The Chicago Tribune did a really nice piece of investigative reporting on pharmacies. What thy found is scary but not too surprising as it is hard for retail pharmacies to make money while saying no.
The Tribune reporter walked into an Evanston CVS pharmacy carrying two prescriptions: one for a common antibiotic, the other for a popular anti-cholesterol drug.
Taken alone, these two drugs, clarithromycin and simvastatin, are relatively safe. But taken together they can cause a severe breakdown in muscle tissue and lead to kidney failure and death.
When the reporter tried to fill the prescriptions, the pharmacist should have warned him of the dangers. But that’s not what happened. The two medications were packaged, labeled and sold within minutes, without a word of caution…In the largest and most comprehensive study of its kind, the Tribune tested 255 pharmacies to see how often stores would dispense dangerous drug pairs without warning patients. Fifty-two percent of the pharmacies sold the medications without mentioning the potential interaction, striking evidence of an industrywide failure that places millions of consumers at risk.
Failure rates ranged from 30% to 70% depending on the type of pharmacy. The independent mom and pop stores did the worst.
Some pharmacists who were tested got it right, coming to the counter to issue stern warnings. “You’ll be on the floor. You can’t have the two together,” said one pharmacist at a Walgreens on Chicago’s Northwest Side. Said a Kmart pharmacist in Rockford: “I’ve seen people go to the hospital on this combination.”
But in test after test, other pharmacists dispensed dangerous drug pairs at a fast-food pace, with little attention paid to customers.
I think this is a business model problem as much as a training problem. Most retail pharmacies make their drug counter money on dispensing fees. Each bottle of pills that goes out earns a fee. Each bottle of pills that sits on a shelf does not earn a dispensing fee; instead it costs money to sit on the shelf. Widget based payments lead to an incentive to sell as many widgets as possible as quickly as possible. More realistically, most pharmacies are not the profit centers of the retail store. Instead the profit occurs as the customer with the prescription buys a couple rolls of Lifesavers and a bottle of Moxie tonic on the way out to make the medicine taste less bad.
Specialty pharmacies like a nuclear medicine pharmacy have the incentive to get it right as all that they sell is a limited number of high value doses and nothing else. If they develop a reputation with their expert buyers that they screw things up in ways that hurt patients or cost money, they lose their business. It is a very different business model than retail public facing pharmacies.
It is hard to monetize a reputation of being always right even when being right means saying no a lot and sending the customer back into being a patient and forcing a new interaction cycle with their doctor. Good enough is often good enough. Sure, there is probably a training need identified by this investigation but I think the underlying business model and its incentives would need to be re-examined.
gvg
I know the pharmacists are supposed to catch that, but in this day and age I would expect there to be a software built into their computers that pops up the warning to help. In fact there should be something that notes if the patients have the prescriptions filled at different times…..if you had drug 1 several months ago and now come in with drug 2, a warning should pop up where the pharmacist would then ask you if you have stopped taking or finished taking drug 1. doctors ought to have it too.
Wouldn’t catch people with multiple specialty docs or who go to the closest pharmacy that day or those who doc shop etc, but it would catch most.
I am not sure they would need to go back to the doctor. most pharmacies will call your doc about something like that and the doc can send a new prescription.
Richard Mayhew
@gvg: The software should catch it (at that point if it is fool proof, quite a few pharmacists are out of a job replaced by happy smiling techs to provide a human warmth/interaction) but catching an error involves back and forth. It is a hassle
MJS
I’m not sure how this is the pharmacist’s issue. Personally, if a doctor prescribed two medications for me, I wouldn’t listen to a pharmacist tell me not to take them together (assuming I even knew the person behind the counter was an actual trained pharmacist, and not an assistant of some level). And if I’m the patient who went to one doctor for one of the prescriptions, but another for the other, and I didn’t inform the second doctor of my current prescriptions, then that’s on me. Sure, doctors make mistakes, and it’s nice to have someone there to catch those mistakes, but the bottom line is that this is the doctor’s mistake.
Mathguy
[Speaking in my GOP moron voice] “The solution is deregulation! Remove the chains! Oh, and throw in a tax cut!”
Duke of Clay
@MJS: In my experience, the pharmacist calls the physician to be sure he/she is aware of the problem and to confirm that he does want the two dispensed together.
satby
@MJS: Several chain pharmacies use their Rx checking software as a selling point, and it’s part of the standard of practice for the pharmacist to know and alert on drug interactions. This should be a standard of care across all health practitioners, because people do go to different doctors and do forget to tell what medications they’re on. So it is on the pharmacist to alert someone about a potentially lethal combination, and if one did and you ignored them, your bad result would be on you.
satby
@Duke of Clay: And yes, most would confirm with a doctor, and most doctors would change one of the Rxs as a result. The problem in this story is that a presumed check and balance safeguard was not followed at all in many cases.
raven
@MJS: So the point of having a degree in that are is what?
MJS
@satby: Understood, but I guess I don’t believe that the ever-younger looking people handing me my prescriptions, and asking me if I have any questions when they do, are all actual pharmacists. Maybe they are. But I can also tell you that were I to get the two prescriptions from the same doctor, took them and suffered because of it, I would not be placing the blame (i.e., suing) the pharmacist.
satby
@MJS: Pharmacy techs work under the direction of the pharmacist, and all medications are supposed to be verified by that pharmacist before dispensing, because that’s the law as well as the standard for medical practice. So even if the kid ringing out your Rx isn’t a pharmacist, your prescription was supposed to be vetted by one before it was even filled. Both the doctor and the pharmacist are liable for medication errors.
Cermet
Then what in the fuck do we train and over pay this profession for? Also, have these dumb asses ever heard of computers (really programs/software) that should exist that automatically looks for such issues? If such isn’t available then shame on these ass-wipes for not developing such programs. This isn’t just not acceptable but is criminal – this is what they are solely trained to do!!! What, do they hand mix all the chemicals and make pills themselves and are to busy doing that to cross-check known reactions between drugs (LOL!!!) They don’t even count them anymore. This is simply insane and reprehensible.
Frank Wilhoit
The title of this post should have been something more like “How To Get In Trouble Saying Yes” and would have been vastly more pertinent wrt opioids.
I had an extended relative who doctor-shopped to the point where she had four different doctors, four different diagnoses, and a total of fifteen scripts. In consequence, she had a pukin’ spell that scared her straight. Fortunately the consequences were no worse, although this was back in the days when the opioid-of-legal-abuse-of-choice was Darvon (propoxyphene), which was quite literally given out like candy and recommended both for pain and as a sleep aid, with the gloss that it was “perfectly safe” (the patient hears, “if the first one doesn’t work, take another, etc.”). Plus ca change, and all that.
Karla
@MJS: They’re not all actual pharmacists at the counter (some are techs, some are interns), but if you have a question they will get the pharmacist to talk to you. (An advanced intern will be able to answer some questions him/herself.) A Pharm.D. is typically a four-year post-grad program (there are some programs that combine a bachelor’s with the Pharm.D. in something like 6-7 years), and retail pharmacy doesn’t require a residency, so a pharmacist in a retail setting may be as young as 26 or so. But s/he will know a hell of a lot.
satby
@Cermet: As Richard points out, this is more on the business model and the relentless drive to reduce costs and increase profit. Overworked pharmacists and replacing pharmacists with techs lead to more mistakes. I bet some MBA somewhere said to just fill the scripts the doctor writes and not tell people no, because very few people appreciate the risks you’re trying to save them from.
For proof, see last election.
Karla
@satby: Exactly. Well, the MBA doesn’t tell them to just fill the script, but sets up the conditions that that’s what’s going to happen sometimes by mistake.
Cermet
@Karla: This article isn’t about such a crazy person but a single doctor/pharmacy and the pharmacist failure. If people want to kill themselves, no one can really do anything to prevent that but the sole purpose of buying at one pharmacy and using one doctor is often sited as a way to protect one’s self from such a simple and easy to catch mistake – last I checked, no one expected the patient to go to pharmacy school before being allowed to get/take a prescription …
Karla
Cermet, I don’t see anything I wrote that indicates I said this article was about a “crazy person.” I merely clarified who the people behind the counter were and a little bit about pharmacist training. Patients aren’t expected to know everything about their medications; that’s exactly why part of the sale process is to ask the patient if they’d like to talk to the pharmacist. Obviously, people behind the counter make mistakes, and should make fewer, ideally none.
Emily68
I read the comments at the Trib story. One guy blames Obama. Another one points out how it’s really the patient who needs to take responsibility, as if we all know about drug interactions better than the doctor or pharmacist. Good grief.
amygdala
Drug interaction software, in its current incarnations, is useless. It routinely spits up so many interactions, most trivial, that significant ones like this–statins have a lot of interactions–get lost in the noise.
There are a few EHRs that make care better, but most of them suck. They’re designed for billing, not patient care, and relegate docs, nurses, pharmacists, and other highly trained individuals to data entry clerks. And they don’t do a good job of that, either.
Raven
@Emily68: never read comments, never!
RSA
The article does a nice job of laying out all the factors that contribute to the problem. It’ll be hard to fix. As Richard points out, there’s a business problem as well as a training problem.
I’m guessing that software systems contribute to the problem as well, flagging all possible interactions, even minor ones, so that techs and pharmacists get used to ignoring most, if they have time to look at them at all. (ETA: As @amygdala says.) It’s easy to see how mistakes can be made and well-understood by human factors people.
And while we customers are on the receiving end, in aggregate we’re contribute to the problem if we treat a trip to the pharmacy like a trip to the bank or a fast food restaurant, valuing speed and cost more than accuracy. That’s tricky, too, because as Richard points out no one gets credit if something bad doesn’t happen in these situations.
Joe Falco
OT but I make money telling people no, you can’t build whatever you want on a piece of land; you have to get the land rezoned or acquire a special use permit.
Dr. Ronnie James, D.O.
1) Most pharmacists know much more about pharmacology and potential interactions than most doctors. My current inpatient family med service and my wife’s ED both involve pharmacists in any decision-making re: potential medications for patients. They’re a great safeguard.
2) interaction checking software is nearly ubiquitous in hospital EMRs and mobile platforms. The Medscape and Epocrates apps offer it. Most attending physicians I know, if an interaction pops up, they will plow ahead with their planned medications unless the potential interaction is guaranteed to be something really really bad.
3) As far as whose responsibility this is, I’d think writing two prescriptions with a serious interaction is the doctor’s responsibility, but filling two is the pharmacist’s. It’s not inconceivable for a patient to bring in two conflicting scripts from two different doctors.
4) if this becomes a more serious problem, I’d expect to see the big provider networks become bigger players in pharmacy.
FlyingToaster
My pharmacist (CVS) caught a potential allergic reaction to a new med and called my doctor; then when I came to pick up, steered me over to the consultation counter and walked through “if you have a reaction, here’s what you’re going to do” routine. Fortunately, my doctor had pulled up the studies showing that this formulation doesn’t spark the reaction, and it didn’t, and I finally had bp meds without side effects. There’s a couple things CVS doesn’t carry, so then I take the scrip uphill to Walgreens.
I wonder if this is where the Chain Stores do beat out the mom-n-pops. It certainly beats out the insurer-choice mail-order joint where HerrDoctor gets his meds. They don’t check squat.
And, FWIW, many of the register folks at the pharmacy are pharmacy assistants. It’s an associate degree field, and they’re pretty meticulous. My niece was a pharmacy assistant; it’s how she worked her way through nursing school.
Van Buren
Didn’t It’s a Wonderful Life cover this, more or less?
On a serious note, this is why I use a momnpop pharmacy.
Sister Rail Gun of Warm Humanitarianism
@Karla: I think Cermet hit the wrong Reply. That looks like a response to Frank Wilhoit’s doctor-shopping comment.
@MJS: The pharmacist is the one expected to be the most on top of the current literature on subjects like drug interactions and why a drug is temporarily (or permanently) off the market.
amygdala
@Dr. Ronnie James, D.O.:
This is absolutely true, especially as med school pharmacology courses have been watered down in recent years. We had a full-time pharmacist at the HIV clinic I used to staff and he was amazing. HIV meds have tons of serious interactions, some published, but even more not studied and requiring deep knowledge of how the drugs are metabolized. I relied on him a lot when I needed to prescribe around ARVs.
Ohio Mom
My neighbor is a pharmacist at the VA. Her main assignment is to review patient charts to make sure no one is taking an untoward combination of medications — her patients have multiple and complicated conditions requiring many prescriptions. It can take her an hour or so to review one patient’s history.
I don’t know how many mistakes she finds but obviously it’s been determined that hers is an important service.
germy
Here’s a story I heard last Thanksgiving:
One neat trick a supermarket chain/pharmacy dept. did to double their profits: Last year, my niece got a prescription for something. She took it for about a year. Apparently, a memo had come down to the supermarket pharmacy that whenever someone got a prescription filled, they’d receive a printout (along with the side-effect warnings) advising them to take a supplement. “If you take medication A, you may become deficient in vitamin K!” “If you are currently taking medication Z, you need to supplement with vitamin A!”
The printout she received told her she needed to take melatonin. I think she took it for about half a year, before she finally gave up. Some absurdly unsafe amount, like five milligrams or something.
It’s a miracle she didn’t crash her car; the stuff made her a zombie. But I’m sure there were high-fives in the conference room the day the supermarket/pharmacy management invented that profitable bullshit.
Capri
The burden of keeping oneself safe is falling increasingly on the patient – usually the person with the least knowledge. Right now there is a commercial for a drug on TV, and in the disclaimer at the end of the ad it says you should tell your doctor if you’ve had an organ transplant. Really? Don’t you think that would come up in the history and be something your doctor is aware of before getting out the prescription pad?
gene108
@FlyingToaster:
I have a couple of mom-and-pop pharmacies open near by. They are set up with a local corner store mindset – buy paper towels for $ 0.50 and sell for $1.50 – and not so much to be quality medical dispensers. They do not have the institutional oversights a large retail pharmacy might try to build into its business practice.
As far as pharmacies not catching mistakes, I have seen my local CVS at peak times and the pharmacists are slammed getting orders filled quickly, because I am sure there is a corporate directive to not keep the customer waiting.
It is one of those cases, I think, where an impatient consumer culture runs into something that is better done at a slower pace, but can be done good enough at a quick pace to keep most people happy and not suffering from bad drug interactions.
low-tech cyclist
@amygdala:
But why does that have to be the case? Surely there can be a way of coding and flagging the potential severity and relative frequency of the interactions. Is this just a ‘because we haven’t been doing this for very long yet’ problem, or are there structural reasons why this isn’t easy to solve?
Barbara
@Duke of Clay: Bingo! Actually, the process most likely to catch this interaction is the insurer’s pharmacy benefit manager, which should be the common point of interaction for all drugs dispensed to a single person even if they are prescribed by different doctors and dispensed by different pharmacies, which is a not uncommon scenario. If, however, you are paying cash, unless you are receiving and filling both at the same time, which would not be typical, the only way this would be caught is if doctors ask which drugs you are taking before prescribing, and if you remember the name of the drugs you happen to be taking (assuming you might be going to more than one doctor). In this case, one drug is for a chronic condition and the other is for an acute condition. Thus, the doctor (Minute clinic?) assessing your acute condition should only prescribe this antibiotic after ruling out your use of the kinds of drugs that have known interactions with it. In my view, without knowing more, it is unfair to blame the pharmacy. As in all risk management and safety processes, there should not be just one actor with the potential to save the day. It requires multiple checks at multiple levels, any one of which would be sufficient.
Gin & Tonic
My wife is a pharmacist, and has worked at several CVS locations at various times, usually just to supplement her income – she is trained and experienced in hospital/clinical settings where she’s spent most of her career. She hates retail because of the pace. As mentioned upthread, it’s all about time to fill, and you spend so much of that time dealing with insurance issues (a bane on “pharmacy benefit managers”) that you’ll just fall further and further behind dealing with clinical issues. Most retail settings also have the pharmacist on a 12-hour shift, and you just naturally lose focus.
This is not to excuse missing the interactions. My wife prides herself on her clinical knowledge and continuing education, and would find these lapses appalling, but not everyone is the same.
Barbara
@low-tech cyclist: Partly this is just the litigation mindset of all actors in the medical industry. Failing to notify anyone of any potential risk could be viewed as a malpractice risk. Providing percentages (e.g., 50% of patients versus .5%) would obviously be helpful. However, some doctors and pharmacists get so annoyed they just turn all warnings off rendering the system totally useless. Another approach would be a “smart” system that is geared to an individual’s use over time, so, basically, a doctor teaches the system to prioritize the circumstances he considers to be most important based on the patients he or she treats.
Doc H
Moxie! (though tbqh, I’d rather chew up methylprednisolone tabs than drink it)
Anonymous At Work
Automation is coming to the pill-counting side of pharmacies. Pharmacists will make their money on the interactions and the customer interaction/working with patients to take their medicines properly.
Weaselone
@Capri:
I have to admit the “personal responsibility” mantra is getting downright weird. It appears to be increasingly applied in a back asswards manners. For example. Leave a gun lying around the house and a toddler blows their brains out. Nobody’s fault. Coal mining jobs get shed for decades, you refuse to get trained to do anything else, you jettison miner’s unions, vote for people who promise the impossible in order to screw you over and it’s environmentalists, liberals and that black guy in the White House’s fault you can’t get a decent paying job. Meanwhile, Pharmacists who are trained in the specialty and one of whose value adds is supposed to be catching adverse drug interactions fail to do their job. Take personal responsibility for catching possible adverse reactions. Get screwed over by a financial advisor. Too bad, should have done more market research. It’s like the people you supposedly pay to act as agents, can’t be expected to act as agents. You have to do your job and their jobs too and a certain group of people seem to be OK with this. It’s OK if you get screwed over by people who you hired to represent your interests.
Ruckus
This is a prime area for EMR. Electronic medical records. At the VA this is built into the system. Drug interactions, as I have been told, can not be prescribed together. And your drug history is on line as well so that a current drug is shown so that a new one can not be prescribed if it interacts. Now of course you can go to docs outside the system and take things without telling the VA but that is currently, and probably always outside their control, same as if you have 2 or 3 private docs with different pharmacies.
Nunca El Jefe
@Cermet: replying to you, because I understand the complaint, but really a question for Richard: how much of this is driven by differences in software platforms for medical records? I know a guy that was running the project for the IT/IS infrastructure for the new university of Chicago hospital and he talked a lot about how difficult the integration between systems was. Is that kind of thing playing a role in what Cermet is taking about?
amygdala
@low-tech cyclist: As Barbara pointed out, there are the legal concerns. I’m biased, but it’s not easy to write a program to capture judgment, especially with medication interactions, which are a constantly moving target.
As an example, say I have a patient with hard-to-control epilepsy on two medications for the seizures. And the patient is also on an antidepressant, depression being common in folks with epilepsy. Doesn’t matter if it’s well-documented in my last several notes, plus the PCP, that the patient is tolerating the meds well. I’ll get several screens worth of harping about additive CNS side effects. And in the worst of these sorts of systems, it will make it hard to refill the prescription, which makes the patient’s visit last longer, throws me behind schedule, and hassles the pharmacist.
The reason the VA’s EHR works is that it’s designed for patient care. Nearly every other EHR is designed for billing, and therein lies the problem. They don’t get input from patients or end-users; they get it from the coders and billers.
raven
@Ruckus: Fuckhead gonna take care of da vetrans. I hope he blows the whole goddamn thing to pieces!
low-tech cyclist
@Weaselone:
Seconded. We live in a very complex society. We can’t learn to do, or even adequately review, very many other people’s jobs. I can’t second-guess my electrician, let alone my doctor. My time is better spent being good at designing representative samples for statistical surveys, and paying other people what they’re worth to do their complicated jobs. Making me responsible for them is absurd.
raven
@amygdala: They’s gonna take care of that!
amygdala
@Weaselone:
God, this, times ten bazillion. Never did I imagine that one of the most enduring benefits of a medical education would be the ability to safeguard my own care and that of family and friends. But there it is, and all my doc and nurse friends say the same thing. Within the system, the practitioners are too pressed for time using badly designed systems on unrealistic schedules created by administrators. When you go home, and have the 15 or 20 minutes to crank through the med list of a parent or neighbor or what have you on a free app that I still update on my phone, even though I’m retired, then you serve the role the system no longer allows. It’s ridiculous.
Kay
@Frank Wilhoit:
It’s different now in abuse-heavy parts of the country. I have a relative who is an addict too and the ER physician was completely honest with her, told her she was drug-seeking and wouldn’t give her what she wanted. She dismissed him as an idiot and spent the whole next day looking for doctor who would give her what she wanted. They’re addicts. They’re really determined. It’s a full time job. It’s a tough, tough dependency because it’s “medical” and they think that makes them better than addicts of street drugs. It adds this gloss of legitimacy.
amygdala
@raven: That’s what I’m afraid of. When the ACA passed, the EHR requirement, without associated standards, really worried me. I know why they couldn’t do it, but if I were running the world, I would have made the VA system the national standard. Practitioners and patients like it and it doesn’t require fancy hardware to run. There’s literature showing it improves outcomes. It’s open-source. Hell, let the billing people write a module to deal with their needs, but leave the rest of us alone.
It could be taught in every school of medicine, nursing, PT/OT, pharmacy and whatever else in the US as a graduation requirement. And as the system evolves, then make relicensure at the state level contingent on showing you’ve passed the update course.
This would get around the interoperability problems, create datasets which could be used to track outcomes, disease trends, and the like. But God forbid the technology industry be prevented from wasting money and a lot of people’s time on their criminally badly designed software.
Stan
I work in regulation….. not pharmacies but close enough.
I am not a lawyer but I don’t understand why State or federal agencies don’t use this type of ‘secret shopper’ method more often.
Yarrow
@amygdala: There are free online drug interaction checkers. I always ask the doctor about interactions. Then I ask the pharmacist about interactions. And then I go home and put every medication and supplement into several of the free online drug interaction checkers. After that I google the new medication to see if something new shows up. I’ve lost confidence in the medical and pharm staff to help me. It’s not their fault – they’re generally doing the best they can within the job and time pressure’s they have. But I’ve had enough bad experiences I don’t want to rely on them only.
One thing I learned recently, because of a terrible experience, is ALWAYS ask how to get off a medication. Is the medication addictive? How long does it take on the medication for that issue to come up? How do you come off it? Taper? Stop suddenly? Need a supplemental medication to get off the first medication? Etc. You may not get the info you need if you ask, but I’ve now learned to ask.
cynthia ackerman
I thought this was going to be advice for John in his new career in the face of loudmouth bigots.
Barbara
@Anonymous At Work: Automation came to the pill counting side of things 30 years ago.
Brachiator
@Richard Mayhew:
But why would a doctor prescribe the two drugs in the first place? The setup doesn’t quite make sense.
Yeah, software ain’t perfect, but I would really like something to back up the pharmacist. Drug/drug interaction and Drug/Food interaction should be standard checks.
I’m also curious as to whether the drug interaction literature that typically comes with a prescription noted the specific danger of taking those two drugs together.
egorelick
So many moving parts in this story. First understand that every single one of these interactions was alerted by software at the chains. In other words, every single dispense had at least one or possibly two (depends on the timing of how they were entered into the system) warnings displayed that the pharmacist had to override. But be aware that the average number of overrides for any prescription is a little less than 2. The average number of warnings/overrides is greater than 3 for a typical system. The warnings are often just alerts with no additional information. The UI is crappy to view the additional information in almost all cases. Viewing and acting upon an interaction like this would take between 5 and 15 minutes (if everything goes smoothly) and will probably guarantee the next 5 to 10 customers will miss their promised time. In addition, the system will show misses for the next 30 minutes to 2 hours depending on multiple factors as the bulge in the python works it way out. Some systems will allow you to sideline a workflow task, but it could be hours before the pharmacist has time to deal with it. This has to be documented and communicated to the patient which will likely take at least 5 minutes and may involve cursing (from the patient; we usually confine our profanities to our inner dialogue). I have not looked up the rate of these interactions actually resulting in harm, but I do know they are some of the most serious out there. There is no chance that harm results in more than 5% of the cases when actually dispensed would be my guess. IOW, 95% of the time for the most serious issues, nothing happens. Of the interactions alerted to on my screen, less than 5% mean anything at all. My cynical take is that the company wants to be able to blame me if anything goes wrong and does not really believe this is a safety issue (because if they did, they would certainly have made changes). So when I blow off an alert, which I shouldn’t, the chance that I will face any consequences is less than 1 in 1000. When harm is done, the chances that someone will actually follow up and trace it back to the dispensing pharmacy is pretty low (less than 50% but I do not know how much less. We are human, 1 in 1000 negative re-enforcement is not enough to change behavior and the actual number is closer to 1 in 10,000 (for the totally oblivious pharmacist). So we have humans doing a checking job where you cannot do your job at all well and likely have few if any consequences in the short term (except for negative one when you try to do the job right given the limitations of the system). I could go on and on, but although this concerns me, it probably won’t change my practice (and I believe I am conscientious and work in an environment with less safety issues than many).
amygdala
@Yarrow: The challenge is how up-to-date they are, especially for folks on treatment for rare conditions. As a physician, I’m horrified that patients have to shoulder this kind of burden. I’m supposed to be there to help them–my pharmacist friends feel the same way. There’s only so much that technology can replace. I never minded going through patients’ pill boxes with them. You learn a lot about how people take their meds that way and can sometimes simplify their routine. But it takes time that is increasingly not available during patient visits.
You’re wise to ask about tapering meds. Even drugs than aren’t addictive in the formal sense may need to be tapered in order to avoid problems ranging from the mildly annoying to life-threatening.
amygdala
@Brachiator:
It’s not possible to know every drug interaction. That goes quintuple-time for PCPs, who deal with hundreds of meds. I used to pick up interactions in my field fairly frequently, but as a specialist, wasn’t dealing with nearly the breadth and number of meds as the PCP. And that’s not even including the fact that new interactions of old drugs come up all the time.
As for package inserts, they’re legal documents more than anything else, the drug company doing CYA. It may well have been buried in there, but not in a way that that’s easy for the general public to access.
Barbara
@Kay: When I was in high school, i.e., the 1970s, there were other legal drugs of abuse and doctor shopping and multiple prescriptions from multiple doctors was a known way to get drugs. I had a friend who was able to get a now banned amphetamine from four separate doctors, most of which she sold, although she had to find new ones periodically because most would accept her explanation for only so long. She always found someone else. What I learned was that, whatever kind of drug you needed, it always started with, “Well, you see, I was in a car accident . . .” The difference between then and now is that you don’t have a determined group of users coming out of the woodwork to complain about their legitimate need every time someone threatens to make it harder to get the drug. Her drug of choice was banned. Now, to get the same effect that she got legally you would have to use methamphetamine or maybe Ecstasy. I used to tell my sister, who was this woman’s “real” friend (I was a hanger on) that anyone who had a “favorite” drug by definition had a drug problem. Eventually my own sister wised up but we used to fight about this all the time until I stopped hanging out with them because I couldn’t stand the way she treated her four year old child. I was only 17. You don’t need to be a genius or have a lifetime of experience to know that these drugs are addictive and mostly bad news.
Jeffro
Btw if people are in the mood for some more great long-form journamalism, TPM has an excellent series up on the Privatization of Everything.
Chapter 4, about Pearson Education’s rise, is pretty chilling…these big corporations can inflict so much harm, so quietly…
Brachiator
@MJS:
I don’t understand your reasoning. If the pharmacist said not to take the drug, I would certainly want to know why, and would talk to my doctor, or even have the pharmacist make the call.
And I don’t know that I would care whether the person behind the counter was an assistant. But in any event, I would not guess and would ask about the person’s credentials.
Meds are complicated. I would be grateful as hell to have an extra checkpoint at the pharmacy level.
ETA: I had a specialist prescribe a drug for me. My primary care physician looked at what had been prescribed, had a different opinion, called the specialist and had the dosage level modified. So, here, the primary care physician backstopped the specialist. Seems like a good way to go.
Brachiator
@amygdala: RE: But why would a doctor prescribe the two drugs in the first place? The setup doesn’t quite make sense.
I expect the doctor to have a clue before they prescribe a combination of drugs. If my assumption is not correct here, we have a huge problem with the medical system from the jump. “I’m going to prescribe some stuff for you, but I really have no idea whether the combination might harm you, but hey, maybe someone else will check” reduces medicine to the level of a witch doctor tossing herbs into a bottle.
Then we have another problem here. I know that a package insert may not be a panacea, but there has to be some reasonable middle ground. Otherwise, a person might as well go into the woods and pick some random flowers and treat himself or herself.
Gin & Tonic
@Brachiator:
Every retail pharmacy in the US is required to have a licensed pharmacist on duty when they are open for business, and to have a sign posted and clearly visible with the name(s) of the pharmacist(s), who also always wear some form of clearly visible identification.
amygdala
@Brachiator: Yeah, all of this. In the hospital, it’s actually designed this way, to have multiple places where errors can be picked up. The doc writes the order, nurse picks it up, pharmacist processes it, nurse gives the drug. On the outpatient side, it’s doc (or NP) and pharmacist, so fewer checks in the system.
Gin & Tonic
@Brachiator: Here’s the model text for a “package insert” for one of the meds mentioned in the article. Feel free to read and tell me what you’d change/improve.
For those who don’t want to click or read, here is the first paragraph of actual text:
amygdala
@Brachiator: If it were so easy to fix, it would have been by now. If followup appointments were 30 minutes, yeah, those kinds of errors would be less common. When PCPs are expected to crank out a half-dozen visits an hour, they’re pretty much inevitable.
Brachiator
@amygdala:
I didn’t say it would be easy to fix. But “hey, fuck ups are inevitable” is not an acceptable answer. Would you accept that answer for yourself, for your family? And if you do, what do you do in the real world to mitigate against the inevitable fuck up?
@Gin & Tonic:
You first. If it can’t be improved, then what’s the point?
The idea is to prevent an individual from taking a potentially fatal combination of drugs. People have indicated a number of areas where there can be a failure. The question is how can the risk of failure be reduced.
Yarrow
@amygdala: Yep, and with new drugs the side effects aren’t always even known. A family member took a medication for a chronic condition. It caused a life threatening sudden drop in blood pressure, but only under certain conditions. This was not a listed symptom at all and at first it was unclear what the problem was – thought it was some kind of food poisoning the first time. Fast forward ten years and guess what – that blood pressure issue is now a listed side effect. Imagine that.
It’s only going to get worse because the new administration wants to gut the requirements for FDA testing for new drugs. Just put them out there once they’re developed and let patients give them a go. If problems come up, they’ll find out then. Yay.
Villago Delenda Est
@Emily68: These fucking people have NO critical thinking skills to speak of, which is why they missed the entire point of the article. I sincerely hope they take the deadly combination of meds and that before they die, they suffer from excruciating pain, because they deserve to.
egorelick
The question is whether the risk of failure is the appropriate level now. The dangerous combinations in the Trib report have been missed for years to a greater or lesser degree. How often are these drugs prescribed in concert? Even when prescribed in concert, how often are they taken in a way that is dangerous (for example, the clarithromycin will be used for no more than 14 days and the ergotamine is as needed so if no migraine in the next two weeks then no risk). How often is the dose actually harmful (looking up the ergotamine/clarithromycin interaction, my initial take is only by using the drug not as prescribed even within the 2 week window would result in harm)? Sometimes the harm is for unhealthy individuals but healthy individuals are at no risk (so how often would clarithromycin be prescribed in someone who already had compromised circulation). The chances of this particular interaction being prescribed together, being dispensed, being harmful is below the level of detection. You think it is easy because you read one Trib report highlighted by a BJ frontpager. That Trib report released more clarithromycin/ergotamine combinations for a single patient into the Chicago area retail pharmacy universe than Chicago has seen in the last 10 years (maybe 100 years). Even then, the chance of actual harm would be less than 1 incident over the entire set of Trib prescriptions for that particular combo. Based on this, you are asserting it is worth billions to change the system.
Brachiator
@Gin & Tonic:
Fortunately, when I go to the Kaiser Hospital pharmacy here in Southern California, I am always asked if I want a pharmacist to go over instructions with me, even if it is a prescription refill. I have been asked this question every time.
At times I have asked to have a pharmacist come over, to make sure that I have not forgot something about some medication I am taking (and fortunately, not too many currently).
I don’t know what goes on at retail pharmacies. It is not encouraging to think of the situations that might occur.
amygdala
@Brachiator: I’m suggesting you’re blaming the wrong people. We have a system that favors speed and satisfaction survey results over safety. Unless and until that changes, med errors will continue.
I’m a fan of the ACA broadly, but the requirement for EHRs, in the absence of standards to make sure those systems are useful made an already difficult system worse. There are more meds out there, not fewer, and the interactions between them increase even more dramatically.
I already said what I do–I keep an eye on interactions myself for me and friends and family who need a hand. I did that for my patients and what did it get me? Being at work until after 9PM most nights and the enmity of hospital administrators and bosses who didn’t like being reminded they were the root cause of the problem. There’s a reason I retired early.
Jonny Scrum-half
@MJS: I hear you, but it’s my understanding that this issue is one of the main reasons pharmacists exist – to advise patients of drug interactions.
Kay
@Barbara:
The Oxi thing was a deliberate marketing strategy, though. They marketed it to physicians as NOT addictive because it had a time release formulation. Purdue Pharma, the company behind it, pleaded guilty to deliberate fraud and mislabeling in a federal action against them.
Doctors knew the drugs were being marketed to a huge new group of people, so Purdue had to reassure them this was safe. They did that by claiming the time release formulation made them less addictive. This actually happened to me. I had a bad disk in my back. It was incredibly painful and I had a ordinary (older) family practice doc tell me Oxy was safe because it had this magic “coating”. I had already been to several continuing legal education seminars on the addiction problem in Ohio so I knew this was bullshit. I went to a physical therapist instead, which worked.
Villago Delenda Est
@Ohio Mom: The VA worries about patients, not profits. Drumpf intends to change all that. Fuck the patients! Seek the profit!
This is what “privatization” is all about…making an already fucked up health care system even worse.
Brachiator
@Yarrow:
I don’t even understand the Republican pseudo-philosophy for this stance.
Brachiator
@amygdala:
Actually, I’m not blaming anyone. I’m just asking how the situation can be improved.
Makes me wish there was a way to harness the experience of people like you to help create a more generalized solution.
amygdala
@Yarrow: Indeed. Even better, that’s supposed to be part of the drug approval process–companies are supposed to monitor for these. But FDA hasn’t forced them to, and it can take longer than it should for more unusual side effects to be identified.
Not expecting this to get better under a Trump administration.
amygdala
@Kay: It’s not just big pharma on this. The prevalent attitude in the pain management field was that when all else failed, opioids and to keep pushing the doses up. It was that and the too-good-to-be-true claims about the drugs that led to this nightmare.
Bobby D
Me mum is an exec with Kaiser, running a large portfolio around their pharmacy inventory management & distribution systems. Obviously a little different scenario, but provides a pretty good look into drug pricing, inventory mgmt of time sensitive products, and software solutions to the drug-interactions problem.
On the rare occasion I have a prescription filled, my local pharm uses software tied to their order processing that calls out instructions, warnings and interaction issues. No idea how standard something like that is these days, but seems fairly easy to implement.
? Martin
@satby:
Right, but my guess is that liability rarely extends to the pharmacist. If someone dies from such a drug combo, do you sue the doctor or the pharmacist. Probably should be both, but I bet the pharmacist is rarely sued. Liability is a perfectly valid incentive in business models, but requires use to function.
amygdala
@Brachiator: $$ Right now in the US drugs have to be shown effective, as well as safe, for… something. And those efficacy trials ain’t cheap. No trials, immediate access to markets… win, win!
Jedi help us. In the meantime, I’ll be watching what the EU does and doesn’t approve with more than the usual interest. They, at least, still believe in regulation.
Yarrow
@Brachiator: Drug companies make money faster. Don’t have to waste time on trials. Aren’t on the hook if there’s a problem because laws will be changed to say the patient knew there wasn’t testing.
It’s hardly philosophy unless the philosophy is “make as much money as possible.”
artem1s
@satby: .
unless of course you are filling scripts for slut pills. every Pharma everywhere that women can’t be trusted with perfectly safe medical treatments, because Babbie Jeebus said so.
? Martin
@Bobby D: Kaiser is almost unique in how integrated their patient management system is. It sounds straightforward, but it took them 3 or 4 tries to get it where it is at huge expense and time. HMOs have the benefit of being authoritarian structures – the insurer and the doctor and the pharmacist are all paid by the same outfit, so you can align them to implement such a system. When those are three different business models with 3 different sets of requirements and incentives, coordinating such a thing is damn near impossible unless the feds mandate it (which they did under ACA). And I know from inside this system (close family is CIO for major insurer) that everyone loves the idea of well integrated data systems, and they are both terrible at actually doing it and terrible at accepting the future benefits to pay for it.
Barbara
@Kay: This has been known for going on 20 years. It’s past time for for doctors to use Purdue Pharma’s bad behavior as an excuse for continuing to prescribe these drugs. At least people at Purdue Pharma actually went to jail and were it not for motivated users there might have been a chance to take the product off the market. Everyone is to blame, and that means one party’s bad actions should not be used to shield another party’s bad actions. States that are serious (like Massachusetts) have begun limiting the number of doses that can be included in a single prescription, and requiring people to go back to the doctor for refills. When Florida cut down on pill mills, evidently, they moved to places like West Virginia where the regulators are happy for people who live in the state to die. Climate change is a difficult problem. Abuse of prescription pain medication is a failure of enough people caring sufficiently.
satby
@amygdala: Agreed. People are trained and theoretically responsible for having the expertise that our “ownership society” now says is our responsibility.
Feathers
I remember reading or watching a report on the malpractice insurers of pharmacies stepping in and saying that they would not cover claims where the pharmacist had filled more than X prescriptions in a given shift. They knew the point where the error rate became unacceptable. From the sounds of things on this thread, CVS went and found another insurer. Mom & pops are great in theory, the wonderful ones are fantastic, but in my experience there are lots of people who have their own businesses because of various personal issues which leave them incapable of working for anyone else. This is occasionally for the best, but I’ve learned to follow that rule until someone proves otherwise.
a hip hop artist from Idaho (fka Bella Q)
@amygdala: Indeed. Big Pharma had the profit motive to mislead – and did – but the medical community pretty casually prescribed in what could be considered inappropriate ways. Continual release opiates for broken bones? And of course, the increasing dosages for med with rapidly building tolerance…
A chain retail pharmacy I use now has some central call center/pharm review elements. I take 250 mgs of an anti-convulsant that is available as 25, 100,150, 200. We settled on 1-200mgs + 2-25mg. With the new “system,” at my last refill, the tech got the pharmacist over, because there was an alert from “central” that I was taking 2 different dosages of the med! Of course I had been for years, and the pharmacy knew that – as did their long time managing PharmD who knows me by sight. But the pharmacist had to log in with her own credentials to get past the “careful!” screen so I could purchase the dispensed med. So while I didn’t mind the extra time, it was really rather wasted on the part of those 2 folks, under those circumstances.
On the topic of side effects, last spring I had a bout of vertigo, and it was quite unpleasant. Limiting without being disabling, but mostly annoying.My PCP verified it and suggested it could be age related – he has occasional incidents, and suggested meclizine tabs, which were not helpful.
After 3 weeks I looked at what had changed in my routine right before the onset. And with the consent of my doc, I’d increased the dosage of that med after decreasing the dosage of a companion. Saturation wasn’t an issue, so I was simply taking 50 mg more daily. That was about a week before vertigo. I emailed my prescribing doc and told him I suspected the lamotrigine and would reduce the dose to see if it helped. His response:
The next day, the vertigo resolved, and that was the end of it. It’s a listed side effect, but very, very far down the list – literally in that there are dozens before it. So his position was a reasoned one, and we chuckle that I’m a champ at getting the very unlikely side effects.
ruckus
@Joe Falco:
I had a job that boiled down to saying no. Everything else was marking time till the next no had to be uttered. It took me about a year to understand this. After a couple more years the job was just a time waster.
ruckus
@Capri:
When I had private insurance, I never got more than ten minutes of any Dr’s time. That might just make it a lot easier for them to not know something important.
quakerinabasement
Don’t bother Mr. Gower right now, Georgie. He’s got to get those pills out the door.
liberal
@Feathers: that’s why the class of small business owners is so right wing: so many of them are antisocial shitstains. /notallsmallbizpeople
liberal
@amygdala: Bullshit. There are a lot of things in medicine that could be improved, but those improvements would necessitate decreasing physician autonomy, why is why they don’t get implemented.
Not to mention an even larger problem, which is misaligned incentives at the provider level.
Barbara
@liberal: Just by way of example, the AMA and most state medical societies still routinely oppose any and all efforts to expand the rights of non-physician practitioners. The latest was opposition to APRNs having expanded rights within the Veterans Affairs System. They routinely make the better the enemy of the best without regard to crushing shortages of physicians in many communities or the fact that many low value services can be more effectively performed by non-doctors. The same is true for professional dental organizations.
Theodore Wirth
@MJS: When I visit any doctor or dentist, the first thing they do is nag me about the state of my current prescriptions. That said, there is no reason why my prescriptions are not electronically accessible.
Duke of Clay
@satby: Yes, I got the point of the original article. I was responding to MJS’ framing of it as the pharmacist telling you one thing and the physician telling you another. As a retired Doctoral level healthcare giver in an allied health field, I was describing the ideal scenario. Only an idiot would unilaterally say, “I won’t fill this for you. Go pound sand [in MJS’ framing].” BTW, for several years I have been on two medications that can have a negative interaction. I have a lab test every three months to insure that I am not experiencing negative effects. And every time I get them refilled, the pharmacist calls the physician to confirm that it’s ok to fill both.
Duke of Clay
@Duke of Clay: In retrospect, I regret saying I was describing the “ideal scenario.” A more apt description would be, perhaps, “the most common scenario” — at least based on my experience.
jame
I worked for a blessedly brief time in Risk Management at the state hospital. So many times it was the pharmacist that caught medications that would have damaged or killed the patient, but were prescribed by a physician. The problem was usually that a patient in the hospital sees so many doctors in such a short time, and NOBODY reads the patient’s file. If you want a long life, stay out of the hospital. If you are hospitalized, get out as soon as possible.
Ruckus
@raven:
I understand your comment, but I’d just as soon as he didn’t. Not that my concern will mean jack shit to the shit gibbon but it’s saved my life once, possibly twice, I like a good record like that and the team the has it.
Ruckus
@Yarrow:
Said here before but I get all my medical care at the VA, including all my meds. I think, as I said up thread that the VA EMR system is top notch. Could it be better? Sure, what can’t? But it’s damn good and as @amygdala: said it’s based on actual health care, not on billing. There are checks to insure that all interactions are known and discussed/stopped. But I still check out all my meds online to make sure. It’s not that I don’t trust the docs, but having that knowledge is vital to your own piece of mind and while it may be their job and license, it is my health.
Ruckus
@a hip hop artist from Idaho (fka Bella Q):
I know this is a dead thread but it’s an important topic and I just got home from work a bit ago.
Anyway….
I was prescribed a medication that has been on the market for over 65 yrs and has a record of side effects for very few people. The prescribing doc is on the far side of 60 and has been prescribing this med for as long as he has been practicing, probably on the order of 40 yrs. He didn’t believe me that I was having extreme side effects after using the minimum dosage for 2 days. He’d never seen this before and thought I was making it up. I had to be very adamant that I would never take this drug again under any circumstances. I also now have a different specialist as I believe he refused to treat me. That’s fine, saved me from having to request a change.
So, yes a large number of the interaction issues/side effects are rare to very rare, and a few drugs have quite high correlation of interaction issues/side effects but are usually useful for some reason regardless.