Labels, Labels, Labels

"Sir, it is too early to refill your prescription.  It was just 2 weeks ago that I filled your prescription for a full month supply of medication."

"Yes, I know, but at my last visit, my doctor told me to double my dose….."

Pharmacists do much more than just put labels on prescription packages.  That said, we do put labels on prescriptions, and quite a few I might add; we take this part of our job very seriously.  These labels, as simple as the process may seem, are a tremendous wealth of information, and they better well be accurate!

We guard our labels.  Every piece of information on the label, from the patients name, physicians name, directions, medication name, description of medication and all of the other required documentation is verified by a pharmacist each and every time a prescription is dispensed.  This is not just a retail pharmacy deal; labels go on all of the medications in hospitals, skilled nursing facilities, i.v. solutions and anywhere else a medication is prepared to be administered or dispensed to a patient.

An issue we run into regularly in retail pharmacy is someone needing to refill their prescription, when according to our records, they should still have at least two weeks of medication remaining.  At this point, part of what we do in the pharmacy is play detective.  We will engage the patient in a conversation and do our best to figure out what happened with the rest of the medication. 

Over the years I have come across many different scenarios explaining why a medication container has come up short; however, one situation that comes up over and over again is the one I described at the beginning of this discussion.  A patients' doctor has increased their dose and no one has notified the pharmacy.  According to our records, the directions on the label of the prescription are not the same as how the patient is now taking their medication. 

At this point, the filling of the prescription is put on hold until we can contact the prescribing physician and clarify the directions.  I understand the patient is here explaining to me what the doctor told them to do, however, I cannot change the prescription label without an order from the doctor.  If the doctor is not readily available, we will make sure the patient has enough medication to hold them over till tomorrow while we wait for the physician to follow-up with us.

Here is the take home message:  If your doctors ever changes your dose of medication while you are at the office, please ask them to forward the new directions to your pharmacy so they will be prepared for you when you show up early to get your prescription.


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Sleep; It's Not Just For The Weak

Just thinking about writing this blog about sleep has got me day dreaming of my soft, comfortable bed.  Can you believe this; we spend over 25% of our life (maybe more) in our bed.  Of course, we may not be asleep that entire time, however, that is a heck of a lot of time during our life to be in any one place! 

We all need sleep for survival, however, how much sleep we need varies with our age, physical conditions, disease states, and how much sleep we have been getting the past few nights.  Our body, in its great design, produces and maintains our nervous system while we are sleeping.  Without sleep, our ability to perform even the most basic decision making processes becomes extremely compromised.

Some of us like to think that we have trained, or adapted, our bodies to survive on minimal amounts of sleep.  While this may be true for a limited few individuals, the theory is that we have just gotten use to the sleep deprivation and have developed a capacity for processing decisions on limited resources. 

Think about it, we love our down days.  If we have worked hard all week, getting up early and staying up late, at some point we love to have a down day where we sleep in, catch up and re-charge.  If we never had the chance to rest our body, our nervous system would continue to deplete its resources and leave us in a state of nervous anxiety.

If you are really interested in this topic, I recommend you take the time to read this discussion from the National Institute of Health.

So then, what do I do if I lie in bed, night after night, and can't fall asleep, or, if I sleep for maybe two hours and then wake up and lay in bed the rest of the night worrying that I will be tired the next morning when it is time to get up. 

1.  Sleep Hygiene; Google it.  We go to great lengths to take care of our personal hygiene, why not put some effort into our sleep hygiene.

2.  Talk to your pharmacist.  There are a few non-prescription sleep aids available and your pharmacist will help you figure out if one would be appropriate for your situation.

3.  Make an appointment to see your doctor.  You may have a sleep disorder such as insomnia, sleep apnea or restless leg syndrome.  Various prescription medicatioin treatments are available and your doctor will help you decide which may be the best option for your particular situation.

To learn more about the prescription medication alternatives for sleep,please register to become a member at AudibleRxTM, and then navigate to the "sleep" section of the Medication Specific Counseling SessionsTM.  You will then have full access to all of the current and future counseling sessions.


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My Pills Look Different

"Hi, I think you gave me the wrong medication, this tablet looks different than last time I picked it up."

"Thank you for calling!  Please, if you ever have a question about whether you received the right medication in your prescription bottle, do not hesitate to call your pharmacist back and verify the medication."

Unfortunately, in the world of generic medications, the available manufacturers change on a regular basis.  We update the computer to reflect the new manufacturer, and the new tablet description is on the label, however, it is still unsettling for a patient to receive a medication that looks different than it did the last time they took it. 

We give these calls top priority.  If a tablet or capsule looks different to a patient, we need to make sure, beyond doubt, that the patient received the correct medication. 

As a pharmacist, I live in a world where perfection is expected each and every time I fill a prescription.  I have multiple checks and balances, verifications, controls, and quality improvement programs implemented to assure the right drug is put in the right bottle for the correct patient.  That said, I am human.  The only pharmacist that does not make an error is the pharmacist who does not practice pharmacy.

My point is not to scare you into never trusting your pharmacist.  Pharmacists are the most accurate individuals I know.  As always, I encourage you to develop a relationship with your pharmacist.  If you find that the pharmacy you are going to does not lend itself to regular and easy communication with your pharmacist, check out another pharmacy.

MY POINT IS:  If your medication ever looks different than it did last time you picked it up, do not take it until you call your pharmacy and speak with your pharmacist to verify that it is the same medication!      


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How Bad Does It Hurt?

There is no other area of pharmacy treatment that has the stigma associated with it as does the treatment of chronic pain with opiate medications.   Unfortunately, these medications are known to sometimes cause addictive behavior.  For this reason, pharmacists and other health care professionals may inadvertently appear suspicious before they get to know you as a patient.

When a patient accidentally throws out their blood pressure medication with the trash, it is
usually taken care of with little question. When a patient accidentally throws out their narcotic pain medication with the trash, the pharmacists and doctors immediately have a stream of questions regarding the legitimacy of this claim. This is unfortunate and is a very difficult topic to address.

There are many reasons for chronic pain and many, many treatments. I am not planning on discussing the different options for treatment, these are all readily available on the AudibleRxTM website.

I would like to bring the general discussion of long term pain itself to the forefront. Pain cannot be measured like diabetes and hypertension. Most medical conditions can be verified with blood tests or x-rays and then categorized and documented. There are currently no blood levels we can do or specific vital signs we can take that give us an accurate measurement of pain. Pain is subjective. We ask the patient to put the pain somewhere on the scale from 1-10 with 10 being the worst pain. All anyone has to compare it to be the pain they had yesterday, or the year before...

How does the health professional know if the patient is in pain? Well, by listening to the patient and if they say they are in pain, most likely they are. Of course, there are patient history notes, past treatments, social and economic considerations, and family issues to review; however, we are working with the patient sitting with us today.

How long does a patient need to stay on pain medication therapy? As long as the Doctor and the Patient think it is necessary. The understanding is clear that over time, the body begins to develop a tolerance to opiate pain therapy. What is not clear is the exact mechanism that allows this tolerance to develop.

The central nervous system has many adaptive capabilities. It is generally understood that the brain “adapts” to the opiates.  Over the course of several months to years, the body is able tolerate a significantly higher dose of opiate pain medication than it could when you took your first dose.  The question is; has the pain really increased that much? Well, to the patient, yes it has because the brain has adapted to the current level of opiate treatment and needs more treat the pain.

We all need to be part of our own treatment. We need to talk to our doctors and pharmacists and therapists and family....and anyone else who will listen, to help us realize what is our best pain treatment path to follow.   

You may also be interested in reading my blog on Spinal Pain Medication Treatment Options or my blog on Bone and Joint Pain Medication Treatment Options.

To learn about the medications used for pain, please register to becomea member of AudibleRxTM and have full access to all of the Medication Specific Counseling SessionsTM.  Please visit the Medications pageof AudibleRxTM to see all of the counseling sessions currently available. 

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Hanging On A Ledge With Sweaty Fingers; Acute Anxiety

Dictionary definition of an anxiety attack;

"An acute, psychobiologic reaction manifested by intense anxiety and panic. Symptoms include palpitations, shortness of breath, dizziness, faintness, profuse diaphoresis, pallor of the face and extremities, GI discomfort, and an intense feeling of imminent doom or death. Attacks usually occur suddenly, last from a few seconds to an hour or longer, and vary in frequency from several times a day to once a month. Treatment consists of reassurance, desensitization statement, separation of the individual from anxiety-producing situations, administration of a sedative if necessary, and appropriate psychotherapy to identify the stresses perceived as threatening."

To me, this sounds like all the emotional and physiological feelings I would have if I was hanging on a ledge over a pit of hungry alligators and my fingers were beginning to get sweaty!

I put this definition up here to help understand the symptoms that anxiety attack sufferers go through.  Quite often, the sufferer is not even aware of the trigger that stimulated the attack; however, the body ends up in an acute state of fear both mentally and physically.  These feelings and emotions are perceived as real by the sufferer, while at the same time, a family member or friend looking on may not see or perceive any threat.  When an individual is in this acute state, it is important to realize that (unless you are a trained mental health professional) you will not be engaging the individual in any sort of logical conversation.    

If you, or someone you know, experiences attacks of anxiety, please take the time to talk with your doctor, or encourage the sufferer to talk with their doctor, about this.  They will most likely refer you to a therapist or psychiatrist to help you decipher what it is that triggers these attacks. 

There is a category of medications called benzodiazepines that promote calming and soothing.  These medications enhance a particular chemical in the brain that helps inhibit excitability.  This calming and soothing effect can be quite effective with an individual experiencing an acute anxiety attack. 

The issue is these benzodiazepine anti-anxiety medications are effective at lessening anxiety, regardless of the cause.  These medications also work very well at decreasing anxiety felt under normal stress of daily life, stress that we know what the cause is from. 

It is important that your doctor take the time to help you distinguish the difference between acute anxiety and the stresses of normal life so that you don't end up taking this type of anti-anxiety medication to help relax everyday stressful situations.

Benzodiazepine medications do not cure anxiety; however, when prescribed appropriately they have a place at helping relieve the symptoms of acute anxiety.  When this category of medications is used to help relax everyday stressful situations, your body may become dependent upon the medication which may lead to addictive behavior.

To learn more about these benzodiazepine medications, please visit the AudibleRx website.

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Men & Their Plumbing (BPH)

Why is it that men are so reluctant to go to the doctor to talk about their penis and urinary issues.  We must have this deep seated fear from the cave man days that lurks in our hypothalamus telling us that if we need to admit to someone that we have a penis issue……….well, than a younger, stronger cave man is going to come along and take away all that is precious to us.


Benign prostatic hypertrophy (BPH) is a non-cancerous increase in the size of the prostate. Women do not have a prostate, so this is not an issue for them.  In men, the prostate grows initially through puberty and then typically stops growing until mid-life, where it begins growing again very slowly.  Even though there are different phases of prostate growth, urinary problems usually do not develop until the final growth phase of a man's life, usually after 55 or 60 years old.

The prostate is located just below where the bladder empties into the urethra.  The urethra is the tube that carries urine from the bladder, through the penis to outside the body.  As the prostate slowly grows, it pushes up against the urethra and causes any number of uncomfortable urinary symptoms.  These symptoms might include urinating much more often than usual, an urgent feeling that you need to urinate immediately, the need to get up many times during the night to urinate, and a difficult time starting a urine stream.  If you are experiencing any of these symptoms, please, tell your doctor about it. 

There are two different mechanisms of medication therapy to treat these symptoms: 

The first medication category works to help relax the muscles in the prostate and the opening of the bladder.  By doing his, the urine and flow may be increased and therefore will decrease the urinary symptoms.  The issue is, the prostate may continue to slowly grow and over time the medication may lose its effectiveness.

The second medication category is involved with the development of the prostate.  The prostate requires the conversion of testosterone to dihydroteststerone (DHT) for its continued growth.  An enzyme called 5-alpha reductase is required for this conversion.  There are a couple medications that will work to inhibit this enzyme, thus blocking the conversion of testosterone to DHT.  This process allows for the prostate to slow its growth and possibly shrink in size.

To learn about these medications, side effects, precautions, interactions and all of the other exciting information, please register to becomea member at AudibleRxTM and have full access to all of the Medication Specific Counseling SessionsTM. 

You may also be interested in a BLOG I wrote a few months back discussing Erectile Dysfunction and the medication treatment options available.  Please follow this link to visit the page.


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TRUST Is Fragile, Handle With Care

Hello, may I speak with Steve please?

I have worked in the same independent pharmacy for more than 15 years and the pharmacist I work with has been there for just as long.  One of our technicians has been there for almost 10 years and the other for almost 7 years.  Even though we are a small independent pharmacy, we have patients who drive past 5 other pharmacies (some drive more than 20 miles) just to come to our store.  When patients walk into our store they recognize us and have come to trust us.  When one of us is missing…it is truly noticed, not only by the patients walking into the store, but by the other staff also.

This is what I like to call "Continuity of Care".  To me, this means that when patients come into our store they can feel comfortable knowing that we will be there taking care of them.  It means that we have taken the time to get to know our patients, and we have let them get to know us.   It means that we, as a team, are familiar with each other and can trust that the other team members will be there to "have our back".  We all work well together, and because of this, we are able to provide outstanding care to our patients. 

We have 2 or 3 relief pharmacists and 2 or 3 relief technicians that our customers are getting to know.  It is interesting that even though a relief person may have been working with us on and off for over 7 years, when a patient calls in, they will still ask to speak with one of the 4 regular staff.

Community Pharmacy is based upon the "Continuity of Care" that happens when regular staff are able to work together in a symbiotic relationship providing complete pharmaceutical care to patients.

There is a very interesting phenomenon that happens when someone works in a particular location for an extended period of time.  It doesn't matter if it is a pharmacy, insurance office, coffee shop, bank, taqueria, or pet groomer; your customers come to trust that you will be there.  People come to trust that their latte' will be made just right by a certain barista, or that their dog will be groomed just like she was last time. 

Patients come to trust their pharmacist after talking with them at the counter 10 or 15 times and knowing that their pharmacist is fully aware of all of the other medications that they are taking.  This trust opens up another avenue in which a patient may gain access to more complete medical care.  Pharmacy is much more than just making sure (beyond a shadow of a doubt) that the right patient gets the right medication at the correct dose. 

Pharmacy has taken on the responsibility of being the medication educator.  It is the pharmacist's responsibility to assure that the patient understands all aspects of their medication treatment so that they will be motivated to follow their pharmaceutical regimen and gain their best possible outcome while avoiding any medication misadventures.

I fear that over the past few years that the measuring of pharmacy productivity (pharmacy metrics) may have diminished the ability of pharmacists in some practice settings to provide the needed education to patients.  Fortunately, the facility that I work with believes in providing the resources to assure that all patients are provided with the pharmacy education and counseling that is necessary to help assure a positive outcome of therapy.

Next time you go to your insurance agent, hair stylist, chiropractor or dentist; think how you would feel if when you walked in the door there was someone different there to greet you and take care of you.  Would you give them the same level of trust you gave the person who had worked with you the last 10 years, or would you ask them where the previous person had gone to?      


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Hormonal Contraception, How It Works

A few months back I wrote a blog discussing the barriers to effective counseling between a pharmacist and patient when it comes to hormonal contraception.  If you haven't read it, please click on this link and take a moment to read it before reading this discussion of how hormonal contraception works in the body. 

My goal here at AudibleRx is to educate people about their medications so they will become motivated to follow their own pharmaceutical regimen.  Understanding what the medication is doing and how it works in your body helps you realize the importance of compliance to therapy. 

The hormonal process of the female menstrual cycle may be common knowledge for many of you, however, when I am counseling someone at the pharmacy counter I do not like to assume anything.  Understanding the basics of the menstrual cycle is key to understanding how hormonal contraception works. 

In simple terms, the first day of menstruation is the first day of your cycle.  At this point your body is very low in estrogen.  Your brain sends out a message for your body to start developing an egg.  As the egg matures over 10-15 days your estrogen level significantly increases.  With a surge of hormone, the mature egg breaks through the ovarian wall and starts traveling down the fallopian tube ready for fertilization.  At this point, another hormone, progesterone, starts increasing.  Progesterone helps thicken the uterine lining, preparing a home for a fertilized egg.   After about 13-16 days, if there is no fertilized egg, the progesterone will decrease and the uterine lining will shed.  Here we are back at the first day of menstruation, estrogen levels are again low, and the whole process starts over again.

Hormonal contraception therapy tricks the body.  By maintaining a moderately constant level of hormones in the body, the surge of hormones around ovulation is avoided and an egg is not released.   Hormonal contraception also thickens the vaginal secretions making it more difficult for sperm to reach an egg and it also affects the lining of the uterus, making it more difficult for a fertilized egg to attach to the uterine wall. 

To listen to a Medication Specific Counseling SessionTM on any of the sevendifferent categories of hormonal contraception, please register to become a member of AudibleRx.

Each hormonal contraceptive Medication Specific Counseling SessionTM will discuss the important treatment information regarding that particular medication. This will include how the medication works, how to use it, what to expect, potential risks, side effects, adverse reactions and interactions, and what do if you miss a dose.


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Mail (Fail) Order Pharmacy

OK, I will just come right out and say it.  I DO NOT LIKE WHAT MAIL ORDER PHARMACY HAS DONE TO THE PROFESSION.  You do not have a mail order Doctor or a mail order Dentist, why should you have a mail order Pharmacist.  Patients need to have a Pharmacy they go to on a regular basis and a Pharmacist they develop a relationship with.  Your pharmacist checks your medication profile, knows what medications you are taking, talks with your doctor about your therapy, and asks you questions when you come in the store. 

If you are unhappy with your current Pharmacy and Pharmacist, walk into a new Pharmacy and ask to speak with the Pharmacist.  Ask them if there is a regular staff, or do they have different pharmacists rotating through.  Find out how easy it is to get 1-2 minutes of the pharmacist's time.  Ask them if they would be willing to work with you as a patient. 

So, back to mail order.  Insurance companies have contracts with mail-order pharmacies.  Financially, it is in their best interest to fill the prescriptions and mail them to the patients.  This is advertised as a convenience to the patient; however, more than that, it increases the profit margin of the relationship between the insurance company and the mail-order pharmacy.  What we are missing here is the patient-pharmacist contact. 

Even though insurance companies send out mass mailing to their clients touting the fantastic and simple process of receiving prescriptions through the mail, I still see 2 or 3 people each week in the pharmacy that have some sort of mail order pharmacy miss-adventure story to tell me about.  Regularly I encourage patients who are dissatisfied with their mail order prescription process to call their insurance and request to "OPT-OUT" of the mail order process.  This then allows them to come into their pharmacy to pick up their prescriptions and discuss them face to face with their own pharmacist.

I am not naive enough to think that this mail order process is just a passing phase.  Unfortunately, I believe it has come to stay and will continue to take up more and more of the market share.  Mail order pharmacy questions were the idea starter behind  Each time a patient receives a prescription in the mail they also receive stacks of drug information papers to read through.

AudibleRxTM gives the patient a simple website where they can go and click on the name of the medication that they just received and listen to a pharmacist describe all of the important aspects of that particular medication in a Medication Specific Counseling SessionTM.  The idea is not to replace the counseling session between the pharmacist and the patient, but rather help educate the patient about the medication so they may take educated and appropriate questions back to their own pharmacist or doctor.


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