Refill Authorization; e-prescribing style

Yesterday I was working in the pharmacy and early on in the day I get a call from a patient asking if her refill was ready to pick up.  I looked in the computer and saw that we had not yet heard back from the doctor.  The lady was frustrated because she had been on the phone with the doctor’s office the day before in the afternoon and they assured her that the prescription would be called in to the pharmacy.  The lady waiting for the refill said she would call the office right away and straighten things out.  After ten minutes, she is calling me back saying that the office told her it was sent electronically to her pharmacy.  I said that that is great; however, it wasn’t sent to us.  I ask her if she ever uses any other pharmacies and she said that a couple months ago she had to pick up something late in the evening so she used the big-box store across town near her house.  I said I would call there and see if it had been called in to that store.  After another ten minutes on the phone, I was able to get a transfer of the prescription that had been phoned into the wrong pharmacy.  I called her back and told her what had happened and that it would be ready shortly.  She was very appreciative of our efforts and said she would talk with the doctor’s office next time she was there to make sure that didn’t happen again.

Yesterday, we went through the above process three times at our pharmacy.  Three times we had sent a refill request for different patients to their doctor.  Three times the doctor’s office sent the electronic refill authorization into the wrong pharmacy.  Three times we had lengthy discussion with patients about the prescription authorization not coming through and then going through the process of tracking down which pharmacy it had been sent to.

Before a pharmacist fills a prescription, they need to have authorization from the patient’s physician.  Quite often a physician will write a prescription that has multiple refills; however, after a certain amount of time the refills will become used up or expire.  At that time, the pharmacist needs to contact the physician and effectively get authorization for another amount of time to fill the prescription.  Ideally, this process is in place to assure the patient is receiving the appropriate monitoring for the condition that is being treated with the prescription medications.

When I began practicing pharmacy in 1987, and for years prior to that, when a prescription needed refill authorization, the pharmacy simply picked up the phone and called the doctor’s office to ask for approval.  The staff would usually take the message and then call the pharmacy back within 24 hours with authorization or a note that the patient needed to contact the office for an appointment.

Sometime during the 90’s the process of faxing the doctor’s office came into existence.  This was nice because it was easy to sit at the fax machine with the requests and just send them off.  This process was much quicker than calling each office and leaving a verbal message.  The issue was, faxes got lost.  Regularly the office would tell the pharmacy that they never received the request, or the pharmacy would tell the office that they never received the approval; however, both the pharmacy and the doctor’s office were positive they had faxed the note.  Perhaps the wrong fax number was dialed, or maybe the fax didn’t go through, or maybe they just really didn’t fax the paper, hard to say.  The thought that faxing prescription refill requests and refill authorizations was going to be this super time saver never came true.

Now, here we are in the 2010’s and the game has changed again.  The mode today is that we send an electronic refill request over the internet to the doctor’s computer, provided the doctor is set up with the service to receive these electronic requests.  If they do not receive electronic requests, we send them an electronic fax, from our computer to their fax machine.  If that doesn’t go through, we print off the request and fax it from our fax machine to their fax machine.  If for some reason that doesn’t work, or if they are one of the few offices that still do not have a fax machine, then we print off the request and call them on the phone and request a refill authorization.

All of this happens in reverse when we are receiving authorization to fill a prescription.  First, it may land in our computer directly from the other office.  Next, we may receive a fax from the doctor’s office, or we may also receive a phone call from the office. 

Many different paths a prescription refill request may travel on its way to becoming authorized and filled at your pharmacy.  I ask this of you, please take a moment next time you are at your doctor’s office and make sure they have your current pharmacy documented in their computer system.  This process will help keep your prescription from being called into the wrong pharmacy.


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DEA Drug "Take-Back" Day

What do I do with my expired medications?
This Saturday, 4/27, from 10am-2pm, the DEA is sponsoring a nation wide drug take back program.  Many facilities will allow you to come and hand them your old and expired prescription medications, including controlled substances.  This is an excellent, and safe way to get rid of those dangerous medications.  Please follow this link to find the location closest to your home.
A common question I get in the pharmacy on a regular basis is, what do I do with my expired medications?

First, let me tell you what not to do with them.
Please, do not give your expired medications to anyone else to take, it is against federal law, in addition to the fact that an individual needs to be evaluated by a health care practitioner and prescribed a medication before they may legally take the medication. Also, please do not flush your medications down the toilet.
Check with your local pharmacy or your waste management program to see if there is a medication disposal program available. If there is no medication disposal program available, then you may take the medications and put them in a container such as a zip lock bag. Then mix in something unpalatable such as kitty litter or coffee grounds. Then add a little water to the mixture. Now, take the container and put it in a brown paper bag and put it in the garbage.


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Circulatory System; Round and Round

On any given day throughout our life, we have a cycle that we complete.  We wake up in the morning, and then, in our own way, we prepare for the day.  This includes many things; however, it usually always includes providing some sort of nutrition to our system and a bit of waste elimination from our body.  Next, we head out for the day.  This can be quite variable throughout our life and can include anything from running a multi-national company to making your way down the hall to the bingo tournament.  Regardless, the point is, each day happens and we participate in it, one way or another.  During this day, we interact with different situations, other people, provide information, receive more nutrition, and deposit more waste.  At the end of the day, we make it back home, or to our resting place for the night, where we rest and become recharged so that we will be in a position to begin the entire process over tomorrow.

Conscious or unconscious, aware or not aware, our circulatory system is flowing through a similar cycle 24 hours a day, 365 days a year, for our entire life.  On average, approximately 5 liters of blood is pumping through our entire circulatory system at any given moment.  This system is comprised of three distinct sub-systems, the coronary circulation, pulmonary circulation and systemic circulation.  All three of these circulatory systems work in concert with each other to provide oxygenated and nutrient rich blood to all of our tissues with the goal of sustaining life.  The system also works to help rid us of all our waste products, whether it be liquid, solid or gas.  What follows is a simplified version of how our circulatory system functions to provide us with our minute by minute energy needs.

Our heart is the pump that keeps this entire system working.  The process begins when our heart pumps oxygen and nutrient rich blood into our blood vessels.  This is the mechanism for carrying these nutrients and oxygen to all of our tissues, from our brain to our toes.  Eventually, after the body has used much of the nutrients, the blood will reach our kidneys (renal circulation) where waste is filtered from the blood. 

From the kidneys, the nutrient poor blood continues its path into the small intestines.  At this interchange, a large transaction takes place.  As blood flows into the small intestines it is directed through the liver where it is then re-directed back out toward the heart.  The liver will filter waste and will also store left over nutrients and sugars.  When we eat, food travels through our stomach and into our small intestines, where our body absorbs nutrients.   The left over matter, after nutrient absorption, will then be eliminated in our waste. 

From the small intestines, our un-oxygenated blood, which is rich in both waste and new nutrients, will be pumped back to the heart.  The heart has a tremendous mechanism which receives this used blood, and then pumps it into the pulmonary system (our lungs).  The lungs will then filter the blood, exchanging oxygen for the waste, and then send the blood back to our heart, rich in oxygen and nutrients, ready to start the process over again.

This system is tremendous at keeping us alive, despite all the stress we put on it.  Our circulatory system provides nutrition and oxygen to all of our tissues, and then works to filter out all of the waste and garbage.  At a moment's notice, our system will respond to our physical needs, whether they be exertion or rest related.  With that in mind, it is important to understand that if something does not work appropriately at any point along the system, the entire system is affected.

Our heart is the pump that keeps the blood flowing.  If the heart has some irregular rhythm, or slows down or speeds up, the amount of blood being circulated will be affected.  An irregular rhythm may also lead to a clot that may clog one of the circulation pipes and cause a stroke or heart attack.

Our blood vessels are the pipes that circulate our blood to all of the tissues.  There are many different reasons that will cause the vessels to either relax or constrict which will affect our blood pressure.  This in turn affects how hard the heart works and changes the level of circulation.

Our kidneys are similar to the faucet in the house.  If, for one reason or another, the renal circulatory system is not working well, the filtering system may back up and not be eliminating the waste products as well as it should.  This then affects the entire circulatory system.

Finally, our lungs are similar to an air filter system.  What happens when the air filter becomes clogged?  Well, the air does not get filtered and it is much more difficult to get the oxygen we need for survival. 

Of course, we have medications that affect each and every system.  These medications work to help our circulation flowing as best as it can.  Remember, we only have one chance at keeping a strong and healthy circulatory system.  Understand that each and every time we breath, eat or drink we are providing energy and nutrition to our body.  Our circulatory system then needs to either use that nutrition, put it into the waste pile, or store it for later use.

Following is a list of different blogs that discuss other aspects of our circulatory system.

Heart Rhythm
Calcium Channel Blockers
ACEI’s and ARB’s
Blood Pressure
Renal Function


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Acute Coronary Syndrome

I remember one time, when we were living in the mountains of Northern California; I stopped by to check on my Mom and Dad.  It had been snowing pretty good for a few days and even though they lived in the center of town and we talked on the phone every day, it was still nice to stop by and make sure the snow wasn’t causing too much trouble.  As I got out of my truck I could see that Dad was shoveling the snow off the driveway back to his garage.  Dad was about 78 or 79 years old at the time; however, he had always been in relatively good health and walked voraciously. 

I noticed that as I came up, he took a rest and reached in his pocket and pulled out this little bottle of pills and put one under his tongue.  I asked him about it and he said that his doctor had told him that whenever he begins to feel his chest pain to go ahead and dissolve one of these nitroglycerin tablets under his tongue and it will help the pain.  I asked him if it works very well and his response was that most of the time it helps, and sometimes he needs to take a second pill a few minutes later.  This concerned me a little so I asked him how often he needed to use these little pills.  He then told me that on any given day he will use about 6 or 7 tablets.

Six or Seven Tablets!  As a pharmacist I was exasperated by the thought that a doctor had told my dad to go ahead and use these as often as he needed.  What exactly is going on that is causing this pain, and is it this particular doctors thought that we will just wait for my 79 year old Dad to have a heart attack or a stroke?  We did a follow-up phone call and a visit to the doctor in the next couple of days and the doctor adjusted Dad’s maintenance medication so that the chest pain was much less frequent. 

The doctor went on to explain again that it was not his intention for my Dad to use these little nitroglycerin tablets as a maintenance therapy.  Yes, if the chest pain comes on go ahead and use them to help treat the chest pain; however, if he needs to use  2 or 3 tablets in a row, or needs to treat the chest pain on a daily basis, please call the office so that we can take another look at what is going on.  Within the next 12 months Dad had a cardiac bypass surgery which relieved the chest pain completely and he lived another 7 or 8 years, free of chest pain.

I can’t express how important it is to be aware of the barriers to effective communication when counseling patients about their medications; however, that is the topic for another blog that we will see in the near future!

What dad had been experiencing was Acute Coronary Syndrome (ACS).  ACS is a syndrome brought on by decreased blood flow to the heart.  This can be described as the crushing pain one feels during a heart attack, or the light chest pain one may feel while at rest or performing light physical activity.  Please, if you experience chest pain at rest or during light exercise, see your doctor as soon as possible and discuss this with them.

Atherosclerosis is the most common cause of ACS.  Atherosclerosis involves the buildup of plaque along the wall of the artery which hinders blood flow and circulation.  Please take a moment to read my blog that describes the process of atherosclerosis.  Quite often, a patient is not diagnosed with ACS until they appear at the emergency room with chest pain.

In management of a patient with ACS, the focus is on three main therapies.  First, the patient needs to be stabilized, second, the chest pain needs to be relieved, and third, anti thrombotic therapy needs to be provided to prevent a clot.  My focus for this discussion is on the third step of therapy management, the prevention of a clot.

Currently we have three categories of anti coagulation medications available.

The first category is the type that blocks the production vitamin K which in turn inhibits the production of clotting factor.  Warfarin is in this category and is considered a vitamin K antagonist.

The second category is the medications that interfere with thrombin and inhibit the clotting cascade at one point or another.  Some examples of medications in this category include (but not limited to) ribaroxaban, apixoban, dabigatran, and enoxaparin.

The third category of medications act on the platelets, which are a type of blood cell that help damaged arteries by forming a plug to prevent bleeding.  The anti-platelet medications work to inhibit platelet aggregation in patients who are at risk for developing blood clots in their arteries.  Clopidogrel, prasugrel, dipyridamole and aspirin are considered members of this category.

Both clopidogrel and prasugrel are indicated for the treatment of Acute Coronary Syndrome while dipyridamole and aspirin are indicated for prevention of a thrombotic stroke event.  To learn more about these medications, visit and LISTEN to the Consumer Medication Information for each specific med.
  • Aspirin/Dipyridamole (Aggrenox-TM)
  • Clopidogrel (Plavix-TM)
  • Prasugrel (Effient-TM)
  • Ticagrelor (Brilinta-TM) 

  • Apixaban (Eliquis-TM)
  • Dabigatran (Pradaxa-TM)
  • Rivaroxaban (Xarelto-TM)

                Vitamin K Antagonist
  • Warfarin (Coumadin-TM)

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Interview with AudibleRx

“The druggist is a counselor, confessor, and adviser, and an able and willing missionary and mentor whose learning is respected, whose occult wisdom is venerated, and whose medicine is often poured un-tasted, into the gutter.”  -O. Henry (1862-1910) writer and pharmacist

-This quote is from the top of website. 

My new colleague, Jason Poquette, R.Ph., is both a writer and a pharmacist.  Jason writes on his own website, The Honest Apothecary, where you will find up to date news and comments regarding the pharmaceutical industry.  In his own words, “The site is dedicated both to patients and to my fellow pharmacists who labor in the trenches and front-line battleground of the retail pharmacy profession.”

I recently had the privilege of sitting with Jason for an interview where he took the time to understand what AudibleRxTM is all about.  This experience was rewarding for me on many levels.  First, it is a fantastic way to spread the word about medication education.  Next, this process helps the reader understand all of the different ways AudibleRxTM may be put to use in order to provide medication education.  Furthermore, this interview required for me that I take the time to once again understand why I am doing what I am doing. 

Please, take a few moments to read the interview and make a comment on Jason’s website.  Next, you may want to consider following The Honest Apothecary on his blog and on twitter.  Jason has daily updates that will keep you both informed and entertained at the same time.


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Is It Time For My Pain Pill Yet?

So, you just had some sort of surgery and you are on your way home from the outpatient surgery center.   These days, quite a few big surgeries are performed on an outpatient basis.  What this means is that you are going to be at home for all of your recovery.  In my opinion, most people are not fully prepared for the process or recovering from an outpatient surgery.

The process is, you show up at the surgery center at some crazy time like 6:30 in the morning, still in your sweat pants and tennis shoes.  After completing all of this paper work, most of which is exactly duplicate of what you have on file at our doctor’s office, you get to sit down and wait in the waiting room for another 30-40 minutes.  At some point, a nurse pokes their head through this big door that leads to who knows where and asks for you to come with them.

Okay, so you say your good byes to the nice soul that got up at 6am to drive you to the surgery center and head off into the unknown world of surgery behind the door.  After changing into this little surgery gown, the best part comes; now is the time that you are laying on the hospital bed and the nurse brings in the blankets from the blanket warmer.  If you have ever experienced this feeling, you know what I mean.  The warmth and weight of these blankets is sweeter than cotton candy.

Count backward from 100: 99, 98… out.  The next thing you know a few hours have past and you are waking up with this incredibly groggy feeling in the recovery room. “How do you feel?”, “What is your pain number?”, “Would you like some ice chips?”, “Do you feel any nausea?”  It feels like you just got there and here it is, 5 or 6 hours later, and the nurse is calling your nice driver to come and pick you up.  In your mind you are feeling, “Wait, I just woke up and you are sending me home?”

You receive a binder full of discharge instructions and then sign a paper saying that you understand each and every word.  Before you know it, we are back to the first paragraph, in the car on the way home.  Again, you are now preparing yourself for the process of surgery recovery, in your home with your family. 

Finally you get home, get settled in an easy chair in the living room, turn to your loving caregiver who has taken care to get you settled in so nicely and ask, “Is it time for my pain pill yet?”  Well, hopefully, you have already picked up your pain medication from the pharmacy and they have counseled you about all of the important information about your prescription.  After an outpatient surgical procedure, chances are, you will experience some significant pain for the first 48-72 hours.  After that, depending upon the procedure, the pain may begin to decrease.  

It is important to follow the directions on the label of your prescription bottle for dosing your pain medication, especially for the first couple days.  Go ahead and treat the pain as prescribed.  After 3-4 days of treatment, the need for pain medication may decrease.  It is important to understand, unless otherwise specified by your doctor, that your pain medication is for the acute surgical post-operative pain only.  This means that over the course of usually 7-10 days, your need post-operative pain medication will become less and less. 

If you notice that your pain does not begin to decrease, or worsens, after 3-4 days of rest and recovery, please call your doctor to discuss this with them.   Your doctor will advise you on how many days you should rest before becoming active after your surgery.  This is an important process for a complete recovery.  It is common for folks to begin to feel much better after 7-10 days and want to begin normal activities.  If you begin your normal routine too soon, you may harm your recovery process and cause further injury. 

In the past, most all surgeries were performed in a hospital followed by an extensive period of rest and recovery….in a hospital bed in a hospital.  Many factors have led to the process described above of patients having their surgery, waking up, and then spending the next two weeks recovering at home.  If we were in the hospital we would surely rest because there really isn’t anything else to do.  At home, we have distraction after distraction which may compromise our recovery. 

My point here is, prepare yourself and your family for your recovery.  Don’t sell yourself short by decreasing your recovery time just because you feel you need to get up and work around the house.  Treat your pain as necessary, especially for the first 3-4 days post-surgery, and be grateful to your loving caregivers who bring you soup and take care of you during your recovery period.

Please feel free to share your surgery recovery stories in the comment section below.  Thanks for your participation!

If you would like listen to any Medication Specific Counseling SessionTM for any of the pain medications usually prescribed for post-operative pain, please register to becomea member  of AudibleRxTM and have full access to all of the sessions for a full five years.

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