Take Exhibit A:

Why is my mouth open when I have to poop in a pool?!?

Now Miralax is like Metamucil, it makes you poop.  Now I’m not sure what floats your boat, but if I were constipated and needed something to soften my food-baby, the LAST place I would want to be in swimming in a pool with my mouth open when the brown tide decides to come in.  Is the woman supposed to represent a poop floating in the water?  How does swimming in a pool go with constipation?  Maybe if her skin were dissolving in the water it would be more along the lines of the ‘osmotic effect’.  Maybe the force of the poop is propelling her through the water?  Should the water be going IN her butt?  I took it upon myself with my awesome drawing skills to make this ad more realistic:

Remember kids, when you’re straining like a puppy pooping peach stones, grab your Miralax and head over to the local pool, because nothing gets your bowels moving like an osmotic effect on both sides of the ole turd-cutter.

Wellbutrin 150 QD

or

Depakote 250 QD

or

Effexor 75 BID

Now how many of those at home after getting these prescriptions felt the urge to slam their face into the counter.  For those not in pharmacy (or for those douche-canoe asshat prescribers out there who are stuck in 1990) all of these drugs come in different formulations BUT in the same mg strength.  The regular-release is the SAME strength as the extended-release.  Its not like Coreg or Paxil which the extended-release dosage form has a different strength than the non-XR form. Hell, in that case its easy.  Dr writes for Coreg 20, and we know that he wants the once-daily CR caps (unless he wants the patient to start shaving the IR tablets, which would be rather funny).

Does the MD want Wellbutrin 150 SR given once daily? Or did he/she mean to write the once-daily XL?  Depakote comes in a 250 DR and a once-daily 250 ER, but depending on the patient they may want the DR given once daily.  I’ve seen Effexor plain given BID as well as the XR given BID.  Should I just guess?

Its shitty at best and outright dangerous at worse, and there is absolutely nothing that we can do to prevent this.  The only thing that we can do is to call the Dr, be left on hold while the patient gives us the “Why cant you fill it? It says the drug on the prescription!!” face, and be at the mercy of the *sigh* wonderful doctors staff to give us a call back saying “Doctor wants the extended release Wellbutrin” *headdesk* “IT COMES IN 2 WAYS!”.  What makes matters worse, is that ALL of these drugs are relatively new (compared to like Theophylline, Cardizem, or Verapamil) thereby removing all shred of hope that we could “guess” what the doctor wanted (since some doctors are stuck in 1990).  It requires a phone call/fax, which is just balls for everyone involved because 2 little letters could have solved this.  This isn’t something that the insurance doesn’t cover, this is just sloppy Rx writing!

Is there a good solution to this problem?  The one time we guess as to the release-mechanism it’ll be wrong, so there is no point doing that.  Of all of the examples regarding sloppy Rx writing, this has to be the most annoying for pharmacists.  I can deal with not having a quantity.  In some cases I can deal with not having a sig if I can tell from the quantity (I mean how many ways can a dentist give 28 amoxicillin caps?).  I can deal if you didn’t sign the damn prescription.  No IR/ER/XL/WTF designation? Boned-every-time.  Saving 2 seconds on your end just cost me (and the patient) 15 to 45 mins.

Just go give us one more kick in the balls, the patient wont understand what the problem is.  They see a drug, a strength, and some T’s with dots over them with some letters.  They don’t care about the IR/ER/XL/OMFG  dosage form, they want the drug on the prescription and they wanted it filled before they handed you the Rx.  Short of yelling at the doctor for omitting probably the second-most important piece of information on the Rx (yeah, that’ll teach him! *sigh*), all we can do is just bend over and accept the 30 min phone-call and hateful glares from ungrateful patients.

Now what makes me angry about this, is that the only other manufacturer of generic Toprol XL is Par.  Par, upon Ethex biting the big one, decided to jack up the price about 75-100% THEN back-order us to kingdom come.  You know, Fuck you Par.  It would be one thing if you would of kept the price the same and been back-ordered, that’s understandable.  However you totally screwed us over both price-wise (since most insurance companies were reimbursing based on the OLD MAC price) AND you cannot supply!  I’m not sure if this shortage is intentional so they can squeeze some extra bucks out of us (if so, go fuck yourself), or why they would need to raise the price as high as they did (other than “because they can”).

So here is a big TAP fuck-you to you Par.  Since you can’t supply to us, I’m getting everyone switched over to another product, and when your shitty product does come back in stock, I’m not going to switch them back.

Lets take a stereotypical patient.  While he/she is sitting around leeching on the taxpayer dollar watching Judge Judy and Maury (“You are NOT THE FATHER”), he sees a commercial for a new drug.  The commercial is happy, wonderful, and promises a new life (in very vague terms) if you take this drug.  “ASK YOUR DOCTOR ABOUT THIS”.  So the idiot does.

Idiot goes to his doctors office, and after signing his name with drug-branded pens on a drug branded clipboard and gets seated in a drug-branded chair while looking at drug-branded posters on the walls, he sees the doctor (who has a drug-branded clipboard and a drug-branded stethoscope).  He asks the doctor for the drug which he saw on the TV.

Now here is where I have the issue.  You see, in a perfect world the patient wouldn’t have advertisements bombarding him that he SHOULD be on this, because in a perfect world someone with medical knowledge would make the judgment call on what medications the patient should be on due to the symptoms presented.  The patient should have zero say in what he/she should be on, because he/she really doesn’t know enough to get the “whole picture”.  The patient shouldn’t say “I WANT TO BE ON THIS BECAUSE THE TV SAYS SO” but “I am experiencing symptom X, what do you think”.

Its now NOT the doctor making the decisions on what drugs a patient should be on, but the patient and the TV.  If the doctor says no, the patient will find another doctor who will say yes.  Now I’m not one to turn down business, but there is a huge problem with most modern trade-name drugs:

1. Insurance companies (if they pay for it) reimburse $2.50 on that $200 Rx.  Its not even worth my time to even carry it.
2. Most of the new trade-name only drugs are just “Me-Too” knock-offs because patents are expiring left and right.  I really don’t give a rats ass that a once-daily drug is coming out with a new XR formulation that is…. ONCE DAILY.  Seriously, who cares?
3. All of the new and novel trade-name drugs aren’t the ones that are advertised on TV, only the shit patent-expiring crap.
4. What the fuck is wrong with the generics that save the patient AND an overstressed health care system money?  Oh, not advertised on TV.

If the generic drug companies didn’t have their heads up their asses, they would advertise on TV.  “Watson Pharma! Bringing you quality generic Vicodin and Soma!”.  However I really wish they would just shitcan all of the DTC marketing crap and leave the selection of drugs to the people with the education to do so.

Why/how generic Plavix (clopidogrel) managed to hit the market is unimportant. What is important is that now you didn’t have to drop $150/month to get the drug.  People had generic copays, cash patients could actually afford something that they couldn’t before, the public rejoiced and the clopidogrel flew off the shelves like Plan-B on prom night.

Fast forward a month.  Clopidogrel is no longer available.  Bristol-Myers Squibb/Sanofi (herein known as douches) pulled out the legal card (ie: probably bribed the FDA) and got the affordable generic withdrawn from the market.  If I remember correctly they somehow magically got a new indication which prolonged their patent (ie: probably bribed the FDA).

The short amount of time that clopidogrel was available wasn’t long enough for word to spread to the doctors that a generic was available.

Now here is why (to this day) I refuse to speak with Plavix reps, they totally left the pharmacies out to dry when questions were asked about Clopidogrel by the doctors.  In other words, they didn’t inform doctors that there was a generic out for a short period of time.  So doctors, in their infinite wisdom and yell-before-asking fashion, starting pointing fingers at the pharmacies.

We had doctors claim that we were illegally importing medications from Mexico/Canada.  Doctors were making claims that pharmacies were selling illegal generics because “Plavix didn’t come in a generic”.  Did the reps stop these rumors and set the doctor straight? FUCK NO.  They just SAT THERE with smug little looks with their studies as doctors were throwing accusations around regarding pharmacies and where they get their drugs.  At this time there was a bunch of bullshit regarding counterfeit drugs, so guess who lumped us all in with that clusterfuck.  Trying to explain this whole FDA legal bullshit to a doctor or a patient is like trying to explain Medicare Part-D to a Phillipino home-health nurse.

Then the safety and WHY it was taken off the market was brought up.  Patients and doctors couldn’t accept that it was yanked off the market due to legal douche-baggery, obviously the generic was ‘inferior’ and it ‘put their patients at risk’.  Did the Plavix reps come to our aid? No, of course not.  Anything to sell their fucking overpriced wanna-be aspirin even at the expense of the reputation of those who dispense it.

To this day I refuse to talk to Plavix reps for not stepping up and taking care of the shit-storm that their douchebag company caused at the expense of the pharmacists and the patients.  You don’t want to be there for us, so in return I’m making damn sure that I’m not doing any favors for you.

I’m not saying that pharmacies should sell smokes and other tobacco entries.  I think that if a pharmacy does that its not only unethical but retarded (however nobody has a problem with gas stations selling beer/liquor, go figure).

The issue that I thought I made clear in the last post was who gets to make the decision as to what LEGAL product you can and cannot sell in your store which is LEGAL in every other store.  Its not really about if a pharmacy should sell, but who gets to make that decision.  Now remember that Tobacco is a 100% LEGAL substance.  Yes it has no health benefits and is dangerous, but that’s not what I’m arguing about.

Now, personally, I should be able to sell whatever legal substance (that can be sold anywhere) I choose.  If I wish to sell tobacco and be a total hypocritical pharmacist douche, that’s my right.  Its also your right to not trade with me because of my choice in what I sell.  With me so far?

However SF now has drawn the line in the sand.  Since nobody really fought it, they have set precedence that the city can dictate what individual classes of businesses can and cannot sell.  Products that the GOVERNMENT not YOU have decided  “for the best interest of the public” cannot be sold in a business that YOU OWN AND RUN.  This is the start of SOCIALISM in pharmacy with decisions made by people who are NOT PHARMACISTS.

This is super bad news here.  You may think that allowing them to ban tobacco is nothing big, but replace tobacco with any of the following and you have Pharma-riots.

• Birth control (if you’re so bent on pressing your religious beliefs on those who do not share the same views as yourself and would want to BAN something, then yes, you are a “shit-eating psycho religious type”)
• Plan-B
• Soda/Candy (see below)
• Sudafed (as if putting that behind the counter did anything what-so-ever)
• Anything that a combination of whining/money/politics can ban “for the children”.

Pharmacies in SF got bent over by the city, and given the dildo of justice on their rights.  The city is putting their nose in what you can and cannot sell, but ultimately has no responsibility if your business goes under.

If SF banned tobacco within the city limits for EVERYONE, this whole rant is a non-issue.  Everyone gets screwed, everyone is on an even playing field, SF sucks, move.  Nanny-SF says that you are too stupid to live your own life, no cancer-sticks for you.  But SF is selectively targeting pharmacies and preventing them from selling a legal product.  Like HIPAA, COMMON SENSE DOES NOT NEED TO BE PUT INTO A FUCKING LAW!!!!!  Now the socialism slope is greased up, how long until you must clear with the city what inventory you stock?

Here is the list that no pharmacies should carry (according to SF)
Tobacco

• Lung Cancer
• Mouth Cancer
• Second Hand Smoke
• Fetal damage

Sugar/Candy/Soda

• Childhood obesity
• Dental caries
• Exacerbation of Diabetes
• Caffeine Addiction

Pork Rinds

• Lipid Disorder
• Heart Attack
• Stroke

Alcohol

• Addiction
• Liver Failure
• Bad Dancing
• UNWANTED CHILDREN
• Fetal damage

See all of the above? NONE ARE 100% GUARANTEED TO HAPPEN.  Stop with the weak “tobacco is bad mmm-kay” arguments.  These are all on the “should not sell” list using the same rationale that SF did with banning tobacco.

Don’t say that I didn’t warn you when this case gets brought up and something that YOU care about stocking gets banned using this tobacco bullshit as a case study.  By the time that happens however the battle has already been long lost. 

I hope that clears up some confusion.  Go ahead, call me paranoid, laugh at me, but deep down you know that I bring up a damn good point.

Now I don’t smoke and probably never will (although how work has gone lately, a crack habit might be in order), but I feel the choice to sell or not sell something is up to the store owner/corporate office, NOT THE GOVERNMENT.

What if the psycho shit-eating psycho religious types got a bill passed in your city/state that said “No more birth control shall be sold in pharmacies”?  Pharmacists would revolt and riot!  Amazing how that double-standard of “its okay to ban something that -I- don’t use/doesn’t apply to me, but god forbid if someone else tries to ban something that I use (even though they don’t)!”

So, when does the point come where what you can-and-cannot stock be decided NOT by your professional judgment but by the lawmakers of your city and state (who are influenced by bribes and ‘incentives)? 

Think about that, then let me know if you still think having a city-wide ban on a product is a good idea in the long run.

Combine the two, and you get 2 classes of doctors:
Dermatologists and Dentists.  Notice how they both start with D as well as the word Dumbass and Dipshit.

Take a completely stupid new drug that is out, Solodyn (Website complete with 1 recall!).  That’s right, they took Minocycline, made it 90mg and ER, sucked the FDA off to give it an ‘acne’ indication, and now they are selling it for $1573.82 per bottle of 100.  Thats right, 1500 bucks for minocycline.  Go look at your shelf at that $20 bottle of minocycline 100mg in generic and tell me what 10 fucking milligrams in an “Extended Release” is going to do (and is it worth the 100x price increase).

What gets me are the Dermatologists who write for this shit.  Are you fucking kidding me?  Are you so incredibly stupid to believe that this bullshit will do ANY better than the 100mg they have had on the market for decades?  Why do you believe that 90mg ER is better than 100mg bid?  Is it because the big-titted reps tell you so?  I don’t even know how you can even justify this! What are you going to do? Show me studies that are made BY THE DRUG MANUFACTURER that show this to be better than Minocin 100?  Yeah, I’ll also show you evidence BY CHEVY that MY CHEVY TRUCK is better than YOUR FORD.  That’s okay, I consider Dermatologists to be on the same level as voodoo witch doctors.  No offense to those out there who actually boot drug reps out and use actual *gasp* knowledge, but your fellow colleagues are stupid and make my life difficult.  Most of you guys/gals are more than willing to switch to generic Minocin (especially when I tell you how much this cost, a figure the rep ‘accidently’ left out), however a handful of you need to lay off the Medicis Kool-Aid Crackpipe.

So instead of having this sleazy me-too producing drug company (Medicis, producer of overpriced shit like Benzoyl Peroxide Pads) hand out samples to the doctors, they hand them these trial cards. Yeah, I’m going to stock a 1500 dollar bottle of your shit on my shelf so I can dispense 30 and have the rest rot.  Go fuck yourself.  If you cared about anything other than your profits/what nationality of imported hookers for the next board meeting you would make this shit in unit-of-use bottles of 30.  On behalf of pharmacies everywhere, you make it in 30′s and we’ll stock it.  Until then, I’m sorry but “our wholesaler is out of it/we don’t stock that drug” because its FUCKING STUPID.  Doctors, if you wish to plop down the 1500 beans and carry this shit in your office, oh, I didn’t think so.

This is yet another reason why medication costs so much in this country, because there are STUPID drug companies who will make this shit, and there are even stupider Doctors who gobble up the bullshit studies and actually write for this and get it sold!

Dental drugs are also notorious for being so overpriced and stupid (uh Periostat?).  At least most dentists are so insecure in their pharmacology that you can get them to change it to something that is not going to cost the patient their first born child, but Dr Dermatologist WD (Witch Doctor) and their chicken-bones (Elidel/Protopic) are hard headed.  I’m sorry the other MD’s made fun of you in school, doesn’t mean you need to take it out on the pharmacist and the patient with the bullshit you get from your big-titted friend with the free pens and clipboards.

I can go on for ages about the stupid these these two classes of doctors write for under the all-knowing direction of some clueless PDR using sales rep, but I think you get the point.  If you stock this shit, let me know so we can laugh at you.

On another note, since the economy is taking a nosedive, I’m sure a bunch of these big companies are going to be laying off some drug-reps.  Anyone around want to spearhead a Drug Rep Porn site?  Its like Pharmacy Hotties (NSFW)  but with drug-reps!  There are going to be a ton of hot big-titted reps that are going to be hungry for work to pay off their boob-jobs.

I’m tired of seeing Rx’s for Vicodin 7.5/500 or Lortab 7.5/750.  Quit making yourself look like an idiot in front of your local pharmacist and heed my words of wisdom.  Here is the chart, print it out and keep it with you (or just write Hydrocodone/APAP <strength> and make it easy on yourself.

First off, Vicodin 5/500 and Lortab 5/500 are THE SAME FUCKING THING.  Don’t give me this bullshit as to Vicodin upsets your stomach while Lortab doesnt.  To be honest, both come from the SAME generic bottle (yes, the Watsons) so that just tells me how full of shit you are.

Now, the breakdown (hydrocodone/APAP):

• Vicodin
• 5/500
• Vicodin ES
• 7.5/750

• Vicodin HP
• 10/660

• Lortab
• 5/500
• 7.5/500
• 10/500
• Lorcet
• 10/650
• Norco
• 5/325
• 7.5/325
• 10/325

Now, for those at home who actually aren’t on this stuff, you may notice that LORTAB always has 500mg of Tylenol and NORCO always has 325mg of Tylenol.  Amazing!  Learn the rest or print this out so you can get it right on the Rx. 

You may also notice that Lorcet and Vicodin HP only have 10mg difference in Tylenol in them.  If you call me up, and get pissy with me over 10mg of Tylenol for dispensing Vicodin HP vs Lorcet I will drive to your office and kick you square in the teeth.  There is NO point in stocking both over 10 piddly mg of Tylenol.  Thats almost as stupid as getting pissy at me for dispensing Prinivil over Zestril (back in the day when they were both trade name).

This has been a public service announcement from The Angry Pharmacist(tm).  No Doctors or Addicts were harmed in the making of this public service announcement.

I want to go on record to say that I hate 3/7/10/30-day one-time-use drug freebie cards.  These bane of my profession entitle the member to a free fill of a certain drug.  We input all of the data into our system as if its their insurance, run a set quantity of tablets through, and after cost + $2.50 their “insurance” magically covers whatever the rep is pimping out.

The intention is to replace the act of the doctor getting samples and giving them to the patient.  However there’s a huge reason why I hate these cards and why the drug companies/reps absolutely love them.  In fact, there are a few huge reasons.

Take a bottle of the latest and greatest drug.  Runs in the neighborhood of about $400 for #100.  Now give the patient a coupon for 5 free days.  Who gets to have $380 (or #95 tablets) sitting on their shelf wasting money rotting until they expire (and only get about $150 when they are outdated and returned).  Me.  Not the patient, not the doctor, I get to eat the entire cost of the bottle minus what the stupid fucking coupon paid for.  Sure, maybe if hell freezes over someones insurance may cover this drug, but unless you’re on the state tit (Medicaid) no sane insurance company will cover the latest and greatest without a prior auth.

Now, this brings me to my second point.  Doctor gives them a free month of this shit because some big-titted drug rep sweet talked him.  Completely eludes the doctor that what they are pushing is just two existing (probably generic) drugs that cost pennies shoved into one tablet and given a cool name like CADUET or EXFORGE.  Cool trade names give better results (ask your local drug rep).  Anyway, patient is on this new and greatest drug for an entire month because the doctor gets his/her drug information from walking whores (like getting sex advice from pimps, but I digress) only to (surprise) have the patients insurance NOT cover the drug after the 30 day coupon is used up.  So not only did you piss off the pharmacy by making them stock a medication they will never dispense ever again, but now you need to alter your patients therapy because that little coupon didn’t magically buy them a prior auth. Big Pharma – 1, Doctor/Pharmacist – 0, Patient – 0.

So the take-home message to doctors is to just give the patient samples from your office.  If for some reason the drug company will not furnish you samples (and just these stupid coupons) then throw him/her out of your office (which you should anyways).  That way, if the drug isn’t covered you only screw the patient and not your local neighborhood pharmacy (but call us so we can tell you what IS covered or what we can do to help you continue therapy).

The take-home message to the patient is that these coupons are evil.

The take-home message to drug-reps is that you need to whore out the real goods instead of just pimping plastic cards.  You still may have the wool pulled over the eyes of the doctors, but we’re all onto your bullshit and scam tactics to make us stock expensive shit that nobody will cover.  If you made a GOOD product and sold it at a REASONABLE price, then maybe insurance companies would cover it.  Think about that next time you’re at your million dollar corporate parties.