Continued from yesterday.

Early refill requests from patients, short tempers, and demands for their medicine in spite of legal restrictions, are red flags pointing to addiction and non-therapeutic requirements for dangerous substances. Dealing with people who behave like this frequently cause pharmacy staffs to become jaundiced and suspicious of customers who take a lot of pain medication. It’s an unfortunate situation and has gotten worse in the last two decades.

Flash back twenty years to the late nineties. A doctor friend of mine back in Louisiana was getting a less than favorable reputation with the local pharmacists. Several were refusing to fill his prescriptions. I invited him to breakfast one day and my main point was, “If you aren’t careful with your prescribing habits, your reputation will continue to deteriorate, and what’s worse, a fleet of black Suburbans will arrive at your front door and they won’t be there to help.” Needless to say, the mood of our breakfast meeting turned somber in the wink of an eye. He said, “That’s already happened. Let me assure you, I’m doing my homework. Almost ninety per cent of my patients are referrals from other doctors. These patients arrive with extensive charts, detailed notes, and X-rays. I’m covering my ass.” I said, “Then you should do some PR with the local pharmacists or your patients are going to have a hard time getting their prescriptions filled.”

Flash back to 1979, again in Louisiana.

A team of undercover agents arrives at a doctor’s office and is greeted by the front desk person seated in the apex of a V-shaped desk. On either side of the desk, leading in separate directions were two doors. After a friendly greeting, she asked, “Are you on a diet, or are you in pain?”  Not a good beginning. That prescriber eventually lost the privilege of writing prescriptions.

There’s nothing new under the sun—and because of the abuse potential, pharmacists are now apt to scrutinize every pain prescription more closely, whether it’s a C-2,3, or 4 drug.

I haven’t heard from Alpha again, although it is safe to predict that she found a pharmacist to fill her prescriptions.

Never heard from Mr. Epsilon again either. If he isn’t in jail, I hope he’s in some kind of recovery program.

Gamma’s saving grace is that all of her meds are being prescribed by the same doctor, an oncologist.

Many pain clinics are simply store fronts for unscrupulous doctors engaged in diversion.

Beta is another story. Beta now lives in Tennessee, sees a doctor in a strip mall in Florida, and uses pharmacies in Georgia and Kentucky. He’s not on the peace train, he’s riding the Oxycontin Express.

When there’s so many bad apples, perhaps it’s time to examine the orchard.

Acknowledgement: Free lance writer and investigative reporter, George McGinn contributed to this article.

Future blog topics: “What is the ‘Oxycontin Express'” and “Why won’t you fill my prescription?”

I would have a lot of questions for both the prescriber and the patient. On the surface, with no details, this really smacks of diversion.

One of my chronic pain patients, “Alpha,” moved to Florida. About a year before that,  I had received notification from the pharmacy chain management where I worked that it would be prudent for me to do a bit of CYA for myself and the company. I was to speak to the prescribers for my chronic pain patients and make notes in their profiles as to their diagnosis. In other words, why are these patients taking so much pain meds? When Alpha found out about this, she accused me of calling her a drug addict and causing her doctor to question her need for the meds. [Not her Rx shown above]

About two weeks ago, I received a phone call from Alpha. She was having trouble finding a pharmacy that would fill her prescriptions in Florida. I referred her to my successor at the store where we had become acquainted. I’ve been gone from that pharmacy for two years. Her daily dose would be fatal for a patient who had not built a tolerance for such high doses. Her doctor requires regular lab tests to ensure she is taking the medication.

Yesterday, I refused to fill a prescription for a “patient” who is on a similar regimen of drugs. We’ll refer to him as “Beta.” His doctor doesn’t do blood or urine tests to confirm compliance.  His doctor requires cash payments for office visits at the time of the visit. This patient drives a new Mercedes. Yesterday, as he often does, he wanted his prescription filled a week early. He became unruly when I pointed out that the doctor himself had put on the prescription when it could be filled.

Pharmacists from around the country report similar occurrences in their practices.

10,000 Baby Boomers reach age 65 every day.

Both scenarios are commonplace now as baby boomers turn gray and average from  three to five prescriptions (not all pain meds) as daily maintenance. It’s apparent that boomers have a lot of pain. This point was driven home by two noteworthy events:

1. pain management clinics began to spring up around the country and…
2. The government made it easier and quicker for pharmacists to order schedule two controlled drugs. (Amazing, isn’t it? The government made something easier?)

Then I met Betty Lou (my favorite generic name) but to be consistent here, she will be “Gamma.” She’s been my patient now for a couple of years. When she first started doing business at my store, her doctor confirmed that she was a terminally ill cancer patient. She’s been terminal now for over two years. She takes three different narcotic pain meds, Ritalin® in the morning, and sleeping pills at night. She takes meds for nausea and constipation. She’s obese.

And this represents only three of the hundreds of patients we see on a weekly basis.

Now meet patient “Delta.” Delta comes in regularly with prescriptions for 240 Ultram®, 180 Percocet®, and 90 Dilaudid® tablets(all generics.) Every month, Delta presents that month’s prescriptions a few days early. Delta’s chief complaint is “Every time I come into this pharmacy there’s a problem.” The recurring problem is that Delta wants early refills every month. Delta’s doctor writes the date each prescription can be filled into the instructions.

Some of the patients who seem legit, take so much, I wonder. Are they really taking that many tablets?

Finally, patient, “Epsilon.”  Epsilon sees a different doctor every week. Sometimes the doctor is from out of state. I’m not aware of any pharmacy in our area of the state that will fill an out of state prescription for schedule two controlled substance.

It’s disheartening to see bona fide long term pain management patients become addicted to drugs and then watch that dependence change their behavior to the point that we cannot deal with them rationally.

Another day in the life of a pharmacist.

To be continued tomorrow, HERE.

_______________________

Acknowledgement: Free lance writer and investigative reporter, George McGinn contributed to this article.

Last week a new acquaintance asked me what I do for a living. My reply, “I spend my day telling people things they don’t want to hear. I’m a pharmacist and I deliver the news that  “your co-pay is much higher than you expected,” “your insurance company requires a prior authorization,” “your prescription was out of refills and your doctor has not responded to our request for a new prescription.” The list of examples goes on and on, but these are by far the most common.  People have high expectations of me and my department to make sure they leave the store happy and on the road to recovery from the ailment that brought them into the store.

Stew Leonard owns one of the most successful grocery stores in the world. Does his policy work in every situation?

Years ago, a syndicated columnist stated in no uncertain terms “The customer is NOT always right.” The article continued with the author’s evidence to support the claim. In retail sales, the age old standard is a difficult hurdle to overcome. In pharmacy it’s almost impossible. Once a shopper complains to a member of management outside the pharmacy, it’s a sure bet the manager will side with the customer—unless it’s a patient requesting something the pharmacist is prohibited from doing either by law or regulation. The distinction of roles they play once they enter the portal of a retail pharmacy is blurred. Sometimes, the clarity of a sharp focus is never achieved.

A simultaneous reference(customer/patient) to the people who shop in stores that contain a pharmacy became noticeable back in the 1970’s.  Was this duality the precursor to changes we see in the perception of consumers today? Are these shoppers  customers or patients—or both?

This labeling of shoppers took on more prominence with the rise in popularity of chain drug stores in the late twentieth century.

When pharmacists (usually independents) began leasing space for a pharmacy inside department or discount stores (such as Walmart’s precursors like “Gibson Wholesale”) the change  in,  shopping nomenclature picked up speed as well as consumer awareness of the trend.

Pharmacies are now being paid for talking to patients.

Contemporary retail practice settings such as a prescription department in a grocery store or Walmart, continue that same tradition with shoppers being both customers and patients. I worked for Walmart for 7 years and by the time I left, we had to document counselling encounters in the computer—yet another conversion of a patient to a number.

Another significant event in the change in perception of shoppers was the influx of non-pharmacists into upper level management of both hospitals and chains. [Historical note: Eckerd Drugs (which no longer exists) had a chain of command of pharmacists supervising pharmacists from store level all the way up to the highest echelons of corporate management. The Sr. VP of Pharmacy reported directly to the CEO. Non-pharmacist management types could influence pharmacy only via him. Those days are gone with the wind. By contrast, the top pharmacy position at Walmart is a medical doctor(or was a few years ago.) ]

Retail pharmacists are now required by law to offer to counsel patients on new prescriptions. The requirement comes not from a concern for customer service, but from the government wanting patients who received government funded medication to use it correctly. Uncle Sam wants the most bang for his buck. Insurance companies now reimburse pharmacists for these same “cognitive services.”

Simply stated, insurance companies want pharmacists to talk to their beneficiaries and, just like our Uncle, get the most bang for their buck.

Many pharmacists complain that the reimbursement is not commensurate with the time involved. Many patients don’t want these extra services. They just want their prescription so they can get home, eat supper, and watch television. Perhaps they don’t mind being just another number. Such a mindset could be dangerous to their health.

Whether they consider themselves customers or patients, the shoppers I serve have one thing in common;

they’re all on drugs.