Dr “4 Degrees” and the Caps-Lock key eludes him

Sometimes all I need to do is to just check my email for a laugh:

for the pill counting pharmisist why is he playing drr?HE ISNT THE ONE WITH

Right, this comes from a doctor who has 15 years of school and 4 degrees. You would think a “doctor” of this caliber would know how to write in proper English or at the very least knows how to use the Caps-Lock key.
I’m not playing “dr”. I’m doing my fucking job. Obviously if you write a sig on an Rx, and that patient chooses not to follow that sig, then I can choose not to fill the Rx, plain and simple. Plus, when I’m bored with all that LOADS of free time that I have, I decide to call MD’s just to chat. Us pharmacists have a secret game that we play called “piss off the MD” where we call up a bunch of MD’s and time how long we can tie them up on the phones! Its fun! You should play! Then, after you play, you can yank your head out of your ass and realize that what you wrote above makes no sense.


I dont know if its appropriate or not because I have no doctor degree? Wait, actually I do have a doctorate, however I do not have an MD, so you’re only half wrong there buddy. It doesn’t take a degree in pharmacology to realize that if your patient is blasting through 120 vicodin in 1 week, obviously you are missing the boat entirely. How is my patient going to own my house/car/etc? Is he going to sue me for not dispensing his vicodin 3 weeks early even if the MD gives the ok for the 20th early fill in a row? Hate to tell you, but the DEA will side with me until the cows come home and will gladly plant that shiny DEA number that you covet so much right up your ass. You figure out why, you’re smart with your 4 degrees and 15 years of school.
Plus where does it even say on here that I wont fill a Ritalin Rx? Where does it say that I wont fill anything but the crackhead’s Soma thats 3 weeks early? You need to start reading the site before you fly off the handle. OH WAIT, YOU HAVE 4 DEGREES, IM SORRY.


Ha! An MD who does not want to hear constructive ‘critisim’? Go figure! Thanks for re-enforcing every stereotype of the “I am god do what I say” MD that pharmacy students dread.
A pharmacist network? Thats right! You have stumbled upon a secret underground network of disgruntled pharmacists who’s sole purpose is to take over the medical world and make that plain-ole-stupid MD just obsolete.
Let me put it to you in a way that you will understand.
Seriously, If I were an MD I’d be pretty embarrassed to have this guy in my ranks (but Im sure people say that about me. Eh, oh well).

Medicare Part D – Mexican Food and NPI

First off, Merry Xmas to everyone.

The 1st is looming closer and closer.  For those in you not in pharmacy, the best way I can describe the feeling is as such.

You just ate at this Mexican food restaurant.  The food was good, but you have this feeling in the back of your mind that you will be spending the evening peeing out of your butt.  However you aren’t 100% sure that you’re gonna expode out of your backside, you’re just 98% sure.

Thats how we feel right now.  I’m about 98% sure this is going to be total clusterfuck, but there is a small hint in the back of my head that it might be okay.

Now something that complicates this whole clusterfuck even more: The dreaded NPI number.

How many doctors have you gotten an NPI number from?  How many insurance companies are going to ‘suddenly’ require an NPI number on 1/1/08 without any prior warning or notice?  How many doctors have you asked “Hey, whats your NPI number?” only to get a “Whats an NPI number?” answer?

For Xmas, all I want is a 5th of good scotch, a few cigars, a box of fentanyl patches and a well-heated hot tub.


The primary reason that I haven’t touched ADD meds with a 10 foot pole its because its just asking for me to get the bad-parent-patrol firebombing my site for me implying that only about 25% of the cases of ADD are diagnosed correctly; and the remainder are just parents who don’t want to deal with kids being kids. Since I just dug my own grave right there, lets continue.

TAP, I’m surprised you haven’t done a rant on ADD meds. When is that
coming – or do you restrain yourself because you have the condition
yourself? The media says it affects 3 to 5% of children (and adults, as
you don’t outgrow it but rather learn to compensate) but around here, I’d
say it’s more like 30 to 50%, and I have heard about school districts (not
mine) who are pushing, consciously or not, to get 100% of their students on
some kind of ADD medication. I’m quite aware that many parents (okay,
single moms) who face being kicked off welfare are coaching their kids to
misbehave in school, or act like they are retarded, so they can get SSI
payments for them. This, IMHO, is not what SSI was intended for, nor was
it meant for drug addicts but that’s another story.

I dont touch this issue (and also abortion) because it tends to piss off a lot of people. Yes, even I have my limits, and I tend to not piss off /all/ of my userbase, just /some/. Everyone can take jokes aimed at their profession, or their jobs, or what they call themselves; however talk about their kids and their ‘parenting skill’ and suddenly my biggest fan is calling my internet provider claiming I touched her daughter where she pees.
I will say that I do see children who need it. They usually sit in the store vibrating as their parents scream at them to not explode and rip stuff off of my shelves as their younger (and sometimes older) brother/sister sit there patiently. You can just see it in their eyes that its not the usual high-energy that a kid has, but something obviously wrong. They will take the store check stamp (you know, you stamp the back of a check when you put it in the register) and STAMP-STAMP-STAMP-STAMP-STAMP all over the counter. In almost all cases this patient has a brother and/or sister who is not on medication and acts perfectly normal. The patient goes to a child neurologist and is on not only some sort of Adderall/Ritalin but also Tenex or Clonidine. They will not be on the medication all year round, but only during the school year. The parents have been patients of ours for years and years and never once asked for an early fill, plans trips around when their refills are due, and are those patients that you really do bend over backwards to help when something hits the fan (you retail folk know what I’m talking about).
Then I see a family of 4, all the children are on Adderall. They zombily waltz in as their mother is chatting some drama up on her cell phone using terms that rival ‘baby-daddy’. She plunks down her imitation Gucci purse on the counter as she throws a handful of Rx’s at the clerk as all the kids slunk down into the waiting chairs on the verge of passing out. She talks loudly on the cell-phone looking at all of the hair products as she bitches about when the Rx’s are going to be done. All of the Rx’s are written by some out-of-town doctor that only seems to dump out ADD-C2’s like they are going out of style. One of the children politely asks for a drink of water and the mother just jumps down her throat and tells her to go sit back down. The mother buys about $40 worth of hair products and fake earrings. I sigh as I get the warning that two out of the 4 children’s Adderall were filled by another pharmacy 15 days ago. She gives me some two-bit smart-assed smoke-up-ass story about being stolen/lost/eaten/whatever (I never pay attention). She’s pissed off that her State Program doesn’t pay for early refills and decides to take her stupidity out on me instead of herself.
Now these are two extreme cases with obvious room for gray in the middle, but I tend to go with the extremes for illustration purposes.

In addition, I have never heard of a child being evaluated for it who
wasn’t diagnosed, usually by the first practitioner who saw them, 10
minutes after they walked into the door.That is, with one exception. I
once worked for a pharmacist who thought his B-student daughters could be
turned into A students by taking meds, and took them to 10 or 15 doctors
until he found one who would write prescriptions, no questions asked. I
told him what I thought, which probably contributed to my being fired a few
months later but it was a temp job anyway. I later learned that this man
has a long history of walking out on jobs without giving notice, and
signing up to do relief work and not showing up and being unreachable.

Lesson anyone in the pharmacy biz learns early in life: If you think you have it, some doctor out there will agree with you. You can be sitting at home watching TV and suddenly feel like you have agoraphobia after a paxil commercial. Sure as shit some doc out there will fill out the SSI paperwork and off you go to a life of no-work and a check every month. Parents will think that all of the doctors in town on crazy for thinking that their kid is perfectly normal except for that one quack out there who churns out C2’s by the truckloads. All it takes is a little time and a good sob story to get that Rx written for Adderall for your 3 screaming toddlers (from 3 different fathers, go figure) and off we go reinforcing the stereotype that ADD does not exist. Its sad, I see it all the time, however proving something as subjective and wishy-washy as ADD is like scooping a turd out of the ocean.
So there is no takehome rule from this ATAP episode, I figure I’m going to get the ghetto-parent-patrol jumping down my throat just for posting this.

ATAP: What we think by looking at your Rx’s

I LOVE your blog! It’s the only “personal” blog that I bother to read. I’m not a pharmacist, but my, uh, passion? for medicine has led to the nickname “Walgreens” from some friends and coworkers… :-/
Alright, here’s my question… what do pharmacists think about people who have a buprenorphine script? I’ve never felt akward or self-concious about picking up a script until I got Suboxone. I feel like they look at me and just think, “Fuckin junkie,” and maybe even dig thru my history in the computer to see what else I could be up to. What about methadone? Is there any less judgement with it because it could be for legitimate pain?

Clearly I can’t speak for all the pharmacists out there, but if you came in to me with the Rx and I saw that it was Suboxone, I would clearly run around the pharmacy yelling “JUNKIE” while waving my hands around and throwing things at you. Then I call the police and say that you stole things to support your junkie ways..
… Or maybe not …
Unless you wanted something filled early, threw a tantrum in the pharmacy, or bugged me 100 times a day to get something filled when it was not due, I wouldn’t even give your Rx a second look or thought. I might think to myself “Shit, I hope I can dispense this whole bottle of Suboxone to her. I dont want this stuff on my shelves taking up space when I get 1 rx/month for it”.
We’re pharmacists, we are used to things like this. We work with controlled narcotics for a living. Coming in with an Rx for Suboxone isn’t really a big deal to us. Obviously if you don’t give us any grief, are on time and actually take an active stance in your care you don’t even blip on our radar (we are too busy getting screamed at by the person behind you about why we wont fill her soma early).
This would be like us thinking “FUCKING FATTIE PIG” for someone bringing in an Rx for some Actos or Glyburide or any other diabetes medication, “BAD MOTHER” for someone bringing in an Rx for lice medication for their children, “WHORE” for Plan-B or 1gm Zithromax, “DONT TOUCH ME” for Valtrex, the list could go on and on and on. We’re more mature than that (sometimes).

I’d really like to hear what you have to say about it. And just for the record, I think bupe is a wonderful drug and has helped me tremedously. I used opiates for about two years recreationally, about 8-10 months daily use, and slid into IV use about two months before I was found out and went to rehab & put on maintenence. It takes away 95% of my cravings and I don’t think I could have stayed without it.

I’ve gone to a few CE’s about it and I think that its magical as well. Its helped a ton of people get back on track and go on with their lives. It seems like its done you well too. Best of luck. πŸ™‚

ATAP: Ambien for depression?

This was sent from an MD to both the DrugNazi and myself. Here is my take on it.

I know you both probably think Ambien is bad medicine….
If you don’t, I do.

Eh, for occasional use its perfectly fine (especially if the patient just had a traumatic event/surgery/etc). Obviously if the patient needs 30 a month in order to sleep there is something deep underlying that needs to be addressed.

Regardless, today a miniskirted, stilletto heeled prostirep came into my office and tried to tell me that some Doc, which she desribed as a “sleep guru”, is now reccomending Ambien for depression.
Yes, depression.
The premise of the argument is that SSRIs can be activating and that ambien CR (which is magical as opposed to regular ambien which is poison) should be used to combat the insomnia “common” to ALL SSRIs.
Ok. Last I checked, and granted its been awhile, but all SSRIs are not created equal. some sedate, some activate, and those of us who prescribe with half a brain will tell the patient to take the activating ones (i.e. paxil) in the morning. and the occasionally sedating (i.e. zoloft) in the evening.

Ambien for depression? Maybe if you are depressed because your brain cannot recharge its neurotransmitters during sleep. Even that is a stretch. I think that people underestimate the power of a good solid 8+ hours of sleep. However one of the clinical side effects of depression is lethargy/sleeping a ton.
Funny how you mention that Ambien vs Ambien CR. I think you’re on the right track here. People are beginning to realize that they can pay 10 bucks cash for 30 generic ambien vs a $50 copay for trade name Ambien CR. Sinofi must be crapping their pants and trying to come up with new indications.
As far as the SSRI’s go, last I checked Prozac was the most activating (which is why it was initially investigated as a weight loss drug, only to be found to improve mood. Henceforth the SSRI craze was born) while Paxil (and its anticholinergic effects) was the most sedating. Its like Artane is way more activating than Cogentin is. Some people have even resorted to abusing Artane just to get that amped up feeling.
If the patient is responding bad to an SSRI, why not just give him/her Remeron and kill two birds with one stone? Knocks him/her out, and has antidepressant effects. Plus its dirt cheap. Trazodone has been used for years for this, and even though one out of a million men will have an eternally hard pecker, its worked wonderful for the last bazillion years.
Treating the side effects of a medication with another medication (AKA PolyPharmacy) just leads down the road to trouble. Next think you know the patient is on 30 different meds, you cannot switch any of them without a cascading failure as they get out of equilibrium, and when they get hospitalized its a real pain in the ass to treat them.

Oh, and the advisability of giving a patient a clearly addicting medicine (I dont care what the prostirep says) especially when they are depressed and at high risk for overdose seems inadvisable at best, and possibly malpractice at worst.

Yeah, I think something is seriously retarded with this drug rep or some key information was not being relayed to you. Giving a clinically depressed person (who doesn’t want to get out of bed, shows no sign of doing things that would normally make him/her happy, etc) a CNS depressant seems like pouring gasoline on the fire.
Overdosage might or might not be an issue here. Clearly the SSRI’s are tons more dangerous in high doses than Ambien (which is very Benzo like). Actually people don’t realize how hard it is to treat an aspirin overdose, and that kills more people than Rx medication does.

Am I off base here? It seems the reps have a new strategy for pushing off label uses. they just pop up with some “study” and pass them out like they are “educating” me. It seems that this is barely legal. (in the bad sense)

No, actually I’m thrilled that you are questioning what the talking heads are blabbing at you. More doc’s need to do this and show the drug companies (and the hot reps they employ) that doctors are not their little pawns in a money-making scheme.

Anyway I thought I would send this to both of you, TAP and Drugmonkey to see if you had a rant to develop.

Mine wasn’t very rant-a-licious. You had a legit question and deserved a professional answer rather than something with a lot of swear words and foul humor. Sorry if I disappointed you. πŸ™‚

BTW, I am a professor at a family medicine residency, I frequently print out both of your blogs and post for the residents to read. I am pushing for a prostirep free clinc. I am not in charge or it would be.

Ah, we are corrupting the youth of medicine one resident at a time. Excellent.

Also, either of you want to travel to Arkansas and give a cme lecture to a bunch of docs?

I’ll keep your contact info.. πŸ™‚

Medicare Part D 2008 – Please Not Again

Does anyone but me have this feeling of impending doom about the first of the year?  For those not in the know, a whole bunch of Medicare Part D plans are changing/merging/switching/etc as of the first of the year.  I know that HealthNet (I think its HeathNet) is switching processors, and there are about 4 or 5 new plans to replace the 4 or 5 that are going away.  People are getting switched around, new cards issued which means new ID/Group numbers (if they have the card AND its printed correctly).

It’s going to be hell all over again.  New cards, down systems (*ahem*Argus*ahem*), confusion, copay changes, formulary changes, hour long help-line hold times, everything hitting us all at once.  The Medicaid/Medicare people are getting auto-switched into new plans, there are confusing letters flying all over the place along with salesmen who will promise golden turds to any senior who will sign on the dotted line.  Add onto that a system that is horribly complex and confusing thats targeted at the population segment that is confused by the most simplest things.  Breaking out the booze yet? πŸ™‚

I hope after the first I quote this post and say “You know, I was wrong, I was really wrong”.  Somehow I don’t think that will happen.

However, aside from all the lost reimbursements, forwarded medication, confusion and swearing, we will again show the rest of the world that us retail pharmacists are the most stubborn, determined, hard working and just outright relentless healthcare professionals out there.  We are the glue that holds the industry together.  Its times like these that retail pharmacists and their staff show their true colors to all of their patients.

I can’t speak for all the retail folk out there, but I know there is a good majority that sat there after Jan 1st of 2006 and 2007, looked deep down into that tall glass of booze, and felt a sense of pride in their profession that wasn’t there before (or it might of just been gas, or psychosis setting in).

Whats with the retail hateage?

Original is here
Before I tear this poster a new one, in his defense the last paragraph:

I know I’ll get flamed for all of this by the retail pharmacists who read this for being too idealistic and for not even being out of pharm school yet, but I’ve seen what pharmacy can be.

Ah, to be young and in school again. Anyway, on with the show.

I agree with your whole post except the one part. Your comment that profs couldn’t cut it in retail bugs me. In my opinion the profs that did the residencies and are making real clinical decisions worked a hell of a lot harder than those who got through pharmacy school and accepted the sign-on bonus from X pharmacy chain.

Because being someone bitch working for minimum wage in some hospital for a year makes you better than the retail folk? Makes you ‘harder working’? Tell the poor guy working graveyard at Rite-Aid who fills your child’s antibiotics at 2am that. Tell the BS’s in the crowd that the PharmD’s are “harder working” and see where that gets you.

I know this is a big source of contention for you, but I have no problem at all calling them “Dr.” At least at my school..aside from teaching, the profs are clinical pharmacists who do a hell of a lot more “pharmacy” as opposed to retail pharmacists who spend more time dealing with insurance issues.

Son, I’m going to have a heart to heart talk with you. You are going to piss off /a lot/ of retail pharmacists with an attitude like that, so change it right now. Regardless on how you view the world from your wool-pulled-over student eyes, you will have to deal with retail folk, and belittling them by saying that they are less than “clinical pharmacists” is going to get your ass hung out to dry.
This is beside the point that when the public thinks of “pharmacy” they think of the retail guys who give their children antibiotics and prevent medication errors.

Many of them left retail not because they couldn’t cut it, but because they were sick of the retail experience and wanted to actually use their education.

That sounds like “couldn’t cut it” to me. I thought they went through residency programs? Why (for all of their “harder work” than us retail folk) would they settle to be nothing more than pill vending machines and insurance agents? Why don’t they go and work in a hospital to put their “clinical skills” to work rather than sit there and recite the same bullshit year after year to student after student?
I think a real “clinical pharmacist” does a whole helluva lot more than just sit there and talk for an hour to a bunch of students from stuff that they could just read in a book for themselves.

I’ve shadowed and had several experiences in the hospital with these professors and pharmacy residents who do have relationships with doctors and who actually make therapeutic decisions that the doctors listen to. They go on rounds and have full clinic days in addition to teaching.

Gold star for you. I’m proud that you set this old retail pharmacists who has never ever worked in a hospital (do you ever read my site?) straight. Because we all know that us stupid retail folk NEVER EVER make any therapeutic decisions and NEVER EVER do ANYTHING that would have anything to do than what we learn in pharmacy school. We’re nothing but just stupid pill counters.
When your testicles finally drop, and you get your shiny diploma and license, think of me as you are getting screamed at by the attending because you gave someone atenolol with a CrCl of < 20 instead of something like metoprolol. Because us retail folk know nothing of that sort. Our PharmD's and state board licenses are obtained via crackerjack boxes unlike yours which is granted upon thine holyness by the great god of pharmacy himself. However something makes me think you'll be working retail after you get out. Having an entire school of uppity "clinical" students tends to sap out the clinical jobs quite quickly.

As if teaching is automatically the fall back option when in reality retail is the fall back option. They actually use pharmacy school knowledge…it’s not a “fart in the wind” to them. The teaching hospital that our school is a part of employs over a hundred pharmacists. It can serve as a model for what pharmacy could be. I know all this is not the norm by any means, but if pharmacists can’t even respect other pharmacists then how can we ever expect MDs to?

*sigh* I’ll let the other retail folk rip you a new one. I’m too tired to tell you how stupid you sound.
I respect all pharmacists, however its fun to sling shit at each other once in a while to stir the pot.

Maybe it’s just my school, but my professors don’t sugarcoat the retail experience at all. They tell us how much they hated their retail experience and why. They tell us that it would be great to sit down and perform MTM, but the barriers are large. On top of that, The majority of our class has or has worked retail. We are fully aware of how shitty retail is in real life.

I’m glad your professors give you unbiased information. How would they know about ‘retail experience’ if they are all ‘clinical pharmacists’? How would you know anything about pharmacy by just being a student? Why dont you go formulate your own opinions about things like I do vs having them spoon fed to you by the faculty of your school.
My post was not “how shitty retail is”, its that what pharmacy schools teach you is NOT what the real life is about. Maybe if you would actually READ the entry before you spout off your holier-than-thou “clinical pharmacist” attitude crap you would of gotten the picture. Retail isn’t crap, its what the population thinks of when they hear the word “pharmacist”. Like it or not, we are the backbone of the profession and will always be the backbone of the profession.
I’ve worked as a “clinical pharmacist” and to be honest, I’d rather stand for 9 hours and actually socialize with my patients and their families than be some doctors bitch up on the floors of the hospital. I’m a person, not a fucking interactive drug book. Retail guys are furthering the profession of pharmacy so much more than the “clinical guys” because more people interact with us, we are accessible to everyone, and we’re everywhere!
If you would of read my post, you would of gotten that one of the major points (other than the “couldnt cut it”) is that most professors have not worked retail for a while so they have no idea what its like on the “real world”. How can a professor who works only floors at a hospital have any sense as to what retail pharmacy is like vs the guy who has been doing retail for 20+ years?

As a response to Nicole…in almost all cases there isn’t time to sit down with patients. However with the integration of MTM and diabetes-ed services into certain retail chains and the new changes to Medicare D there is an opening for retail pharmacy to move towards allowing actual counseling to happen. Did you know all those techniques for talking with patients IS actually used in the clinical ambulatory settings? Soo…maybe it isn’t all BS. However, if we all as (future) pharmacists continue to keep saying that this will never happen and continue calling all of this BS, then it won’t.

Make sure you make FUTURE pharmacist quite clear, because you are spouting off shit like you have been in the trenches for years. Damn PharmD CANDIDATE (hahah! I hate that word).

Maybe the reason doctors are so mean to you on the phone is because you’re a bitch. I’ve talked with and clarified scripts with more friendly doctors and nurses than assholes.

HAHAHAH I cant wait until you get screamed at by a doctor and end up crying in the pharmacy. Maybe your preceptor will hand you a tissue between giggles. Oh wait, you’re smarter than that stupid retail guy that just ‘settled for’ his job. Or maybe when you make that suggestion to the doctor and he totally shuts you down you’ll get the idea. Getting a script clarification is easy, getting something changed when the doctor has his mind set on something is a completely different story.
Pass the boards first and get your degree before you start throwing shit around, you just look like an idiot.

I know I’ll get flamed for all of this by the retail pharmacists who read this for being too idealistic and for not even being out of pharm school yet, but I’ve seen what pharmacy can be. My retail pharmacy (that does over 400+ scripts a day) has MTM, diabetes ed, flu immunizations, and other counseling sessions that people pay for. I’ve seen first hand the impact and the role that pharmacists can play in the clinical setting. It CAN happen, but if we keep denigrating our own profession and our own colleagues it won’t.

Your retail pharmacy? Son, you have no retail pharmacy and by the way you threw shit at the retail scene up there, what are you doing settling for a retail job anways? I hate to break it to you, but most retail outlets do all that diabetes/immunizations crap too. Of course we are expected to help people manage DM, to council and answer their questions and to give injections. Its part of the job, so don’t think your shit smells any better than ours because we have been doing for years.
You have NO idea how much you are going to get flamed by the retail guys. I really think you should stop visiting this site, because you obviously take stuff obtained from THE ANGRY PHARMACIST as the gospel of pharmacy.