Comp-LIE-ance

Patient compliance is one of those words that’s thrown around pharmacy school/trade magazines like singles at a titty bar.  Its the illusion that you have the ability to make your patients take their medication like they are supposed to.  Yet another concept that looks great on paper/in the magazines but in real life, not so much (gee, sounds like OBRA90?).

Lets look at this from a realistic standpoint.  You have say 500 patients that you fill medication for on a regular basis.  Do you really believe that you can help improve compliance for each and every one?  You don’t even have time to take a lunch, let alone remind the 90 year old Mrs Smith (who’s clock should of ran out a LONG time ago) that she needs to take her water pill?  Why spin your wheels making MORE work for yourself when you can focus on the patients who ARE compliant, who DO care about their medication, and are willing to work WITH the healthcare system vs just wasting money?  Its just a frustrating losing battle – the sooner you realize this the better off you are.

Sure, you can be one of the pharmacist in the APhA magazines who sit and talk with each patient for 45 min about compliance/MTM/unicorns and pixie dust, but after your store goes under (or you get sued into bankruptcy because your bargain basement techs you hired to do the grunt work killed someone) then will you understand that enforcing compliance is a war long lost? Compliance begins with the patient, plain and simple.  They need to choose their level of involvement of their own health and well-being.

Nothing pisses me off more than having a damn intern pharmacist spend 30 min talking to a patient about compliance.  The patient just gets a glazed over look, says “uh huh” a ton and walks out in no better shape EVERY SINGLE TIME.  Patients don’t want to be lectured about their medication, they want to pick up their government-vicodin and go about their day.  PATIENTS DO NOT CARE WHAT YOU HAVE TO SAY UNLESS THEY ASK YOU FOR HELP.  This is cold sobering fact of retail.  Unsolicited advice gives you blank stares and a “mind your own business”.

So what this boils down to is that once that patient leaves the store with their pills they are on their own to take them correctly.  Stop wasting your time with the hand-holding, they are on their own to take responsibility of their own health (foreign concept I know).  If the patient can’t get their pills straight, well, that’s a whole lot of their problem isn’t it?.  My problem is making sure that the 20 different medications don’t kill them.

You all may think that I’m being quite the asshole about the subject (gee, thats a first!), but the fact remains that I would rather spend my not-making-the-store-money-by-not-filling-Rxs time helping those whom choose to help themselves.  Choose your battles or you’ll have nothing but losing battles.  DrugMonkey and I should teach a class at pharmacy schools.

Not only are non-compliant patients a detriment to themselves, but are a detriment to the entire system as a whole.  Say Mrs Madeupname gets some glyburide.  She just blows off the doctor (and your) warnings about not taking her medication and gets a refill every month (that she just stores/ditches) so “the doctor wont yell at her”.  On her next visit, the doctor will see little/no change in her glucose.  Doctor increases the dose thinking the current medication isn’t working.  Or doctor switches/adds Avandia/Januvia/Actos thinking that will get more control.  See where this is going?  Then when Mrs Madeupname finally feels like shit because her glucose is 500 and takes her meds, she bottoms out her now maxed out dosages and ends up in the ER.  Doctor calls you all pissed off and blames you for not making sure she is compliant (but you are quick to point out by her refill records, she /is/ compliant as far as you can tell).  PLUS the moment you question her about compliance she quickly transfers her medication to WalMart who “doesn’t butt into her own business” (good riddance!).  All this for a $2 dispensing fee.

Now lets talk about the patients who ARE compliant:

There are only 2 settings where compliance actually takes place; controlled substances and patients with high copays/no free ride.

Controlled substances is obvious, when the patient takes them there is an immediate physiological reward.  Your pain/anxiety/etc is gone (or you get a good buzz).  This rewards you to take another dose, and another, and bug your pharmacist for an early refill.  You don’t take your medications and there is an immediate penalty (pain/anxiety/dealing with your shitty life/etc).

Folks with high copays are also more compliant because not only do they have to shell out the cash for the medication, but most (if not all of them) don’t have the luxury of a taxpayer funded ambulance ride/hospital stay if their health goes down the shitter.  These patients are looking at multi-thousand dollar hospital stays/ER visits – they have no safety net of the nanny-government to pick them up when they fall.

They should teach interrogation and water-boarding in pharmacy school.  While they are at it they should teach a mind-reading class too.

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105 Comments

  1. Christine says:

    one more situation where compliance can occur: when the patient is sick and needs the medicine to get better.
    it’s not all financially motivated like you’re suggesting
    some patients understand medicine and are able to use it correctly.

    • Aussie Pharm Assistant says:

      That is, they’ll take the entibiotics until they feel better, and save the rest for next time…

    • RxGirl says:

      I agree. I was diagnosed with a liver disease and get my medication for free through manufacter coupon programs. I need the meds to keep me well and I take them qd like I was instructed too. I dont play around with my health even though I get the meds for free! I am well because of my compliance and I know it! Even with infections that require antibiotics that are usually cheap if you get the generics, Publix even has a list of free antibiotics, I understand the role antibiotics play in clearing an infection: finish the bottle. Not everyone who doesnt have high copays or “free rides” take advantage of the system. Im quite thankful for my free meds and I dont go around feeling entitled to my ‘handouts’.
      BTW I START RX SCHOOL IN A MONTH. YEAH!!!

  2. Do ya have da blue watsons? says:

    Good article reminds me yet again why I dumped my previous employer and the stupid fucking PCI calls. Waste 8 techs hours doing fuckall for the their half assed attempt to get feet wet with charging MTM fees for compliance without doing fuckall.

  3. Feeduppharmacist says:

    Good rant angry. I really don’t have anything to add. However if I may can I suggest a topic for your next rant. What is your overall impression of your interns and/or young pharmacists. I am a pharmacist of 3 years experience and see a few grads every year who have no clue what they are doing but most hit the ground running pretty well after say 6 months. On the other hand I have had a bunch of interns who seem to believe all the crap the pharmacy school is throwing at them. Maybe its just my company. Do you see a large disconnect between general pharmacy students and young retail pharmacists?

    • RxGirl says:

      Couldnt the same be said about you and say every other pharmacist out there when they first started working or were in rxschool? Or any graduate starting off in their field? Could AngryRX even say that about you, you only have 3 yrs of exp? The only difference bw a seasoned rx-ist and a recent graduate is experience, which working contributes to in time. Im sure youll think differently about those same newbies in 2.5 yrs after their “fresh and newly graduated” wears off..

    • jimmbo says:

      Soooo, you’re an old timer after 3 long years? It’s amazing how quickly we learn the reality of the business. Pharmacy schools need to teach the business of pharmacy, not just the way it would be in a perfect world.

  4. Intern Lover says:

    Well, I do love the interns who spent 30 min talking to patients. That’s 30 min I don’t have to spend suffering the indignity of giving ignored advices. Even those who are really sick don’t comply either. As soon as they feel a little better, they stop their antibiotics “to save it for the next time.” Ask anyone. Ask yourself!

  5. John Woolman says:

    There are a group of patients who will comply with long term medication, prescribed for a probablistic benefit in the future, rather than to produce an immediate and obvious short term benefit. They are intelligent, well educated, rarely smokers or heavy drinkers and usually don’t have a liberal arts degree. (The later group would rather rely on Wikepedia than the advice of a professional with their best interests at heart. Their choice).They constitute about 5% or less of the population.

  6. dorkyrph says:

    Christine says:
    one more situation where compliance can occur: when the patient is sick and needs the medicine to get better.
    ———————————————————
    Oh sure, they take a few doses of the antibiotic and stick the rest in the medicine cabinet. But they always call for a refill on the Tussionex/Hycotuss/etc. Then they get recrudescence of their problem, with likely a resistant organism. GODDAMMIT, LISTEN when I tell you to finish your course of therapy!

  7. Nuclear Fire says:

    Me: So how do you take your medications?
    Them: Just like my doctor prescribed.
    Me: Yep, and how is that?
    Them: Um…once a day?
    Me: Sigh.

    Me: So how have you been treated for this?
    Them: Well, my doctor has prescribed tylenol, motrin, aleve, voltaren, tramadol, gabapentin and vicodin.
    Me: Did any of them work?
    Them: No.
    Me: How long did you try each one for?
    Them: I never took them because I knew they wouldn’t work.
    Me: Sigh.

    The vast majority of my consults for “treatment failure” are actually “patient taking the medication failure” but not wanting to tell the doctor.

  8. slapaho says:

    I think the only logical conclusion to draw is that we must put hydrocodone in all prescriptions.

    Instead of AvandaMet, VicoMet will have greater compliance.

    Oh, and we get to charge up the wazoo for it!

    • Mike Prymowicz FUCKIN RPh says:

      Great minds think alike! (actually I hate that saying). Lisinopril with “New Magic DRONE”aka hydrocodone,= LisinoDRONE. Hydrochlorthiazide= HydrochlorDRONE. (get it, turns everyone into DRONES) Heck, everyones bloodpressure and blood-glucose levels would be too low! Funny thought, do this anyway with hydrocodone instead of using APAP which was supposed restrict abuse. That’s worked great, Huh? Just a small subtherapeutic dose of say…metformin, but if you take more than say 8 tabs a day a persons blood sugar goes low. Sorry, I’m a sick bastard.

  9. PATech says:

    We love these folks on the insurance end as well. I particularly enjoy getting bitched out by a doctor because I (who have absolutely no power) denied his patient’s Januvia/Symlin/Byetta… but according to the pharmacy fill histories this patient has NEVER FILLED A DIABETIC MED IN HIS LIFE.

    Try explaining THAT one to a pissed off guy with a small dick and a God complex.

    • JustADoc says:

      Is it possible there are no pharmacy fill records as they paid $4 cash for their metformin or glipizide as that was cheaper than their insurance co-pay?

      • LTCPharm says:

        Ummmm…there would still have to be a fill history, even if they paid cash for it….

      • PillCounterRPH says:

        If they choose to pay cash, there would still be a record of them buying the medication for $4 regardless of whether they were covered by insurance or paid cash.

        • JustADoc says:

          I am not a pharmacist so if I am wrong let me know but I would think you would only have fill records of prescriptions bought with cash at your pharmacy or maybe at your chain of pharmacies. Since many Mom and Pop stores can’t match the $4 scripts of Walmart, Target, etc there are many people who use the big box for the cheap cash drugs and the MomandPop for their other meds. Is this good patient care. No. Does it happen? Of course.
          And of course the original reply talked about the insurance end. The insurance company has no knowledge of meds the pt. took prior to being on that insurance.

          • pharmdoc says:

            Yes, we would still have a fill hx at the LOCAL pharmacy. The problem is, if the patient fills at a $4 pharmacy who doesn’t submit the $4 as their U & C to the insurance company, the insurance companies would NOT have their fill hx on file, therefore denying their claim. I guess that $4 pharmacy really didn’t save them that much in the end, huh?

  10. retailwhippin'boy says:

    Oh, Slapaho!! BRILLIANT!!! How I wish I had thought of adding hydrocodone to nearly (notable exception is naltrexone) all prescription medications! I mean this very sincerely….you have reached demi-god status with this post!!

    • rph3664 says:

      There was once a proposal to add ipecac to narcotics and tranquilizers so people who OD’d would throw them up and not die. Not a good idea.

  11. sarcasticrph says:

    I couldn’t have said it any better. If they paid for consultation without running thru hoops there may be more compliance. The insurance companies want to pay less on reimbursements plus -50% steer patient to mail order= more $ for them and less for us

  12. peyton says:

    Agreed with Christine, but I also think you’re way off on your criticism of pt counseling. Patients are sometimes intimidated by the overworked pharmacist with a short wit and bad attitude and do not ask questions they want to…or they don’t really know what to ask. When you pull them aside for 30 seconds to 2 minutes, they appreciate good, concise info on what a drug could cause side effect wise, and how to properly use it. The same goes with compliance coaching or whatever it’s called in magazines. HIV patients get little if any encouragement to take their meds, except from the md they see twice a year or so. So I think just a small word or two to them is encouragement and does help. I agree a 30 minute session from an intern may make a patient enter into a trance state, but a concise bit of professional advice is very helpful. I’d say that’s a large part of our professional responsibility.

  13. hannah says:

    I think that for some conditions (HTN comes to mind), often the side effects of the med are worse than the early stages of the actual problem.

  14. Mike W. says:

    I graduated from West Virginia University and the state gave our school a lot of money in exchange for sending students out to very rural areas for our rotations. I did my retail rotation in a retail health clinic where we did about 40 to 50 rx’s per 8 hour day. It was great. Counseling was mandatory…..and there was a quiz afterwards. If patients were in a hurry and wanted to refuse counseling, they didn’t get their medicine (next closest pharmacy was about 12 miles away). It was great to see people’s faces after giving them a 15 min speech about their medications and then asking them to repeat back everyghing that you just told them. Sometimes they just laughed and kind of said “yeah right” then they realized that you were serious….ok time to start over…lol.

    Great idea slapaho!

    • PharmIntern says:

      While I love that idea, try to imagine that from the patients’ perspectives. I brought something like this up to my mom, and while she is almost more vigilant about her meds than I am, she would tell the tech “none of your beeswax”, and call if she had any questions after reading the literature for the medicine extensively.

      But of course, I speak for the rational, common-sense-laden individuals among us. So in dealing with everyone else then, what else can be done? So maybe my line of thinking is better left to history, and bring on the mandatory counseling and quizzes. . .

    • Maxwell says:

      That would really piss me off if I was a compliant patient. I’d probably leave to another pharmacy that won’t treat me like a baby if they won’t give me meds because I refuse to listen to their baby talk.

      • Feeduppharmacist says:

        As he said the next pharmacy was 12 miles away. Most people will deal with being treated like a baby if it saves them 24 miles of round trip driving.

    • rph3664 says:

      It’s a great idea on the surface, but in my case, I would almost feel like I was being held hostage. What about someone who has to be somewhere and can’t listen to your 15 minute spiel?

      • PharmacyisaBUSINESS says:

        What if I came into that pharmacy (another pharmacist)? Are they going to make me go through a mandatory session? I can’t stand to listen to incompetent physicians go through their diagnosis of my medical problems for more than 60 seconds much less another pharmacist tell me about medications.

  15. Mallory says:

    I think you’re exagerating. I’m on 5 medications, and compliant with all of them. And I always finish the entire course of antibiotics. If I stop taking something due to side effects or adverse reactions, I always inform my doctor and the pharmacy. If I think something’s not effective, I discuss it with my doctor before stopping.

    Surely this is basic self-care? Other than needing help due to dementia, mental illness or mental retardation, surely an adult can manage to take their medication?

    • Intern Lover says:

      If there is any adult among these patients!

    • PSYCHO RPh says:

      You’re living in a bubble. He didn’t say there were no patients like you, he just said they were a small percentage, and he was SPOT-ON! Your’s is the ideal, not the reality sadly…

    • HospitalRPh says:

      “surely an adult can manage to take their medication?” – not on your life!! My husband wouldn’t take his meds if I didn’t bug him about it! AND he has NO clue what meds he takes!! When asked, he replies “I outsource that to my wife”. And this comes from a well-educated man!!

  16. slapaho says:

    It’s too bad that self preservation has gone out the window. I want to get paid to just live and be me… kinda like a Hilton or a Kardashian…
    Lazy Motherfuckers.

    http://www.neatorama.com/2010/06/22/paying-forgetful-patients-to-take-their-meds/

  17. Dr. Grumpy says:

    Agree. Compliance is their issue, even from my view. I do my best to explain why they should take it, but in the end I ain’t following them around.

  18. JS says:

    Why it is that every pharmacy blog I read (I was a Pharmacy Tech for about six years while working on my degree in Education and Psychology and THREE MINORS; TWO and 1/2 Masters until my health took all that away from me) the RPH bases all patients that use narcotics. Why do the people who really need them get such a bad rap? I don’t ask or request early refills (because of my doctor’s policy of only Fed Ex C-11 scripts we try to start the process about a week before I need the refill. Therefore, I usually pick up the script 2-3 days ahead of time. It’s easier for the doctor and the pharmacists so they have time to find the meds before I submit the script. Since it is hard to get I call the pharmacy first and ask them how many bottles they have and if they don’t have the full total then I ask my MD to write to scripts one for what she has and one for the difference. That way if the Pharmacy Manager can’t get the balance in within 72 hours then the script is still valid in my state for 90 days. Which gives us plenty of time to find the medication or for my pharmacy to get it in? My pharmacist is working with another chain to help me in those situations. I am not a drug seeker. I use one pharmacy, one doctor/practice (in fact I go as far as having the nurse call when another doctor has to sign the script when my doctor is OOT). I do everything right and I get black balled because all of you pharmacists are the first to call all of us drug seekers. How about a post about what the patients who are not drug seekers? And what they do to make their experience and yours appropriate. I wish someone of importance would read some of these Blogs and confront you. Think about if it was you or your family on the other side of the counter of bed in the ER. Why must everyone be treated is an addict, or a criminal or whatever.

    • Intern Lover says:

      JS, Dude! First of, you need to go back to TAP’s definition of a drug seeker to see if it fits you. If it doesn’t, you ain’t one. Why all the hurt about our rants? And if it does, shut the hell up!

    • PharmIntern says:

      Man, get bent. Like Intern Lover said, *TAP IS NOT TALKING ABOUT YOU*. He is referring to CRACKHEADS. There is a DIFFERENCE, a HUGE DIFFERENCE. We need more patients like you at the pharmacy, but 80% of what we get are CRACKHEADS, as in DRUG SEEKERS.

      • Joshua A. K. says:

        PharmIntern,

        Do you understand what makes up an addict? Crackhead/Drug Seeker/Addict/Fat People are all one in the same. Why don’t you start understanding how the brain works before making shite arguments.

        • Intern Lover says:

          Hey Joshua, lay off my intern man! I need him(her) so I don’t have to spend time counseling these addict/crackhead/drug seeker/fat people (fat people? that’s new to me). And for your information, the brain works the same in these people: it doesn’t!

        • PharmIntern says:

          I use the term crackhead to mean anyone trying to obtain controlled medication ( hell, anything that gives the user a high ) illegitimately. Hence, drug seeker. People using pain medication like controlled meds legitimately are fine in my book, obviously.

          No need to hurl insults around.

      • Maxwell says:

        Excuse me, you aren’t watching these patients 24/7. How exactly do you know that they are “crackheads”?

        • PharmIntern says:

          When you read about the majority of them in the local paper, and they come in and rat on each other to you, you get the idea after a while.

          Experience also tells you volumes about people. And let’s not forget that pharmacists do network with each other, as well as with doctors.

          Other than that, you’re absolutely right. We really don’t know, and we realize that. The only ones we truly treat as crackheads are the verified *crackheads*.

  19. It is a shame that compliance is as low as it is. And there are several reasons for non-complaince. Heck, there is no telling how much healthcare dollars are wasted due to non-compliance to medication therapy. But I see your point, it is frustrating to try and explain why a medication is important to take to someone who obviously doesn’t care about their health or what you are saying. It makes you feel like you are wasting your time. But I still try and do it just in case something gets through to them. You never know right?

  20. Nate says:

    Ugh, I have a hard enough time trying to get my wife to be compliant with her Asthma controller meds. If I can’t get her to take them what hope do I have convincing 85 year old Mr. Smith he needs his cholesterol meds. People that are compliant don;t need to be told to take their pills and no amount of spewing counseling points will convince the non-compliant from taking theirs. In addition to CS, the only people I see that are routinely compliment are transplant patients and people with RA and/or MS

  21. family MD says:

    This compliance issue is turning into a real bear for docs. Under pay-for-performance programs, I can refer a patient 10 times for a colonoscopy, but if they don’t go, my payment from the insurance company is dinged. The amounts are miniscule now, but if they ever become significant, there’ll be a lot of non-compliant patients looking for a new doctor.

    • rph3664 says:

      When I worked in retail, we once had a patient who just plain old never picked anything up. We even told his doctor this when he called and asked us. There was a note in the computer, and I did make an exception for this when an RX was faxed to us for him from urgent care one Saturday for Phenergan suppositories. Those, he picked up.

      Even worse are people who take their kids to the pediatrician literally every week, and don’t pick up THEIR meds! I told the doctor about this, and we never saw an RX from that family again.

  22. Kady says:

    LOL at Slapaho, you just made my night.

  23. VaTech says:

    I agree, there are several reasons for non-compliance and not all of them are easily avoided. I was working today in my little pharmacy when a woman brought me 16 prescriptions to be transferred because she had moved. She disappeared and said she’d be back later and I got to sorting through what she wanted and was appalled. Simvastatin 80…last filled in September of 2009 for a 90 day supply…there was a full 90 pills today on June 2010, and there were 3 different manufacturers in the same damn bottle. 3…i pulled out each different pill and made sure. So what has she been taking for the last 9 months and how old were the all the different pills? And why the hell would she demand to have them filled right away when obviously she doesn’t even know what’s in the bottles? Another med she had was Metoprolol ER 50 mg. Again, 2 different manufacturers and not only that, but there were at least 30 tablets of Metoprolol Tartrate 50mg mixed in that the other pharmacy has no record of her ever being on in the last 5 years.

    It’s cases like these that I wince when my pharmacist doesn’t troll into compliance and such…but at the same time i can totally understand. What good would it really do? You could preach over and over and ask the patient again and again why they aren’t taking their pills and there’s always an excuse…always a reason…and once you try…they pick up and leave and you are left wondering what in the world the next pharmacy is going to do and what she’s going to end up with.

  24. Joshua A. K. says:

    I’m with JS.

    Angry, you are an amazingly witty and talented writer. Your website has been a tremendous resource when dealing with the small dick/god complex pharmacists that you so aptly represent, it has come in handy.

    Answer me this, you are preaching about the basic freedom for the patient which I never expected to come from you. How can this be?

    What would be your solution, for example, a patient with a pain medication that has to refill early by a week? Being the medication is written PRN; how can you specifically say that this patient is /not/ compliant? You’d be the first asshole to call the doctor and report the patient as a drug seeker, yet in the same sentence here you are preaching about the freedom you take away on a daily basis? Am I the only one that can see this huge contradiction? I think you need to re-evaluate your stance on /basic/ patient freedoms and come to grips with understanding that, sadly, you didn’t finish med school and are /not/ a doctor, instead, a lonely dork from high school that finally has a little bit of power and it really has gone to your head.

    At the very end of the day, angry as you are, you (IMO) deserve a Xanax. Swallow, my friend, I’m pretty sure you are used to it.

    Ignore the witty/mean remarks, I am only playing the same game you do with verbiage. I really do appreciate your website as a resource and will continue to enjoy your writing.

    Cheers Angry.

    -Joshua A. K.

    • r0tten says:

      “Being the medication is written PRN; how can you specifically say that this patient is /not/ compliant? ”

      It’s never as open-ended as just “PRN.” There is a maximum dose for pain medications in general, and scripts are written with specific directions, “PRN” directing that if they do not need to be taken the maximum amount written, then, do not take them. Either the customer is taking more than prescribed, or they need a new script. Period.

    • pharmacypete says:

      Really, bro?

      If it’s a PRN medication for pain, the day supply is usually calculated as the LOWEST POSSIBLE amount of days you could have it, therefore, if you ARE seven days early, you actually are early.

      If you’re 10 days LATE for a refill, it just means you didn’t use it as much as you were maximally allowed, and you’re slowly weaning yourself off the medication.

      See that? Destroyed your point without the need for a condescending attitude, dumbass.

  25. Joshua A. K. says:

    P.S. I cannot stress enough how proud I am that you really are preaching about patient freedom. Kudos.

  26. Isitworthit says:

    On my list of things for which I don’t give a shit, patient compliance is right up there. At some point, these people we share this planet with have to start taking some initiative. It never ceases to amaze that the same patient who bitched about how long the rx was going to take to fill because she (typically it’s a woman), is in a huge hurry, but what’s this?!?! She now wants know how to use Armour Thyroid. Is it gluten free? Oh and I’m a vegetarian. After 20 minutes of explaining, she decides she doesn’t want it and that I need to call the doctor because she can’t remember what to say. Didn’t you say you were in a rush? Oh? No..that was a lie.

    Then you have Ms. Octogenarian who insists that 10 mLs of Lumigan is only a month supply, because not only does she hoard it she apparently Lumi-bathes her eye. Your rx is to early because you’re using to much…fine!! This happens everytime! I’ll have my md call somewhere else because ‘you people’ keep making this mistake.

    Really, for 99% of patients screw em. Pharmacy schools teach about pharmacy in utopia. Not in any environment that’s like what’s out there.

    I loves those silly saps in the trade mags talking about how they did this and that for patient X, and the article goes on and on about how amazing they are. Pffft..no one cares. We all do the same stuff, but most of us don’t want a 4 page spread on how we got furosemide changed to hctz.

    Happy Pharmacy Wednesday!

  27. Rivalry says:

    My main problem with your post is that an RX is never written for just “Take PRN.” There are always time frames involved. 1 every 4 to 6 hours prn, 1 every 8 hours prn, etc etc. With that information, the pharmacy can recognize a days supply and determine early refills accordingly.

    P.S. Pharmacists *ARE* doctors.

    • Joshua A. K. says:

      Pete,

      You destroyed the argument that I presented alright!

      How do you preach for patient compliance, ala: freedom to be held accountable for medication, yet so obviously deny their own reasoning capability for understanding /their/ own pain or anxiety [etc] threshold? Does this require a PharmD? Understanding one’s pain threshold is very subjective in and of itself, to have the Gods of Medicine cry foul when John Doe needs his Scheduled medication that has refills on the books (theoretical Schedule 3 medication, say Xanax 0.25MG ‘as needed’ for a GAD/Panic Disorder) early labeling him as a drug seeker a) without understanding (again very subjective) details surrounding the reasoning for such a refill, b) potentially causing his doctor to cancel the prescription due to this new label causing more pain/anxiety/etc.

      It is extremely contradictory. You can not preach for one and deny the other. Accountability is accountability. I believe this issue can only be addressed internally within the field of Pharmacology as, obviously, the reasoning/logic already within the field is flawed; a paradox of sorts.

      Angry, the more I read your post and other replies the more I see the horrible ignorance that makes up your industry. You assume the patient is guilty before innocent. It’s really simple. How it became this way is strikingly sad.

      With the availability of information, online and offline, your profession is essentially dying. We no longer are going to require a person of your stature to dispense medication, which is exactly what you are going for in your post (ultimately). If patient’s were granted accountability, the information regarding medication would fall upon the Physician’s level and any subsequent information that they would require would fall upon them doing research, or the research given to them by their physician. I hate to be childish and say we should just put robots that fill up on the medication, check insurance and dispense medication but at the very end of the argument made in your post this is what the outcome would be if it were EVER to become true.

      I hate to err on the side of, say a psychiatrist who from my understanding will dispense medication (through samples) and rely upon the patient to understand, be held accountable, etc — all without the need for a pharmacist. Is this part reason why marketing by big pharma was struck down so hard by Pharmacists?

      Sorry to have a revelation of sorts, but I find this all interesting.

      Thanks again for a forum, and comedy. Cheers everyone.
      Thanks again for your replies, I do appreciate the corrections however (Rivalry).

      • Intern Lover says:

        Joshua, I luve you man! You are a hell of a source of information for me to dig. Fist of, psychiatrists don’t often dispense samples. If you’re seeing one of those, I suggest you change your psychiatrist since he/she likely gives you medications based on what the drug companies preach to him/her without actually verifying the information through evidence based practice. Secondly, psychiatrists do not just rely upon the patient’s own understanding/complaints/grandiose delusional interpretation of their diseases. They are “mentally ill!” Infact, we hate those patients who self-adjust their meds because they think they are better when in reality they are just becoming more manic. (Did I say we? I mean … er… they… as in … not me.)

      • tank says:

        the reality is the insurance wont accept prn as direction, weve taken a lot of audits over this, there is always a set min days a rx should be good for. and no the pt cant make informed decisions on there meds because there pts not doctors

      • PSYCHO RPh says:

        Joshua, you’re showing your ignorance. I suggest you go back in the archives and read TAP’s post “replaced by machines” to show the error in your conclusions.

      • Rivalry says:

        Patient compliance is preached to a crowd of people that don’t want to hear what we have to say. I say, “The pharmacist wanted me to tell you to make sure to not skip a dose on these” and they think “WTF? THAT PHARMACIST THINKS I’M A DUMBASS?” Then I get to see these people in 2 weeks when they come back for a stronger antibiotic because they stopped their first therapy in the middle since they started to “feel better.” It’s ridiculous.

        Generally, when a controlled substance is being refilled early based off the prescribed directions/days of supply, we let the patient know it is early and it will be ready on X day. Most of the time, people are fine with and will come back whenever you tell them. The so called crackheads, however, are the ones that bitch/moan/complain and demand their refill early even AFTER the pharmacist tells them the situation.

        “You assume the patient is guilty before innocent. It’s really simple. How it became this way is strikingly sad.”

        We see the same people over and over and understand the habits of their filling. Lady drops off RX with Metoprolol/Simvastatin/HCTZ/Doxycycline/Xanax. I die a little inside when she blurts out “I just need the Xanax filled” and never gets the other meds. Ever.

      • HospitalRPh says:

        If a patient needs more pain medication than the physician prescribes, then the patient needs to contact the physician, period. Only the physician is able to determine if there is a problem that requires additional pain medication or a rehab referral.

        • Rivalry says:

          Well, that’s the patient’s responsibility. I tell ‘em they have to wait. If they decide to contact the doc for a new RX for a stronger med or more frequent dosing, that is on them.

  28. pharmacypete says:

    I’m pretty sure I’m getting trolled but I’m bored.

    I’m having a hard time finding a statement that is contradictory. I was merely attacking your fictious and implausible “PRN” prescription for a controlled substance.

    If you filled a prescription for alprazolam 0.25 #90, 1 po tid prn anxiety, and wanted a refill on day 22, we got problems, but it doesn’t mean you’re a seeker.

    Is this the first time at my pharmacy, with no history of this sort of behavior? That’s a pretty low starter dose, so it may be your first time being treated for this. Maybe you were supposed to drop off the other Rx for citalopram 10 mg that your MD wanted you to try for your GAD, and he gave you that alprazolam Rx for adjunct treatment until the SSRI started kicking in. Who knows? The point is don’t assume I don’t know what you’re going through with your anxiety, I might be on BZs too when I see the tech hours getting cut again.

    I can call your MD and let them know your 9 days early, and that you may not be adequately treated. Maybe they’ll ask if you filled for that SSRI. Maybe they’ll bump up your dose, change to an XR formulation, or change BZs entirely to one that acts longer. These are the conversations you don’t see or hear about, because you’re too busy yelling at the girl at the register, who is a 2nd year student worried about her Organic Chemistry final next week. She can’t help you.

    The point is there are many scenarios to cause a patient to become non-adherent, the majority not involving abuse. You could argue it doesn’t take a 6-year doctorate to take these scenarios into account; and I’d actually support some points regarding that. But it definately takes more than the 2-hour training program technicians go through to operate my pharmacy software.

    But go ahead, get your samples directly from your providers. Grab some tramadol from your PCP for back pain, grab some bupropion from the PA in HR at your job for free now that they’re advocating a smoke-free workplace, and get that citalopram from your psychiatrist. If you end up having a seizure* while driving to work or worse, at least you can attempt to sue 3 providers. If only there was someone tasked with making sure your medications are utilized safe and effectively!

  29. Joshua A. K. says:

    Pete, you aren’t getting trolled. The debate started off on the wrong footing with my witty/sarcastic remarks, which I took back. More over, I appreciate the latest reply. I’d like to see Angry chime in, not devauling your replies Pete by any means but since he was started the post about compliance and accountability I would still like to get that answer.

    As for the contradictions in medications that could lead to a partial or tonic clonic seizure, the patient should have open communication with all medications being taken with each different M.D. that dispenses the medication, on top of that doing their own *home* research on such contradictions.

    Humans make mistakes, it is part of life. Sometimes specific medication may be overlooked by the physician and he misses a contradiction in another med (he RX’d, not sampled) — the pharmacist did /not/ catch this and I ended up doing my own research as I do have a wealth of personal knowledge (not professional as you, angry, etc) so I found the contradiction and called both my doctor and pharmacist to inform them of what had happened. Needless to say this leads me back to the personal inventory and accountability for medications I am on, the research that I put effort into before taking such medications and the neccesary preparations needed for using such medication.

    I am a very big fan of giving the patient more rights, accountability and so fourth as it is up to the individual to understand what they are putting in their own body. Not the governments, not yours but mine.

    That’s my problem and the root of my frustration; the simple contradiction in what the definition of accountability and how far it should be extended.

    I apologize if you felt you were getting trolled, I’m trying to have an honest debate. Truth be told I appreciate the knowledge and view points you present.

    -J

    • Intern Lover says:

      Ow Joshua, sweetpea, you ass! It’s all good for giving patients more rights, more accountability and so fourth if they actually excercise them appropriately. I’m with you when it comes to formulating the treatment plan. It should be a cooperation between physicians and patients and not just “you will take only 1 vicodin a day because I’m a god and I say so.” But I’m sicking tired of patients who take more, or less, then what was prescribed and didn’t tell any one. If they bother to tell their physicians what they are doing with their meds, adjusting according to their “feelings” if not scientific justification, I’m all for it. Most of the time, patients just do whatever the hell they want then they come in to the pharmacies demanding their meds because they’re in so much pain that they will sue us if we don’t accommodate them immediately. Really? And you wonder why we are so jaded by these airheads! And don’t get me started with the drug interaction. We are pharmacists who spent 4 fricking professional school (not counting residency for some of the “clinical pharmacists” out there, hats off to you) to learn what combinations of meds can kill you so we can help prevent your early demise and all we got was “who the hell are you to tell me how to take my meds?” Give me a break! Who have you been talking to? Dr. Google?

      PS. Before you get all bent about having a better knowledge then us lowlife of a pharmacist, I do admit there are some dumbass pharmacists out there who should really go shoot themselves for making us all look bad. But then again…. I once called an MD about a serious drug interaction; the guy yelled at me “I told my patients not to go to xxxx pharmacy, you guys are terrible pharmacists.” And I was so very happy to tell him “That’s exactly what I told the patient about you, sir!” He didn’t get it!

    • Fluffy says:

      its contraindication, not contradiction.

  30. pharmslave says:

    Let us get to the corporate greed behind the term “compliance” At the greedy CVS/Caremark pharmacies, we are asked to call at least 120 + patients whom they think are late for a refill or nearing refill. This is to be done on a saturday and sunday. Big project for us. They call it as compliance calls. Usual medications are Claritin, Benadryl, some times diabetic and heart medicaions. If they dont pick up the phone the first time, we have to attempt the call for a total of 3 times and on the last call we have to leave a message. Our calls do not register if we dont talk for a minimum of 30 – 40 seconds and the next day corporate will be after us. Out of the 120 calls at least 40 – 60% of the patients agree to refill and they some times pick up the meds or it will be sitting in our bin for the next two weeks.

    If anyone transfers in from anorther pharmacy, then they will be flooded with some thing called “Consolidation” calls basically telling them to transfer in all other medications from others.

    CVS is making money in the name of compliance. Just FYI

  31. eighthchord says:

    You are wrong. There are many patients on both the govt tab and snazzy insurance who appreciate my taking the time to talk to them. What I am irritated with is the old pharmacists who are just in it for the money now who are more a deterrent to patient care than the patients themselves are, with their attitude of \oh they won’t listen anyway\. I’ve been in retail for 5 years and they DO listen. Just don’t look downtrodden and sigh when you talk to them, maybe that would help. As if your 120k weren’t compensation enough. Do your job!

  32. littleking says:

    As long as Medicaid and Medicare D copays are 1.00, 1.10, 3.00 etc we will have a shitload of non-compliance. If that’s all they’ve got to lose its no big deal to them to stop their meds. It’s got to hurt the wallet a little to mean something to them. They don’t even know the NAME of the med when they’re paying a buck for it. “Gimme my white one, I don’t know what it’s called… oh just fill ALL of them”
    But if you have to pay 10 or 20 bucks for 1 month of meds it’s funny how you can remember the name of it and know what it’s for. And you’re a lot more careful about saying, “just fill ‘em all”.

  33. Cracky McCrackhead says:

    I am always compliant when I score my Vic’s and Perc’s. When I pick up my booty from the cashier at the counter I always ask for a consult from the pharmacist. Yeah, I know the drill but it helps me get by scoring around town and the pharmacist’s love my honest, sincere attitude.

    • dr. uppity rph says:

      CRACKY TAKE YOUR ADVICE FROM A MORE UPPITY TYPE OF PHARMACIST WHEN I SAY YOU SHOULD NOT SEEK AND ABUSE NARCOTICS. SHAME ON YOU. HAVENT I GIVEN YOU TWO REFILLS OF YOUR XANAX AND VICODIN AND YET YOU STILL ARE SEEKING NARCOTICS. I KNOW WHO YOU ARE BUDDY LIKE THE MATRIX YOUR LOST IN THE DRUGS BUT U MUST BURY YOUR DRUG HABIT OR IT WILL BURY YOU -BENJAMIN FRANKLIN 1791

  34. the burnedout nitemare says:

    I’ve been in the biz for 30 + years and I seem to be more a highly paid boxboy(sorry, box person) than an R.ph. But the company I work for makes me make calls to raise compliace so their money losing pbm can look good on paper. Does nothing but make angry those folks we get and most see the name on caller id and don’t pickup. Frustration runs rampant, Anger over paying for public aid rx’s with MY taxes for tattooed, cigarrette smoking, cell phone texting, new car driving slime balls and then not getting paid for the rx cause the state is broke. Why do we do this?????????

  35. Herr Morgenholz says:

    This is off topic, and for that I apologize, but there seem to be a lot of folks here who know what’s up.

    I was just thrown out of a Wal-Mart pharmacy. My kid got a prescription for augmentin. The thieving bitch told me “Augmentin doesn’t come in a generic form, so that will be $74.00″. I informed her it did. She then commenced to start screaming at me that I didn’t know what the hell I was talking about, that she didn’t go to school all these years to have some…. {I missed the rest from elevated blood pressure}. I informed her that I have four kids and know every antibiotic known to man just by that fact. (Which may even have the advantage of being true. Hell, I don’t know.)

    I’m dressed in a sportcoat and tie, so she says to me “What? You look like you have the money. What’s the problem?”

    “Bitch, I have plenty of money, and I don’t intend to be fucked out of a penny of it”

    At that point, I was introduced to an earnest young security guard with the education and demeanor of angry cardboard, and exited the store.

    Nice co-professionalists some of your folks are.

    She was on commission, wasn’t she?

    • rph3664 says:

      Actually, if someone really did use language like that, I’d call security too.

      Augmentin’s manufacturer is always tweaking with the amoxicillin/clavulanate strengths to keep that old patent alive.

      • Herr Morgenholz says:

        She richly deserved it. You had to hear the tone. And I wasn’t the first to pull profanity out of the old bag-o-tricks.

  36. jLuke says:

    Some strengths of augmentin don’t come in generic. The RPh shouldn’t have been so rude or assumed you had the money to pay…but next time assuming we are lying or work for commission try asking your Dr to write for a generic or have the RPh call the Dr & get the drug changed.
    We don’t work for commission…thank God…because the $3 made off that Augmemtin doesn’t cover the payroll for the 20 minutes spent filling it!

  37. pill pusher says:

    Joshua,
    Go get a license to practice pharmacy and see how many days you have it before the DEA revokes it. If you wan to practice like a street corner pharmacist, so be it. Just have fun in cleaning up garbage cans in jail.

  38. nightrph says:

    The “angry” guy knows this profession, no doubt about it. I gave up caring about our beloved patients (AND profession) long, long ago. With an endless variety of doctors to see and and an endless list of pharmacies to annoy, it is effing impossible to give advice and counsel on ANY prescription presented. Hiding at night is the best solution I can come up with to deal with the the endless BS that is shoveled into every pharmacy on a daily basis.
    I worked a day-shift for the hell of it a few days ago… just as eft up as I remember from 15 years ago. Dr’s offices STILL CALLING in prescriptions . . . . unbelievable! They all should be left on TERMINAL HOLD until they figure out they can leave a message, fax, or e-prescribe.
    I was angry as hell 20 years ago! Luckily alcohol and night-shifts exist for professionals like me, or i would have lost it years ago.

  39. toddq138 says:

    Hey speaking of titty bars did you hear the governor of California had to remove strip club and casino ATMs from the list of ATMs that can accept welfare ATM cards? Millions of dollars over the years have been withdrawn at California strip club and casino ATMs using welfare ATM cards that are suppose to be used to feed and care for their children.
    http://www.latimes.com/news/local/la-me-welfare-20100701,0,6705176.story

    I don’t mind people spending their OWN money at these places, but if they are spending my TAX dollars that are suppose to be used to help their children then I get upset. And people wonder why I dislike the welfare system…. Even once they ban welfare ATM cards from being used at strip clubs and casinos the welfare junkies will simply just use the bank ATM before coming to the strip club or casino.

  40. dr. uppity rph says:

    yes i do say i do require all my patients and techs to call me doctor cause i earned my dr degree in pharmacy

  41. glache says:

    I know. The ever so optimistic graduate whose optimism and faith in humanity will be banished all at once the minute they start working in real life. Though the occasionally grateful (and compliant) patient does come through. The other week we had three Champix (varenicline) scripts, after months of not encountering a single one (well I’m sure there was but as I work only Sundays….), and all of them were very grateful that I took the time to open up the pack and show them how to take it, and they really did seem to take it on board. But seriously, the only patients who’d be maximally compliant are those taking meds for erectile dysfunction *rolls eyes*

  42. Watson349 says:

    Can you believe that the term now is actually “adherence.” Compliance has been deemed condenscending. Whatever, take it or not take it, it’s your choice. Last time I checked, I am not your mother. Just pay the copay and get out.

  43. PharmDad13 says:

    I’m a second year pharmacy student. I love how in school we are taught the “PROPER” way of counseling. We are taught to spend thirty plus minutes with the patient when in reality we have two minutes MAX if that.

  44. PharmacyisaBUSINESS says:

    Why are we all crying about the increased dispensing of medications that these crackheads provide. If they want the med early I tell them I’ll check with the doctor, and if he/she says yes…then it’s time to fork over that crack money. I don’t allow hand-outs on early fills. If they throw a fit then \peace\ bitch…no crack for you. Plus this silly \clinical pharmacist\ era has pharmacist forgetting that we are \drug dealers\. We have the stuff people want, and we have the say in whether or not we want to supply it. People come to pharmacies for the goods…not the services as preached by the know-it-all clinical pharmacist. If they were coming for services then we would become prostitutes instead of drug dealers. I don’t know about the rest of you…but I’d much rather sling drugs then be a hooker. Plus, I do more \clinical\ work in a day in my retail store then \clinical phrmacists\ do in a month walking around with a med team. So let’s stop pretending. All pharmacist are clinical, but if you want to spend your whole day rounding with docs…well…then your an MD-want-a-be.

    • PharmIntern says:

      I think I love you <3 <3 <3

    • Clinical Pharmacist wannabe says:

      Hm… MD-want-a-be! I wonder… I agree with you on the business part of the profession, except you forgot that pharmacists are not just drug dealers. You took your pharmacist oath, didn’t you. Remember that piece of paper you read while waiting for your diploma? “I will apply my knowledge, experience, and skills to the best of my ability to assure optimal outcomes for my patients.” Though, now that I think about it, no where in that oath says “do no harm.” Hm… curious! I guess “optimal outcomes” are pretty subjective then.

  45. James B says:

    Do you have a summary of the Good, Bad, and the Ugly of being a retail store Pharmacist? I am interested in this info because I am thinking about a career path change into Pharmacy.

    • ann says:

      Short answer—DON’T DO IT!! ANY career choice would be a better option.
      I have 20 years experience to back up these statements.

  46. pharmslave says:

    working for evil chains; CVS, Walgreen etc is ugly in the most civilized words.

  47. Abby says:

    I’m starting pharmacy school in the fall. Love reading your blog!

  48. Do ya have da blue watsons? says:

    CVS by far the deepest layer of retail hell. Textbook example of toxic management.

  49. Resident says:

    I agree that adherence counseling is difficult/impossible to do in the retail setting. You barely have time to take a piss. But outside of retail there are opportunities to counsel on how the med works and why its important to take it. A lot of it is the patient’s lack of medical knowledge. If they know they could get some super infection that lands them in the hospital b/c they don’t take their meds correctly, they might think twice. Retail just doesn’t give you this luxury. I have been frustrated by the person that pisses away their expensive yet free Medicaid Rx, but they typically end up hospitalized (hopefully learning their lesson). On the other hand, I have seen adherence counseling work once the light bulb goes on. Sometimes it just takes longer than we would like.

  50. [...] Comp-LIE-ance:  ”There are only 2 settings where compliance actually takes place; controlled substances and patients with high copays/no free ride.“ [...]

  51. AngieA says:

    Maybe you should hire good techs, pay them decently and respect them…. then you could worry less about them fucking up (but again YOU should be actually checking the rx in questions) and focus more on how you want to cop out on doing your job.

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