litigation, growing as we speak. A lot of people have said that the fun has gone out of pharmacy, and I think it is because the rules, the rules, the rules, and more rules, have come in. Are people healthier for it? You tell me. Potassium chloride, that was a good rule, yes. But pseudoephedrine? "Counseling?" It is either gilding the lily or passing the buck, or politicking so someone in the State House gets to look good.  I wouldn't mind having to talk about Turlington's Balsam at long last. But, I have to get back to preparing tigecycline. All this way we've come, and tetracycline-oids are still with us. Everything old has been made tight.




* Turlington's Balsam: see http://inhalatorium.com/page152.html

I wrote about this before (http://oleapothecary.blog.com/3076023/), but have to do it again, because this time I looked into the face of pure grief, or rather, many faces of pure grief, due to a motor vehicle crash.

I cannot recount the exact circumstances surrounding the accident, so I will not comment on it directly except to say that I believe almost all motor vehicle crashes are preventable.  But, this playout was different.  The driver, now the patient, was going to die. I saw family and friends gather in the hallway outside the critical care unit. There must have been more than 30 people there. Most of them were moaning.  Crying is cathartic, but there is something awful about a moan. A moan is sustained emotional pain, and this entire crowd of people was moaning in the painful throes of  fresh grief.  It felt like some infectious wave in the air around me, like the tenth plague of the book of Exodus.  But, I knew it was from a car crash, so I knew it might have been preventable. I remember John F. Kennedy's warning: God's work must truly be our own.

How long will it take for this nation to think historically about its highway carnage, and make the operation of motor vehicles a closely guarded skill?  We should certainly be entitled to pursue mastery of this skill,  but we must also be required to prove mastery before we are allowed to drive independently. True drivers' mastery requires a complete education, and that education requires an indoctrination into the culture of safety that might have saved this young woman from herself, and her loyal cadre of loved ones from their bereavement.

I do not give a hoot or a hang any longer about what anybody says regarding "rights" or "freedom" or "it won't do any good."  No person, regardless of age, should be granted a license to operate a motor vehicle without passing a rigorous program of driver education. After hearing the mournful moans of those people,  I demand such a law in every U.S. jurisdiction.

On May 15, 1999, a quiet revolution occurred in my personal practice of pharmacy.  My employer at the time, The U.S. Department of Veterans Affairs ("the V.A."), ordered the end of the use of paper for all medication orders, inpatient and outpatient.  Only prescribers were allowed to write or amend these electronic orders.  They had been well trained in the use of the new computer system, even to the point of receiving a short course in touch typing. At least in this one corner of U.S. healthcare, it looked as if chicken-track prescriptions would come to an end coterminously with the 20th century. When I left the V.A. in 2000, it seemed that the new system was working very well.  I believed that, if the U.S. government could do it, why not the rest of the country's prescribers?

Seven years later, the same system--the one used at the V.A.---happened to be adopted at the private hospital I joined. With some small exceptions, all the orders do get entered electronically, and the problems of legibility and the actual availability of the orders have been eliminated.  During this period, I heard President Bush call for the changeover of all medical records to electronic form (say what you want about the man, but I never heard a president complain about prescription handwriting until he came along).  On April 1, 2008, paper prescription pads became a thing of the past at my hospital. Thanks to the Medicaid requirements, all outpatient prescriptions from our institution are now computer-generated on tamper-resistant paper, so community pharmacy personnel in our area can read everything the first time! Whodathunkit?

I do understand that there are still many problems to be worked out before electronic RXs become the norm in retail. I am not a retail pharmacist any more, but I read and hear that there is no standard of communication for these prescriptions, and they come out awkwardly and goofy-looking.  But, please, folks, know that it works well when it does work, and you should press for the establishment of a true national transmission standard.  We may be a nation of states, but we are a 21st-century nation with people constantly on the move, and each state should craft its laws and rules to help this new standard along.  The Joint Commission has tatooed the phrase "medication reconciliation" on our foreheads, and coherent communication of health information is a must. 

So, to prescribers I say, get on the bus!  Enter here--that is, write your prescriptions on this machine, the one you are looking at now.  I lost my fear of computers almost 20 years ago, and am very, very glad that I did. Not only did I lose my fear, I could kick myself for ever having been fearful. Computers and the internet have improved my life by improving communication. Yes, there are many naysayers who say that they have affected people's attention spans, but they have expedited and simplified everything from airline reservations to tax returns to banking. It has taken much too long for this tool to reach prescriptions, and now that it is here, I say, all aboard!

In 1999, I took my first airplane flight in 17 years. I don't know why, but for 17 years I stayed away from flying. I don't know if it was an unconscious fear of a plane crash, but the year before, I heard that the U.S. had gone without even one commercial plane crash for the whole year. That's a lot better record than for motor vehicle crashes, that's fer shur! So, in January of 1999, I took my first airplane trip to, of all things, the annual convention of the American Society of Automation in Pharmacy at Amelia Island, Florida, because I wanted to meet people in that specialty. I also decided to pamper myself by staying at the site of the event, the Ritz-Carlton Hotel. It was both my first visit to Florida and my first stay "at the Ritz."

Nope, it didn't work for me.

This "peasant" child of a Boston neighborhood felt just as ridiculously out of place as the pauper who played the prince. I am just not happy with people coming in to "turn down " my bed and direct me to the plush bathrobe and slippers. The notion of room service is bizarre to me. I tried it, and I'm just not the room service kind of guy. I was not born to be a king with servants, and I never will be such. I know some people are; they act as if they were born to be Alexander or Cleopatra, and they come off like trash. The entrepreneurs at this festival of technology were equally distant from me. I was in the wrong place; I wasn't one of them, just an interloper, and I could not maintain much of a dialogue with them; I had no magic box on the drawing board to show off. The thing should have been by invitation only. I guess I'm not one who thinks big. I can't pretend well. Yet, I am this big, fancy "healthcare professional." I am one person who can carry that image only so far. I can be helpful, but I cannot be imperious. Guess I'd be lousy as a chain drug store executive. Too much humanity and mercy in me.

Back to flying. The in-flight magazines bespeak the life style of the "jet setters" (ever heard the term? It became popular in the sixties, mainly due to alliteration, I suppose). The technology offerings in those mags seem to consist only of the tasteless toys of the hopelessly yuppified. I don't need a dog dryer (well, maybe because I don't have a dog, but still!) I'd rather drink from a mug, not a snifter. I'd much rather have some Texas barbecue eaten off a piece of wax paper, or some marvelous steak fingers up at Buddy's (a real place in Texas), than to go in for the "nouvelle cuisine" of rack of lamb (six bones in the middle of your plate for $60.00!). And, those first-class sections in airplanes: yes, the seats are wider, and there is a real meal, but I sense that I get to board the plane quickly enough in coach, and I can always bring my own steak fingers with me. First class is for the pointlessly pompous, or is something purchased by the corporates for shipping applicants to interviews to tell them that their resumes are "impressive."

Hey, if I'm sounding like Andy Griffith in No Time For Sergeants, well, guilty, guilty, guilty. But I can still match my vocabulary and diction with the best of the best, be they real or be they trash trying to be real (I love it when one of these diamong-ring ladies shows she can't spell or pronounce some words; I wouldn't openly ridicule her, but I'd just laugh to myself). I'm just a well-dressed hobo, and proud to be one. Sue me, whip me, stick out your tongue, or as my Dad used to say, "call me a pisher." Yes, I'm supposed to be like Captain Kirk in one of the original Star Trek episodes, requiring the good spirit for compassion as well as an evil component for leadership. But I don't have much of the latter.

I'm on vacation in New England this week.  In a drive around my old New Hampshire haunts, I saw cancer spreading: a big box chain was declaring the outgrowing of its old locations in two adjacent Granite State cities, and moving those stores to newly built digs just across the respective streets! The sight of it was enough to make me hold my pharmacist's neck and search for rope marks.  Continued prosperity for the chains means, to me, continued reduction of the practice of pharmacy to a legal abstraction.  The many indies of Rochester, New Hampshire, have long since turned into pizza parlors, and the disease of modern commerce is getting dumped over their corpses like peat in a new garden.  I saw no hearse, but I felt as if I was attending a funeral.  Requiescant in pace apothecario.