“Why do I feel so bad, Doctor?” … “Hmmm, Betty, you have Chronic Fatigue Syndrome”.

COUNTER-PRESCRIBING.

This has been going on since well before Durham-Humphrey ordered two classes of drugs.  Prescription Only and Over The counter.  It was wild west.  Snake Oil at the pharmacy.  The best example is a drug that cured just about everything.  It was called Coca-Cola and it contained Cocaine.

We counter-prescribe today, but are limited to legitimate OTC drugs.

DE FACTO Prescribing.

This is when the doctor has screwed the goose, you have told him and he doesn’t have a clue.  Perhaps, she has grown used to depending on your expertise or knowledge.  Either way, if the doctor says:

“What do you think I should prescribe, Beverly?” 

When you tell him what drug to use, you are the defacto prescriber.

BEHIND THE COUNTER DRUG PRESCRIBING.

Last winter, an FDA panel recommended a BTC class that could be sold only with a pharmacist supervising.  The AMA whined about it.  Apparently it is okay with the AMA that Monistat can be sold at a truck stop and that women with BACTERIAL INFECTIONS can use it and end up with PID and be infertile.  A good pharmacist will make sure that the infection is yeast before selling.

CERTIFIED PHARMACIST

A class of pharmacist that I dream of.  Qualified to diagnose and prescribe.  UTI, allergic rhinitis, birth control pills (some pharma are pushing for OTC class for BCP.  Yaz at the truck stop) You tell me some more categories.

WHY NOT?  If you don’t want to, you don’t have to.  This could open up a new world for independent pharmacy.

If we neglect to counsel, we will sacrifice our professional standing.

A Pharmacist Captive Of The Prescription Mill

I am a strong believer that our salvation as professionals is counseling.  If we follow our personal professional standards, ethics and the law, we will counsel.  We will counsel with new prescriptions and we will counsel on OTCs. 

I can hear some of you whine, “But, Jay Pee, the timers.  The DM nails us when the timers look bad.  I DON’T HAVE TIME.”

You can be a slave to the Prescription Mill, a glorified technician or you can be a pharmacist.  Your choice!

Counseling does not have to take a lot of time.  Thirty seconds to hit the high points.  Beyond that, most patients won’t listen.  Some drugs may take five minutes.  I had a woman the other day who did not want to listen.  I had to repeat the warnings.  Finally, I grabbed her hand and made her look at me.  I asked her, “Do you want to decline this counseling?”

“No, why would I do that?”

“Because you are not listening to me.”

“After that, it took 30 seconds.”

I want to examine pharmacist prescribing.   Either defacto when the doctor screws up and asks what you would choose or when the pharmacist is the primary prescriber.

We need to bring this to light.  We need to bring this out into the world because it is only reasonable that the drug expert would prescribe the drugs.

Please send me your thoughts at jpgakis@hotmail.com.

Tell me about your prescribing.  I’d like to hand over a ton of evidence to the editors at the magazine to influence a cover story.

I have corresponded with a psychiatric pharmacist in California who prescribes for every patient in the hospital.

A hospital pharmacist in the Midwest reported that he was captive in the ER because the foreign ER doctors had no clue when the emergency was a real emergency.  The stress got to the RPh.  He used CIII drugs illicitly to take the edge off.  He now works for a retail chain and considers it to be paradise.

I know that many of you prescribe.  Please tell us about it and send me your thoughts privately. 

There is a matter of respect here.  Big Pharma has been ignoring us for over a decade.  If we are going to be prescribers, and it is inevitable, I want Big Pharma to come back home and court us a little.  We are the drug experts and they aren’t even advertising in our magazines anymore.  That is disrespect.

Jay Pee

Great job on the comments, you guys.  Remember this.. Nothing is perfect.  Most doctors know about only that handful of drugs they use often.  Most of them know what they know from Big Pharma.  How many are prescribing Lexapro?  Pristiq?  They didn’t just pull those names out of their asses.  YOU KNOW BETTER. Their job is diagnosis.  For optimal patient care at the most reasonable cost, you should be the prescriber.

"Dream Lover" Bobby Darin

Every night, I hope and pray a Dream Patient will come my way

“My insurance plan requires me to fill certain prescriptions by mail order, but I’d rather you fill them even if I have to pay more.  You take good care of me.”

“We do our best, Jane.”

Jane laughs, “It is more money, but I like it that my pharmacist knows every pill that I am swallowing and why I am taking it.  You even gave me a few pills to hold me over while waiting for an okay from the doctor.”

“You can’t just quit clonidine cold turkey.   The doctor should know that.  That is a warning in the literature and that makes it ‘the law’”.

“Remember when you gave me that cream when I had poison ivy?”

“I remember, Jane.  The mail order pharmacist can’t do that.”

“I’m a sophisticated medical consumer, Ron and what I like most is that you have conferred with my doctors to make sure that I am getting the right drugs.  The doctors, clearly not know-it-alls have followed your advice.”

“I like being a pharmacist.  That’s my job.”

“Your store, Ron.  You have spiffed it up and have added supplements and health food s and herbs.  Your new cosmetic line is all natural.  I love the old-fashioned ice cream counter.  Your fruit smoothies are the best in town and they are chock full of nutrition.

And you mix prescriptions by hand.. what is that called?”

“It’s called compounding.”

“That’s it.  Your glassed-in lab is impressive.”

A grumbly voice jumped in.   He was an older man.  “I am semi-retired and do not have a regular paycheck,” he says, “I’d love to bring all of my prescriptions here, but I can’t.  I can only bring you the one-shot prescriptions, like this one for my pink eye.”

“I understand, Tony.” 

Ron knows that the days of making his living filling prescriptions are long gone.  There is more profit in what you call your “Hi-Protein, Omega-6, fiber strawberry smoothie” than there is in one prescription for Lipitor.  The Smoothie only costs you $1.23 and sells for $3.95.  Betty Jill, a high school graduate, manages the smoothie counter.  She gets $15.00 an hour plus benefits plus bonus.

Tony speaks up, “Ron, I feel guilty that I get my recurring prescriptions from Medco and you still advise me on my prescriptions.”

“It’s my pleasure, Tony.  You buy your supplements from me and you love that special Vanilla Chocolate Smoothie that Betty Jill makes for you.”

“I love that Smoothie.  I think it helps me keep muscle.”

Jane is interested.  “Can she make me a carob butterscotch smoothie?”

“I can make any smoothie you want,” Betty Jill says, “but, Jane, butterscotch will add calories.”

Paul McCartney comes on the music loop,

 “Jojo was a man who thought he was a loner, but he knew it couldn’t last.”

All three sigh.   They are mature.  The music is emotional.  Ron remembers the day when 150 prescriptions paid for a good life.

“Jojo left his home in Tucson, Arizona for some California grass.

“Goddamit, Ron,” Tony says, “I hate frikkin’ mail order.  It makes me feel cheap when I call you for advice on medicine I get from them.”

“Get back, Get back where you belong.”

“Ron, Tony, I love this song,” Jane smiles.  “Don’t tell my husband, but it reminds me of some very horny days when I was single.”

“Yeah, Ron.  You’re the pharmacist, what is up with Loretta?”

“Sweet Loretta Martin thought she was a woman,

But she was another man.

“Premarin, probably.  Give a guy enough of that and he will be a woman.”

“All the girls around her says she’s got it comin’,

But she gets it while she can.”

“Jane, what do you think?”  Ron is looking at her with interest.

“Premarin for sure,” she laughs.  “How about three smoothies.

I’m buying.  Are you ready for us, Betty Jean.

Three smoothies.  $8.28 profit. 

There is a way, you guys.  You are never going to provide for your family by filling prescriptions.  Those days are in the rear view mirror.  It will take a paradigm shift, some lateral thinking.  Some daring and courage.

We have just started offering this valuable professional service and CVS treats it like popcorn

Just when you think that grocery stores (the bottom of the professional ladder) have done their worst, a major drug store company diminishes your professional standing with this.

The perception that pharmacists provide a valuable professional service has been diminished, if not outright killed, by all of these bargain Rxs and give-away Rxs.  Now, CVS is attacking another professional service that we provide before we even get out of the gate.

For decades, included in the definition of pharmacist is The Administration of Drugs.  That could include putting the tablet in the patients mouth, I guess.  Perhaps applying the cream or sticking the suppository.  Certainly, administering vaccines applies.

There was a day when giving shots was perceived as a particular talent that nurses had.  This was when most doctors were fee-for-service, ran their own businesses and wanted that revenue stream for themselves.

Any idiot can take blood pressure, but I got my ass chewed in 1978 for doing it.  I worked in a slow Rx volume mall drug store and put a sign on the counter.   A doctor jumped me with a question like,

“Don’t you think that you should leave that to people who are skilled?”

“What skill is that?”  I kept on doing it and found two men in the most dangerous group.. young, black, male .. to have dangerous numbers.  I advised both of them to take the day off and get to a doctor.  Both returned with prescriptions.  Both thanked me profusely.  Taking blood pressures was a valuable professional service and I did it for free.

You and I know that any idiot can be trained to stick a needle in the arm and press the plunger.  That idiot may not know what to do if that 59 year old gasps, grabs his swelling throat, starts wheezing with his eyes bugging out.

We know enough to start popping him with Epi-Pen, one after the other if he stays in distress, until the EMTs get there.

We now have a valuable professional service that we can sell and, trust me, we will eventually be paid for it.  (just as we will be paid for MTM) 

So, what does CVS do, as CVS seems so eager to do…. they lay another turd in the punchbowl.  CVS is not a big box store.  CVS is not a grocery store.  CVS is a drug store company.  How does CVS think they will get the best pharmacists if they do this kind of shit?

This is all about CVS.  The company is huge.  Second only to WAG in number of stores.  CVS is the rap star playah of the industry.  CVS looks good on the outside, but they treat their professional staff like they are not competent to make the appropriate choices.  CVS times everything, including the drive-through.  CVS is the control freak of our industry.  Pharmacists can get in trouble if they don’t swipe the patient’s discount card.  The word from Cape Cod is that drive through customers in the vacation area are invited to ask for out front items items that they need.  Can you smell a technician going out front for beer, chips and sandwiches with your eyes closed?   

Now, they take our newest, highly respected professional service and give it away if you buy enough Charmin, Dawn, Tide and Cruisers Diapers.

I’m sick of it.  If a grocery store did this, I would be pissed off, but not surprised.  To have a drug store company engage in this bull shit is treachery.   It is deceit. 

One of these days, there won’t be enough H1B Visa holders to keep CVS pharmacies open.

Diana Prince is a weak woman. General Darnell has her intimidated. Where is Wonder Woman when we need her? Double Click On Cartoon

From: JP’s 20 Simple Rules for the Successful and Satisfying Practice of PHARMACY

I have watched female pharmacists just stand there and take it.  Frozen while an aggressive male verbally abuses her.  She is almost unable to assert her right to some little bit of dignity by just walking away.

Set your boundaries early.  Every adult has limits or should have them.  Assert yourself vigorously and you will never have to again.                                                  

Sexual harassment no longer works only in one direction.  It runs both ways.  You female pharmacy managers who have been sleeping with that handsome intern, watch out.  Tommy Boy could have your ass when your company is ordered to pay damages and this kid is able to pay off his student loans with one check.  You can’t win. 

Running his fingers through your hair is not normal management behavior.  Put a stop to it right now.  If you laugh off harassment, it will only be exponentially more difficult to bring to an end.  In a letter sent by Certified Mail, just mention the words Employment Equal Commission Opportunity all together in the right order, in on sentence, and watch them jump. 

Boys, you may think that a pat on the fanny from an attractive female manager is sort of cool, a compliment, but it is harassment if it is unwanted and you can get that company to pay for your ride for a long time if it continues.

Second Edition Bonus Material:  In 1978, the technician I was sleeping with asked me for a raise when we were in bed one afternoon.  I almost dropped the after-cigarette and burned us both to death.  I fired her and she wrote a damning letter to my boss.  He came to San Diego from LA and asked, “What were you thinking?”  He bawled me out for a few minutes and then he became a man.  This technician was beautiful and exciting.  He let me know that he would love to have had that kind of chance with her.  That was in 1978.  It would never happen today.  In the 21st Century, sexual harassment is severely punished.  In my case, it would have been “He said, She said”  She would win! 

You are a pharmacist, the most important employee that a drug store company employs.  Without you, they can’t even call it a drug store.

Is this what it is coming to?

Next thing we know, Home Depot will have pharmacies.

Grocery store companies did not just blindly fall into the pharmacy business.  They saw what was coming a couple decades ago.  They saw an opportunity.

Big Box store companies fell right in line.

They saw a blossoming population. 308,000,000 million now.  They saw an aging population.  They saw a Big Pharma dedicated to profit bringing out new and expensive drugs.

90% of all doctor visits end up at the bottom of the funnel.. That’s YOU.  Everybody wants to be at the bottom of the funnel.

So, my friends, what’s next.  Heino Heinkanen’s Neighborhood Sauna and Pharmacy.  Come in, take the steam, get real clean and have your prescriptions filled while a buxom blonde is pummeling you with a sheaf of vitta.

How about the neighborhood massage parlor.  Come in, get a massage and ancillary services and have your Viagra filled with no wait.

Mazowski’s Tire Center.  I’m just having fun.  You make some up.  

Is this better "Pharmacy Chica"?

In the wordsof Ben Franklin, RPh, "The Pharmacist in Vegas who doesn't have babes for Techs is an Idiot."

Two Tecnicians discussing the patient wearing a heavy gold Italian horn on a thick gold chain nestled in his chest hair. Tipping the Technician with a $100 chip from Caesar’s.  Only in Vegas.

Who Cares How Much They Charge?

We get paid no matter what…. so Wal-Mart can charge whatever they want.  Publix can give away antibiotics.  Giant Eagle can hand out free metformin and glyburide XL.

Our value to the patient and to the company will be our professionalism.  Essentially all forms of counseling.

That is good.  Pharmacists need to separate themselves from the filling process and therefore from the price of the commodity.  I like that. 

Now, let’s freak out some of you who still have dreams of Masters of The Universe, Scions of industry, a second house in Barbados.  How about we have the government buy all of the drugs.  They could drive some hard mother-effing deals. 

Our techs prepare the prescriptions.  We dispense and counsel.  Total fee of $20.00 per Rx.  I pulled that out of the hat.  200 Rx a day.

$4000.00 a day to pay the pharmacists, techs and overhead.  The playing field would be leveled and most of you would be scrambling to get into your own place where you know you could out-service the big boys in a minute.

The big boys would then raise wages to stay in the game.

Call it socialized pharmacy.  I call it win win.

Get real, Plagakis.  Okay.  Give it all away. Just let me counsel and pay me every two weeks.

It is time for pharmacists to strand up and say "NO". Give your Giant Eagle brothers and sisters your support.

 Hey JP. Thought you might be interested in the latest and greatest gimmick to come to pharmacy, FREE diabetic meds. Check out the link: http://www.gianteagle.com/pharmacy/home Giant Eagle is a large, very profitable, very high rx volume regional grocery chain based out of Pittsburgh, Pa. I live and work very near to quite a few of their larger stores and can quite honestly say that this could be a MAJOR turning point for pharmacy in PA, OH, WV and, eventually, other areas. Programs like these are why I cannot share in your unbridled optimism as to the future of the profession. Let me know what you think.

                                     Pharmacyslave2000 

Thank you, Pharmacyslave for the heads up.   Back when Wal-Mart came up with the $4.00 professional humiliation, the pharmacist at Wal-Mart were ambushed.  They had a chance in Florida to stop it, but they just went on willy nilly.

Then Publix Grocery Stores said, “Hey, let’s give antibiotics away free.”  Again the pharmacists were ambushed.  They stood there like deer in the headlights.  The same at Meier.  Then Giant Eagle.

Do you notice that these are not drug store companies.  The brains are certainly not pharmacists.  They do not give a shit about you or the profession that you spent years preparing yourself for.  The brains are mostly likely not as smart as you.

There is NO DIGNITY in this.  The pharmacists who allow it can’t possibly hold onto golden self-respect.  Where is the professional integrity? 

Now, with this…DIABETIC MEDS FOR FREE…. All three, dignity, self-respect & integrity, are in the Giant Eagle toilet.

This time you see it coming.  No ambush this time.  They are jerking your chain and laughing at you.  “These assholes aren’t gonna say word ONE about this.  We’ll fire a couple of them and that’ll be it.”

Not if five of you take a stand.  Watch them line up behind you.  Could be the start of a guild.  Now, that will scare the Eagle.

I urge all Giant Eagle pharmacists to start taking back our profession today.  Refuse to give away your services.  You provide a valuable professional service.  Giving it away devalues it.  Perception is everything in the 21 st Century.   Unfortunately. many of our patients are trash.  You give it away, your service becomes a piece of shit and you become a “Hey you, Pharmist.  Where are da garden hoses on sale?”

I can’t wait until Pennsylvania and Ohio force you to counsel according to the law as they are in Texas.  All of a sudden, overhead goes up and when you have to spend too much time with an illiterate, dull knife on her Amoxicillin Rx that you are giving away for $0.00.

What will Giant Eagle do then?  Tell you Eagleaires to “suck it up”?

This is your time.  Evil can only flourish when good people keep silent.

Free prescriptions are evil.

Definition:  Evil.  Profoundly immoral or wrong.

Jay Pee!

8-5-2010

I don’t always agree with Peon, but I think he has nailed it in his comments. 

This morning, I was reading an article published by The New York Times on nightmares.  I came upon some disturbing statements.  They indicated that patients who are terrorized by repeated traumatic nightmares are usually victims of PTSD, not necessarily associated with wartime events, but usually from childhood sexual abuse.

The results of a randomized controlled trial were published in a 2001 paper in JAMA, of the subjects:

95% had moderate to severe PTSD

97% had experienced rape or other sexual assault

77% reported life-threatening sexual assault

58% reported repeated exposure to sexual assault in childhood

Reading that article got me to do some research.

The statistics are shocking

• 1 in 4 girls is sexually abused before the age of 18.
• 1 in 6 boys is sexually abused before the age of 18.  
• 1 in 5 children are solicited sexually while on the internet.
• Nearly 70% of all reported sexual assaults (including assaults on adults) occur to children ages 17 and under.
• An estimated 39 million survivors of childhood sexual abuse exist in America today.

Some of you have read about my first marriage.  I stuck it out for 9 years even though it started to go bad right after the honeymoon.  My wife was an alcoholic. She abused every drug she could get and got her doctors to write for drugs like Doriden, Quaalude, Librium, Fiorinal and others.  Donna was a victim of incest.  Her father used her and her sister as sex partners for years.  At one point of her middle teens, she ballooned to 175 pounds.  She was five foot tall.  She hoped to make herself unattractive.  Donna had serious sleep issues and episodes of traumatic nightmares.

Most of you are from backgrounds in which this is not a possibility.  It certainly was not in my paradigm.  That was why it took me so long to get it, even though she tried to tell me after marriage counseling one evening. 

My point is that we all have patients with sleeping issues.  If there are 39 million Americans in this group, how many of them get their Ambien from you?

Most pharmacists are not from the socio-economic group where this is prevalent, but there are plenty of us counseling patients who have been victims ourselves.

Paul Rogers was a brilliant psychologist who always looked at what got his patients where they are.  He gave the example of seeing a potato in the root cellar as a boy.  The potato got no sunlight, but it still tried to grow.  It had white, plastic-looking shoots, all curled and malignant-looking.

Rogers said that the same thing happens to people who get no light.  Some of them have been sexually abused.  Many of them have nightmares and can’t sleep.  They end up with us at the bottom of the funnel.  How do you counsel them now?