Most complex concept in medicine – the Do Not Substitute box

I’ve ranted about how DAW-1s in the past, however a good chunk of “doctors” out there cant seem to understand exactly what it means when that “Do Not Substitute” box is checked.  I use the word “doctors” in quotes because I am also referring to people who write prescriptions such as NP, PA’s and the extremely clueless Dentists and Certified Nurse Midwifes.

In California (and pretty much every state), pharmacist have the authority (which are few and far between, trust me) to switch from a brand name drug (Prilosec) to an FDA rated generic alternative (Omeprazole).  We can do this all by ourselves!  7 years of college and a doctorate degree and doctors have trusted us with the power to switch the Brand to the Generic of a SINGLE DRUG without their all-knowing permission.  I’m sure that when this law was snuck under the doctors nose they shit all over themselves!  In fact, most pharmacists love it when doctors write the old brand name because I’d rather see “Adderall” than “Mixed Amphetaminescribblescribbledontknowwhatcomesnext”.

Now here is where the confusion comes in.  That little box that says “Do Not Substitute”, that is to prevent us from switching from the BRAND name to the FDA approve generic FOR THAT DRUG.  Idiots seem to think that we have the authority to switch from a Brand name to ANY GENERIC, we don’t.  Unless you work for a hospital, have some P&T committee overseeing you, or have some collaborative practice agreement; pharmacists CANNOT switch to a completely different drug (even in the same class) without the doctors approval.  We can just switch from the BRAND to the GENERIC of the SAME CHEMICAL.  See how simple? Obviously not.

What blows my mind is when Dentists (*sigh*) check that box and write for Amoxicillin and Ibuprofen.  So I read that the Dentist (*double sigh*)  does not want me to auto-substitute a generic for… the… generic that he/she… uh.. just wrote for…. yeah.  Certified Nurse Midwifes (uh, yeah, they can write for Rx’s and we cant, how’s that kick in the nuts towards our profession) LOVE to forbid me from substituting Docusate.. uh.. for docusate… hmm..  These people have prescriptive authorities?  They don’t even understand what that damn little box means!  “Oh, I don’t want this pharmacist substituting a generic alternative for this GENERIC THAT I’M GOING TO WRITE FOR!”  I’m sure that DDS’s and CNM’s have their reasons for needing prescriptive authority, they could at least do their profession some justice by not sloppily abusing that privilege.

The other end of the spectrum is when MD/NP/PA’s write for Lipitor and check the little idiot “Do Not Substitute (DNS)” box.  Uh, is there a generic out for Lipitor?  Why are you preventing me from switching to a generic that hasn’t even come out yet?  Do you even know what that little box does?  Obviously not.  Single-source drugs (meaning drugs that come from one source, hence the name) doesn’t require you to check the little “DNS” box because there isn’t anything to substitute them for (hence, single source)!

Then you call the doctor up and call him on it because obviously the insurance company is NOT going to pay for a brand name that costs 100x more than the generic just because he checked a little box.  What response did you get?  “Oh, the generic is fine.”  I really feel like answering “WASTE MORE OF MY TIME BY CHECKING THAT MOTHERFUCKING BOX YOU ASSHOLE!!”  Doctors can be so damn frustrating at times.  All that college and they can’t understand a simple concept like the DNS box on their Rx pads.

Don’t get me started on OB/GYN’s and checking that fucking box on prenatal vitamins or iron tablets.

If the state allowed us to switch a non-covered brand to a class-equivalent brand/generic (meaning switch the whole drug to another in the same class) then I can see them checking the box for everything.  However we can’t switch drugs, so checking that box just because you have no idea what it means just makes yourself look like an idiot.

This has been a Public Service Announcement by The Angry Pharmacist.

The Long Leave-you-on-hold-time Leader

I’ve ranted about this. JP has ranted about this in Drug Topics. However some big-chain pharmacists *ahemWalMartahem* don’t seem to get the idea across.

You see, I really hate to bug pharmacists for copies/transfers.  Usually I’ll call their confusing little voicemail system, hit the proper combination of buttons to get to the “Voice Mailbox for New Prescriptions” (that is reserved for doctors), and kindly give all my information, what I need, my fax number, etc.  I figure that the pharmacist will check the mailbox for any new prescriptions, get my request, and fax over my copy.  Works great for Walgreens, Rite-Aid, CVS, etc.  The pharmacists like it too since I’m not bothering them and they are already in the ‘write down stuff’ mode when they check the voicemail.

Note to all of you out there:  I tried to do this with WalMart.  I waited 3 hours with no response.  I called WalMart and was left on hold for over 10 mins.   My tech called on another line and said “My pharmacist has been on hold for over 10 min, why are you answering my call?”.  I didn’t even get the common fucking courtesy of “The pharmacist is tied up, can he/she give you a call back”, “What numbers do you need and your fax number and I’ll give them to the pharmacist”, or even a “We’re really sorry, it’ll just a little bit longer”  I was just left on hold for 10 long non-intterupted mins with nothing but dead air to listen to.  I fucking hate being on hold because not only do I hate working while cradling a fucking phone on my shoulder, but its $1/min wasted for the store and just tells me what kind of outfit I can expect when someone does pick up the phone.

The response when I finally got through to someone (15 min hold time total by the timer on my phone): “You shouldn’t leave copy requests there, you should just call us.” *blink blink*  For once, I was at a total loss for words…  Yeah, after I was left on hold for 15 mins he said that…  Please tell me that I’m not the only one who thinks that what this pharmacist just said the completely wrong thing to me.  I’m sure glad I wasn’t a doctor leaving a new prescription on that voicemail system since it would be 5 hours before it would be filled!

Is this really how we treat our own?  Seriously, what the fuck.

Listen, we’re all busy.  We all have shitty patients we have to deal with, shitty doctors offices, and shitty staff.  We are overworked and stressed.  However that’s no excuse to shit all over someone who is in the SAME boat you are in and sooner-or-later you’ll need a copy from them.  If you didn’t get the whole idea about professional courtesy from my previous rant and JP’s rant, then obviously you need to go work in a mail-order joint and get the fuck out of retail.  I don’t give a fuck what your ‘corporate’ office says, or what your district manager or store manager says.  You know those people who boss you around in ‘management’ positions?  They couldn’t cut it in the trenches, thats why they have to boss you around.  If your manager actually works retail, they won’t bitch at you for letting that whiny crackhead bitching up a storm wait a whole 2 more mins longer while you give some professional courtesy to someone else who has that exact same crackhead bitching at them on the other end of the phone.

Unlike how I act on here, I choose to take the high road.  I don’t “lose” copy requests from pharmacies that are slow/unresponsive to copy requests.  I don’t get even with them.  I don’t fax over reams of pure black pages in the middle of the night to burn out all of the toner in their fax machines nor filling up their voicemail with me singing drunkenly in their voicemail at 2am on weeknights.

In the long run, its not worth trying to get even by petty things, real retail pharmacists are better than that. What really counts is when you’re at that fancy CE dinners (with the free booze), and after 4 gin’s you meet that WalMart pharmacist from the store that is giving you grief.  As you look him/her straight in the eye, you introduce yourself and say “Your store is the shittiest store in town for sending out copies.  I send copies to you within 10 mins, and you send them hours later if that.  That’s really bullshit, I hate calling your store, but your lack of service brings a ton of business to mine so I’m forced to.”  Then you see the reaction.  You see the stammering, the excuses, and with all that Gin in your system you can get that good concerned/blank look.  Blowing up on the phone at the person won’t do a bit of good, but in person, face-to-face is when you can really nail someone.  And after all of the excuses and apologies that fly in your direction, you just shake your head and walk away disgusted leaving them feeling like shit.  One of these days I’m going to stop by the DrugMonkey’s store and use this on him, then we’re going drinking afterwards.  I know he’ll want me to subsidize his bar-tab.  Some things never change (I kid, I kid!)

I’m prepared for the onslaught of Walmart pharmacists now who read this site commenting with “You’re right” or “You are so wrong I’m never reading this site again”.  You know, thats life, sometimes the truth hurts and it takes someone to publically blast the lack of professional courtesy that some chains have (plus you all get off on how awesome and blunt I am).  If you give this letter to your boss/DM and they say “eh, whatever” vs “I’ll look into this”, doesn’t that say right there what kind of company you work for and how they view pharmacists?

Walmart – $4 prices, $4 service.