Category Archives: Ask The Angry Pharmacist

The dreaded RTS

What is the public enemy number 1 of any pharmacy?  No, its not the patients.

Its the dreaded RTS bin.

Thats right! The Return To Stock bin.  The glorious bin of drugs that patients called in to have refilled “RIGHT NOW” yet never got off their lazy asses to come and pick up.  You know, all the simvastatin and lisinopril that the patient pitched an absolute fit right in the store because they “were out” and didn’t have any refills remaining yet never bothered to pick up 2 weeks later.

RTS’s absolutely kill pharmacies.  Here’s why (to those at home who don’t work in a pharmacy).

It takes money to fill a prescription (gasp!) other than the raw cost of the drug.  Everything from the vial, to the label, to the computer system/printer/toner that spits out the label (that you fucking don’t read) to the tech that fills it, to the pharmacist that checks it, to the clerk that puts it in a little bag and takes your whiny phone calls.  All of those steps cost money.  Thats not even counting the electricity, insurance, employee taxes, etc.

We get a dispensing fee paid for by YOUR insurance to cover these fixed costs.  Why are they fixed? Because the dispensing cost is the same if the drug costs $1 to $5000 kerzillion dollars.  When you pick up and sign for the medication, we have proof to your insurance company that you in fact received the medication and their piddly $2 dispensing fee was in fact put to its intended use.

Now say that drug filled vial with your name on it just sits out front for a few weeks.  It starts to get lonely sitting by itself in the pharmacy because contrary to what you read on the internet, just ordering your medication doesn’t make it magically work, you need to TAKE the fucking medication.  Eventually, we need that space to store medications for people who give a fuck about their health.  Your vial then gets RTS’d.  Since we didn’t dispense that medication, we legally cannot accept the money that your insurance company paid us for the drug + dispensing fee.  So now, we “back out” the prescription (meaning we give the money your insurance company paid us BACK to them, all of it), and now must PAY someone to put the drug back into the big stock bottles.  We have to throw away the vial and the label as well.

Your laziness now has cost the pharmacy double the labor + the cost of the vial/label  for which we are getting paid a whopping $0.00 for.  All because you called in a refill and didn’t get off your ass to pick it up.  My store has a policy that we call people once their medications have sat for a week, then we give them a second call 5 days later.  Yes, we PAY someone to call you to remind you that the prescriptions that YOU CALLED IN have sat here for a week.  This is after we told you when you called in your refills that they will be ready later on that day.   Ask me how this can be any more straightforward!  Oh, I guess its as straightforward as paying your fucking phone bill because every time you come in you give us ANOTHER phone number (thats disconnected 2 days later).

After about the second time I RTS a prescription for a patient, I put a big note in their profile to make sure they are told that we will fill their prescriptions when they are IN the store due to us always putting back into stock what they order.  What do I get? A bunch of swearing at me from over the counter by some idiot unwashed mouth-breather to the tune of “I called these in a week ago, why aren’t they ready yet!”  This is after they were EXPLAINED why they must be here for me to fill their “diabeetus and list-o-pril” pills.  I swear I can’t fucking win.

This shit really pisses me off.  Its a waste of my fucking time and a waste of the stores money.  Since my store doesn’t do auto-fills, if you’re not going to take your fucking medication, then save us all the headache and don’t call it in.

Oh, and a cool pharmacy fun-fact, is that controlled prescriptions are a good chunk of what I fill everyday, yet less than 1% of the drugs I RTS.  Big fucking surprise.

ATAP: Returned to Stock

Today we have another episode of Ask The Angry Pharmacist, where our very own TAP answers YOUR questions about life, pharmacy, drugs, and why that soma is too early to be filled!
Today we have a question by Adrienne:

Dear TAP,
Your rants are fantabulous. I agree with you and share your disgust. Thanks for exposing the real drug underworld. I have to deal with much of the much of the same BS; and then some. (Perhaps More about me another time.)
I have a billing and medical record question. I don’t have prescription coverage (self-employed so to speak).
Scenario: Someone with BC Fed brings in a Rx and the pharmacy says they have to “run it” to see if it’s covered.
Pharmacy fills the rx; it’s ready for pickup; but the patient doesn’t want to pay the copay or for whatever reason, they don’t pick up the script.
What happens to the meds? back on the shelf?
what does the insurance company/pbm pay the pharmacy?
what does ins co pay the pbm?
how does it go down according to the ins co/ pbm as though the patient received the meds?

Wow, fantabulous eh? Is that like Fantastic and Fabulous?
To answer your question, what you speak of is what we (in the “industry”) call “Returned to Stock” or RTS. RTS’d items are the bane of our existence and are a bigger money hole than a 19 year old mistress. Heres why:
1. We get the order for an Rx. We bill the insurance company and recieve cost+$1.50 (if you’re filling a MedImpact managed plan. Fuck you MedImpact!) for the work we do. We fill the prescription (using the insurance reimbursement thats above the drug cost to pay for the labor to fill your Rx. ie: the power bill, vial, label, my payroll, my tech’s payroll, computer costs, rent, etc)
2. You don’t pick up the Rx within a set period of time (usually 1 month, but varies between pharmacies). The Rx just sits there taking up space.
3. When the time is up, one of the clerks goes through every Rx waiting and picks yours out to be RTS’d. Since you did not pick it up, we have to REVERSE our billing to the insurance company, lose whatever money they gave us, and put the drug back. The PBM reimburses the insurance company (we hope) and the entire Rx filling process gets thrown into reverse. However knowing PBM’s, I doubt this happens.
4. This means that the pharmacy spent the labor to fill and unfill that Rx, but did not get paid. We lost all labor costs in filling that prescription (but we did not lose the actual drug cost since we can resell that drug that you didn’t pick up). Sure we can recoup the cost of the vial, but the label is lost, our labor in filling the Rx is lost, rent, power, etc. All lost. Plus we need to spend labor dollars to put that drug back in stock.
Obviously antibiotics are RTS’d sooner than other drugs, since why pick up an antibiotic 1 month after the ER called it in for you. Usually we do everything in our power to make sure you come in to pick up that Rx. Not only does it save us money, but it reinforces compliance and the feeling that “we care(tm)”. This involves paying someone to call you when you have medication sitting here looking for a home. We hope you would take the Rx after leaving the pharmacy, but once your signature goes into that log and you walk out that door, its all yours. No give-backs!
This is the reason why pharmacies are so reluctant to transfer medications that they have already filled for someone. If I call a pharmacy for a transfer, and the medication is filled and waiting for them at the other store, I will make them get it there this one time. Nothing pisses me off more than to fill 15 discharge medications from a hospital to have another pharmacy (*ahemWalgreensahem*) call and want me to back out (reverse from the insurance company) everything and send their way. I usually tell them to go fuck themselves (unless its a pharmacist I know, but those would never ask me to do something like that).
I hope that answers your question. If you at home have a question that you wish answered by a real-life angry pharmacist, please email and I’ll do my best to answer what troubles you. Obviously more ripe/risky/personal questions get priority. Think of it like Love Line, only with someone a lot more angry (and funnier) than Adam.

ATAP: What exactly do you do?

Welcome to another installment of Ask The Angry Pharmacist, where the most famous pharmacist on the planet (heh) answers YOUR questions and concerns in a not-so-nice (usually) way!
This is a genuine question, so I won’t be burning her at the stake (much) 🙂 For those of you new here, mail with your questions and I’ll answer them on here. Be warned that the answer may end up making fun of you, but I wont publish who you are.. 🙂

Dear Angry Pharmacist,
My husband and I, (physician and nurse practitioner, respectfully) recently found and subscribe to your blog. Wow. You really are one angry guy.
Before you go hating on us, if you knew us or worked with us peripherally, you would most likely put us in the category of “good guys”. We genuinely appreciate pharmacists who check dosages and allergies, and sincerely thank you if you catch a mistake on our part.
But humor me for just a minute and allow me to ask you something that Hubby and I have always wondered about. Please recognize this question comes from a combined total of over 18 years of higher education, and is meant with absolute respect and sincerity:
Just what is it that pharmacists DO?
We know you guys are smart…colleges don’t go around passing out Pharm D’s based on your looks. And from our own painful experience, we know there is more paperwork and red tape involved in your work than should be allowed by law. But I gotta tell you, from John Q. Public’s perspective, it appears that you guys have these huge bottles of pills in the back, count a few out, put them in a bottle, and put a label on it. Why does that require a doctorate and 7 years of college?
I’m being dead serious, not disrespectful. Oversimplifying it, yes, being jocular, yes, but I really am serious. Hubby and I are above average in intelligence. If we don’t know…and we actually WANT to know…then I am sure the docs with whom you regularly engage in sparring matches don’t have a clue. Even the ones with God complexes.
So, would you take the time to explain to us, and to your readers, what all you guys do? What you studied for 7 years? Maybe it would help them have a better appreciation for your intelligence and get that huge chip off of their shoulder.
(Who am I kidding? That chip is soldiered firmly onto said shoulder. But maybe some people would appreciate it…and you…more. We would.)
Thanks, TAP. Keep ranting.
Just The Nurse Practitioner

Well Nurse Practitioner, you partially answered your own question. How do you think we catch said mistakes and dosing errors and allergies without the 7 years of college? Most pharmacy computers marginally handle this (or go overboard with the interactions part) but almost all the time we do it off the cuff. Amazing isn’t it with all the drugs that are out there.
Let me run down for you what a typical Rx filling process goes like in retail:
1. Patient comes in with an Rx. We get the insurance information, personal information, allergies, etc.
2. Patient has 400 questions about OTC products, we answer those so they don’t bug you about if Tylenol will help their arthritis vs Ibuprofen.
3. We start to input the Rx into the computer. The computer, being a computer, spits back at us 900 drug interactions (99% which are theoretical and drug-food and drug-alcohol interactions) to which we blaze through sorting out the true interactions (warfarin and Codorone, Flagyl and Alcohol, etc) from the ones that are in the system because one idiot in Nebraska had it 30 years ago once. Knowing what is crap and what is a legit concern comes from the 7 years of college (however mostly experience).
4. We learn to find that the Rx is not covered. So we select the next best alternative that the insurance will cover and ask you to change.
5. We bill the insurance (to watch them reimburse us $3 over cost for all this work).
6. We tell the patient how to take it, as well as handle another 400 questions about if it will cause headache, diarrhea, anal seepage, hemorrhoids, when the next shipment of cards will be in, etc.
7. We send the patient on his/her way after a long discussion about how high the $1.05 copay is, and why he/she has to pay it.
8. We spend the next week getting phone-call after phone call from this patient about every little side effect that he/she is having claiming them to be ‘allergies’.
Now, this is if 1 person is bringing in an Rx. Most pharmacies have at least 3-5 (or more) of these processes going on at the same time with only 2 or 3 pharmacists to handle this. Add this with Dr’s and NP/PA’s calling at random times (which causes us to drop what we are doing and get the phone) and you have yourself quite a mess. We don’t get to shove people in rooms to wait and come around to them and work one on one. Imagine if you were seeing a patient in a big room, and someone just came in and tapped you on the shoulder derailing your train of thought. We shovel medical advice out the front door as the money is being spooned in through the window.
This doesn’t even touch on the clinical folks at the hospital who need to know what a patients renal or hepatic status is when selecting drugs. Try to give atenolol to someone with a GFR < 20 and you'll have quite a mess on your hands (hint: use metoprolol instead). Unless you're a specialty doc, we know as much (if not more) about drugs as you guys know about diagnosing stuff. Sure, any pharmacist can diagnose heart-failure, or diabetes, or hypertension just like any MD/NP/PA/etc knows the basic drugs to give, however when someone has no kidneys, or is in hepatic failure, or their insurance doesnt cover it, or how much Tylenol to give to a 4 month old baby, we don't have to look these up. Retail guys don't carry around PDA's or Tarascon (which is full of mistakes, be warned). Sure, we have Lexicomp or a Facts around for the weird stuff, but all the things that you have to look up we know off the cuff. Plus retail folk don't get their heads polluted with drug-company shit from the reps (which reminds me, I need to rag on the reps some more). Finally, (this is a big one), most (if not all) pharmacists have a uncanny ability to translate medical -> commoner. Doctors are notorious for using medical-speak to patients (which sound scary and just confuses them). We are the ones who get the “what does this word mean” when patients get the warning from their doctors about rabdo with statins. We are good at bridging the gap between a very precise big-latin-word based language to the language that is used by people with annoying song ring-tones on their cell phones.
I hope this answers your question, I’m sure that the commenters out there will add on what I leave out.

Not so hypothetical situation

OneAngryTech ( wrote in:

Ok.. Pharmacist(s): Time for WHAT WOULD YOU DO?
Cash-Patient A comes into your pharmacy with 2 prescriptions, 1 for Vicodin and 1 for Xanax. The prescription for Vicodin is 100 tabs, TID and Xanax is doesn’t matter. Patient inquires as to the price for the Xanax, but not the Vicodin.
Your enterprising tech (me) for some unearthly reason decides to do a central search (which checks all the pharmacies in your chain) and finds that Patient A just filled the same prescription for Vicodin 7 days ago (30 day supply) at the neighboring town store.
What do you do?

This brings up a good point. Whenever someone who usually uses insurance comes to you with a narcotic and demands to pay cash, something isnt right. I always do a courtesy run-through to see what the magical insurance company pops up with. 9 times out of 10 they received some narcotics from another doctor and another pharmacy just like in this instance.
Then I outright ask them if they picked up the Rx from [storename] a week ago. Usually thats enough for them to give me the deer-in-the-headlight look as if to think “holy shit, how does he know?” If they say “no” then I call the other store to see if they are lying (which they are). If its from another doctor I outright ask “Did you tell Dr. A that you are getting pills from Dr. B?” When they say “Yes” I call. You wouldn’t believe how many people I get kicked out of practices that way. They especially get pissed when they tell me “I specifically asked them if they were getting vicodin from another doctor and they outright said no!” Whoops.
Sometimes they demand the Rx back (to try another store). Before I give it back I write on it in pen “Filled [date] [quanity] [store]” on the front of it. Is that an asshole move? Yup. Do I care? Nope. Whats the doctor going to do, bitch at me that I defaced his Rx that he gave to someone who is fraudently doctor shopping? Yeah, lets call the police on that drug dealer that put borax in my cocaine while we are at it. I mean seriously, if there is so much deception going on that they need to outright lie to me, what legitimate purpose do they have trying to get it filled?
If they are up front with me and dont lie/give me any lip, I give it back without question and say that I wont fill it until its due. What they do from there is their own dealing.
Lets see how this story pans out:

When Patient A comes to pick up both RX’s, the Pharmacist in Charge lets patient know we didn’t fill the Vicodin prescription since it was just filled 7 days ago. We have said prescription in the bag.
Patient then remembers that “well.. er someone stole my Vicodin so I went to Dr. Pain Clinic and he wrote me another one.. der der der”
Pharmacist let’s patient know that we will need some kind of proof as to this happening (maybe say a Police Report.. it IS theft after all) and patient angrily walks away and shows us birds.
We then decide it would be a good idea to give neighboring store a call and let them know what happened. They thank us.

Good move. Usually when you say the word “Police” they bail. Works especially well when they use the line “Well I didnt pick up my vicodin Rx, you gave it to someone else”. Just saying “Well I’ll call the police and pull the surveillance tape” turns their bitch into “Oh, I forgot my cousin picked it up for me, no need to call the police”. Its like magic!

They then proceed to fill that prescription the very same night.
I am only a tech, so of course I don’t know shit, but would I be within rights to say WHAT THE FUCK IS WRONG HERE AND WHY THE FUCK WOULD THEY FILL IT??!!??
The only response: “Well, it is the pharmacist license..”

Pharmacist, Pharmacist in charge, your store license, and a whole bunch of DEA paperwork. Yeah, fun shit. I hope they jacked the cash price up to cover the cost of all of the crap that could of went down.

Is the insurance company telling the truth?

This is a comment by a “Med Student” to that 4-degree doctor comment. I love getting emails from students.
— Part 1 —

I completely understand what this Dr. is talking about. I always have problems with insurance at the end of year, start of new one. I have chronic pain and also am on a maintenance drug, I take daily for my heart. I went to refill both as I normally do on day 28-29 since the last refill and of course I get the dreaded “It’s too early” from the insurance..but no problem right?

That right there tells me that something is up. Most insurance companies will give a 5 to 7 day window before it kicks back the “refill too soon” error.

Because they tell me to pay cash, and send them the receipt, so I tell this to my pharmacist. Well now, even though I have been going there for over a year, same meds, same amount, same Doctor..she parrots the insurance company (who doesn’t realize there is a HUGE difference between the meaning of THEIR “too early/soon” and a Pharmacies “too early/too soon”) and I ask her, how is it too soon? It’s been 28 days since I last picked up my meds? She wouldn’t answer me. She instead says that she would fill it next week (which btw is at day 33, which means, I’m without my meds for 3 days, which is HUGE, if I miss even one night without my heart med, I start getting some major palpitations..) but it seems she’s made up her mind. She decided to make her OWN medical decision without knowing my complete medical history, as my own personal doctor of over 7 years knows.

To be honest, you are giving me only the information that you wish to give me and I’m sure there is a key bit of information that would make sense that you aren’t giving me. There could of been an ER script in there for a week supply thats throwing everything off, another pharmacy involved, etc. Something however really doesn’t jive with what you are saying. I’m not saying that you are at fault, but with all of the insurance companies I have never heard of one that will kick back a ‘refill too soon’ error when its 2 days remaining on a 30 day supply. Even if you had no coverage, it would say ‘patient not covered’ not ‘refill too soon’.

So, tell me, why is there NO recourse for me for Pharmacists like this when I assure you, I’m no crack addict. I’m a normal person who unfortunately got JRA at 13 with horrible joint damage and chronic pain that I have been living with all my life. Instead of collecting disability like most would, I instead went through school (honors) and now am in my 3rd year of Med school getting my MD/PHD while also working with Congressional members and House members on a daily basis.

Dont take this the wrong way, but if I had a dollar for everyone assured me that they didn’t have a problem as I am looking at their state narcotic report and seeing 4 doctors, 3 ER’s and every Walgreens in town I think I could retire. When everyone and their brother lie to you day in and day out, you tend to not believe everything at face value unless compelling information states otherwise. I hope you would actually read the study on a new drug rather than take at face value what some drug rep tells you, right?
You may think this is bad medicine, but wait until you get out and get a visit from the DEA because you are shoveling vicodin out of the door to everyone who gives you a half-assed sob-story. Its amusing to see new Dr’s backpedal from their ‘we must treat everyones pain’ after I tell them that their patient is going to 3 different pharmacies and 2 other doctors for their narcotics. Its like a real-world shock that there are people who lie and deny to get what they want.
I deal with tons of legitimate pain patients every day, and you know what? I never deny them their pain pills if they are a day or so early. However, this being ‘The Angry Pharmacist’ it doesn’t make for a good read to tell how much I help people. People want to read what pisses pharmacists off, and I know that I have been extremely clear stating this in the past.

There is WAY too much stigma attached to ANY type of pain killer. If it’s for legitimate pain, one shouldn’t be denied healthcare.

Yeah yeah, save me the ‘chicken for every pot’ story. There is no stigma unless you make it a stigma, and in your example above something red-flagged that pharmacist. Vicodin + “Refill Too Soon” = something is going on. Now if your insurance company would not have given that error message back, do you think this would be even an issue? I dont think so. I would also like to hear your definition of ‘legitimate pain’, because last time I checked people don’t go into the doctors office saying “Hey, I need a vicodin Rx to make my car payment or to deal with my bitchy ass wife”.

I do want to point out that:
A. This has never been a “problem” for the Pharmacist before, until insurance denied my claim for a week or so until coverage kicked in
B. The amount, doctor, strength has NOT changed and it IS a legit script, so you cannot argue that she may have denied it on basis of some sort of “suspicion” that it may be fraudulent, etc..

Blame the insurance company, not the pharmacist. They are the ones who threw back a “refill too soon” message. As I said before, if the insurance company wouldn’t of thrown that back, would we even be having this debate now? So, lets break this down a bit more.
Something happens and DEA gets on your case for something. DEA officer comes in and asks to see the hard copies. DEA also has subpoenad your insurance company. DEA asks pharmacist “When you filled this Rx, it came back from the insurance company as ‘refill too soon’. Why did you fill it?” Whats the pharmacist supposed to answer? “Because shes in legit pain and says that she isnt a pillhead?” Yeah, that’ll fly like a turd on a birthday cake.

THOSE are the types of Pharmacists that are trying to practice Medicine without a degree. There should be some sort of consequences. *I* was ticked off at the fact that she “offered” to call my doctor to see if it was ok to “refill early”..MY argument here was, it was NOT early. 28-29 after getting the original fill is NOT early, ESPECIALLY NOT when your on maintenance medication in which you must take it every day.
My doctor is a nice guy, but he REALLY is busy, he spends 12 hours at a busy ER and the rest of the time at the practice, he does NOT have time to get on the phone (which can be backed up by his wife!) to be questioned about nonsense!

I think you should nail your insurance company for practicing medicine without a degree. If the insurance company is kicking back an early fill error, then something else is going on. I would call your insurance company to see who possibly stole your identity or your insurance card and is running up some vicodin scripts with it.
— Part 2 —

I’m sorry, I forgot to add a little more background.
I had been at Walmart Pharmacy last year and the same thing happened then. At the end of year, my insurance changes because that’s what the company forces us to do, they LOVE making life miserable. Well, Aetna has 2 numbers, the business number for customer service and the PHARMACY number the pharmacies are supposed to call. Well, when I needed my refill, the computer denied the claim and the tech called the BUSINESS line, which BTW they are completely useless. All they said was basically it was “too soon”

Wait, so this has happened with 2 pharmacies? Something now is really fishy especially if its coming back ‘refill too soon’ both times.

Well, at THIS point, I had been EXTREMELY busy, I was the campaign manager for a House member and forgot to call in my refill, so I called at day 30! (I almost NEVER do this..or at least try not to..with my luck, something comes up and I forget to pick it I always give myself 2 days wiggle room)

Filling your Rx on day 30 when you have a 30 day supply should go through with no errors. Unless you are getting it filled somewhere else, the Rx was mistakingly put in with a days supply higher than 30 (doubtful with Aetna, it would of gotten rejected), or someone else is using your card.

Well now, I get there and the pharmacist and I literally get into it, she starts screaming that it’s TOO Soon! I KNOW this is wrong, so I sit there and call the CORRECT number for the Pharmacy portion of the insurance and I actually am able to get the DIRECTOR of Aetna on the phone, she tries to speak with the Pharmacist, but the pharmacist will have NONE of it. the director feels bad for me and apologizes and says, I’m sorry, but she just wont listen to me. (The director tried to explain it’s all about the coverage and end of year etc..that it’s NOT too early for the refill)

You got the Director of Aetna? I’m sorry, but I’m having a hard time believing you. The pharmacist has to go by what is on his/her screen, and if Aetna is claiming its too soon then tell them to fix their shit to give back accurate error messages.

So, my DOCTOR calls the pharmacist (keep in mind, Im standing there at the pharmacy for 2 HOURS watching all this) and he tells her, you HAVE to fill this refill! The pharmacist REFUSES, quoting the comment of the clueless wonder at the insurance company the very 1st time, “Insurance is saying it’s too soon” which at THAT time, everyone in line almost faint FOR me because the director actually called and the pharmacist would NOT listen to her. So, my doc calls me on MY cell phone and boy, is he pissed! He’s like, I dont know why she wont listen to me, I’ll go ahead and call a new script at a different Pharmacy because this is ridiculous.
THATS when I go to this new pharmacy, I explain what happened and even though I feel as if I dont HAVE to or need to, I actually go through all my medical conditions, etc. MY thinking is, this is a smaller Pharmacy, I want a more personalized interaction. I want to feel like a person and NOT a refill number, ya know? My Physician even went as far as to stop in and introduce himself! Seriously, we have gone above and beyond here.

Its always good to explain yourself even though you don’t HAVE or need to. You know, we’re just stupid pill dispensers and don’t need to know ANYTHING about you. Give me a fucking break, you must really be a med student with an attitude like that.
Pharmacists tend to get a bit pissed when you withhold information especially when the words “another pharmacy” and “refill too soon” are in the same boat as your narcotic Rx.

So, That is just another reason why I’m sooo ticked that I’m having this problem. Is it so difficult for her to look at the dates?
I’m thinking (in both cases) it’s a matter of their pride, they were wrong and don’t want to admit it. But *I* am paying the price for that while they have absolutely NO consequences for their actions.

Blame Aetna, didnt they give back the refill too soon message that started this whole thing?

After reading quite a few posts of yours, I know you have this thing about thinking everyone is a “pillhead”, but I’m guessing even you would be able to put aside pride or ego and not actually DENY a patient legit care…afterall.. isn’t that why you became a pharmacist? One has to wonder about these pharmacists, is it an ego trip that put them in this field or is it helping people.

No, I dont think everyone is a crackhead or an addict. I however dont take people’s word for anything now days unless I have good and solid evidence that they are being legit with me. Its not pride or ego, its doing our fucking job to control narcotics and to manage the medications that multiple doctors prescribe because its impossible to call each other to see what the others is giving. Amazing how stories change when I get a refill too soon error, ask the patient if they received some at another store about 4 times, call the insurance company to find out what store filled it, then ask the patient point blank if they got it as that store. Then I asked why they fucking lied to me when I have to crowbar out of them that they did get some at another store. Get this done to you (which is a complete waste of my time) about every other day, then you’ll realize that its not “pride” or “ego”.
Lets face it, Aetna probably gave that pharmacist some bum information. If it would have been me, I would of called Aetna and had them give me the pharmacy that last filled it. If you had no idea about this other pharmacy then I’d ask for a copy of the sign-out log and inform the police about narcotic/insurance fraud. You would not believe the amount of shit dropped in pants when I threaten to call the police. Amazingly they manage to remember that they got 30 from an ER doc YESTERDAY. Must of slipped their mind.
However from what you have wrote, you don’t really sound like the easiest person to get along with or work with to get this sorted out. You probably just started screaming at the pharmacist which really doesn’t help anything. Screaming isn’t going to get your pills filled when there is documentation (from the insurance company) that it was too early to be filled (something had to trigger that message).
Of course I will also entertain the fact that you gave me everything and the pharmacist is just being a dick. It happens just like there are asshole doctors in the world who think their shit is worth as much as Zyvox and their farts smell like Warrick Albuterol MDI’s.
So good luck in Med school. When you get out you can rant to me about that mean ole asshole pharmacist who wont fill the Rx’s you write for yourself.


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. 🙂

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. 🙂

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.. 🙂

Why do people still think Marijuana can be prescribed?

As a pharmacist what type of medical marijuana abuse do you see?

I see tons of abuse, and zero Rx’s. MJ is a C-1 narcotic like Heroin, LSD, and PCP. It cannot be “prescribed” or “dispensed” legally in the good ole USA.

I’m in college and I always hear of Doctors illegally prescribing Marijuana to kids who pay a couple hundred bucks. Is this just talk or does it actually happen? How big of a problem is this and how can it effect your pharmacy?

Doctors cant prescribe a C-1 narcotic nor do pharmacies stock C-1 narcotics (research facilities excluded). Regardless of what those fruity fucks in California say, MJ is illegal, and always will be illegal. States cannot make a less-strict law to override federal law (however they can make a state law more strict than federal).
DEA has the final word, and the only reason why there is this MJ Rx bullshit floating around is that they have bigger things to worry about like inspecting pharmacies for vicodin use and making our lives hell than to bust some broke stoned pothead.
So the “Doctor” that is “prescribing” this MJ is just a glorified pusher who should have his license revoked and publically strung up by his peers by propagating this stereotype. The “kids” who are buying this shit for a few hundred bucks are getting ripped off and should just visit their local stoner for a better deal.
MJ is not an Rx drug, and the people who are getting “Rx’s” for it are just rationalizing their abuse and pulling the wool over the retarded eyes of the local law enforcement. If I were a cop, and some douchebag showed me an Rx for MJ, i’d laugh at him and arrest him (if he had some on him). I’d win in court every time.

Can’t feed me that info and expect a serious answer!

This is an honest question.
Every month I call the computer at Walgreens to have my monthly
prescription refilled.
I always give the computer a pickup time that is hopelessly optimistic. I
usually don’t really pick it up until 12 to 36 hours after the time I
Am I a bad person?

You go to walgreens, so yes, you are a bad person (Come on! How can I pass up a line like that)!
Honestly, I really dont think it matters. They just sit in a drawer waiting for you. Now if you ordered a bunch of expensive stuff then sat on it for a month or two (so the pharmacy had to Return-To-Stock it), THEN came and wanted it (so they had to fill the Rx twice), you are a doubly bad person.
Oh! If you want to ask me questions, please email I miss questions in the comments, etc.