SNOW DAY!

Today was very exciting in the Future PharmD household. The spouse's school was closed, so all that remained to do for the day was excavate the driveway from the 10-14 inches of soggy snow we got, take the kid to daycare (because apparently a snow day is no fun without being home alone), and then drive 24 miles to take a very scary exam.  It took from 8am until about 11:45 (with breaks) to get the driveway cleared, but from there it was only about an hour until I arrived to take the test (at 2:30 or 3pm, I was really early just for good measure).

While the spouse was working on the driveway, the kid went out to play twice or thrice, and I studied a great deal.  It's a rare occasion where I am very pleased with the result of an exam, BUT in this case I was very excited to see my score because not only was it passing, IT WAS ABOVE A C.  I'll grant you that Cs earn degrees, but it still irks me. On some level I am a terrible perfectionist. ugh. After this semester I'm sure I'll have survived being a slighly irked perfectionist and be super happy that there's only 1 year left before rotations.

I had a good time watching the kid climbing around in the snow though, between bouts of frantic cramming reviewing my notes.  And I made her hot chocolate twice! Well, the first time, I heated the water, and then everyone got distracted and forgot about hot chocolate and went back outside to frolic in the snow/shovel it off the driveway/slave away learning about proton pump inhibitors and asthma drugs.

Tonight instead of studying like I should be, I am loafing. I watched 2 whole television episodes and played Legos with the kid! For more than 10 seconds! I designed a lunar lander vehicle and used the Lego Barbie Horse Adventure door as a solar panel and one of those gates horses jump as the tail fin.  When the kid's Favorite Uncle was here while I was in the hospital the other week (maybe I'll get to that eventually), he foolishly was talked into bringing the Lego/Duplo bin upstairs and our feet will never be the same.  However, despite my sore feet, the Legos have been a good time.  I'm curious about whether or not I requested the Lego Barbie Horse Adventure playset or whether some well-meaning person [::cough:: my mother] got it for me. My memory is that I asked for it, so that's strange.  I apparently had a very short horse adoration phase before returning to life in total terror of horses.

Prescription Drug Shortages and Formulary Shenanigans

http://consumerist.com/2012/02/fda-green-lights-imports-of-cancer-drugs-to-ease-shortages.html

This week the FDA decided to allow some cancer drugs to be imported because there's a long-term shortage of them here in the US. 

Why do we have a shortage here in the US but other countries don't?  The short version is that we have very picky manufacturing standards (this is good), it takes a long time for a "deficient" manufacturing facility to get back up to snuff (and lots of money too), and it costs a lot for generic drug makers to bring a new product to market.  Because for some reason we let the market decide the price of drugs, generics that save lives but are inexpensive to make end up in short supply (Lasix in the IV form, for example, or morphine single dose vials, or a calcium supplement to be injected) becuase it would be so costly to comply with regulations and when selling something for relatively little, it doesn't make sense to put so much money into supplying it.

Then there are the manufacturer delay shortages that mysteriously happen shortly after a newer version of a drug comes out.  Ritalin and  Adderall for example have a new competitor in the ADHD treatment market called Vyvanse that costs 2-3 times what a generic Ritalin costs (which is about $130 a month if paying cash).  Vyvanse is certainly not in short supply at all, and I have noticed that some area doctors are switching patients over so the drug shortage is less of a hassle.

The final kind of shortage is the change in formulary/market shift shortage.  This is shown very well by a new blood pressure medication that combines the blood pressure med with a diuretic (so 2 things lowering blood pressure, one capsule to take instead of two).  It was approved for sale by the FDA in December or so, just after a study in a journal that apparently all the cardiac doctors read was published saying it was more effective than the older combo products.  Very suddenly a whole lot of people who had been taking one product got switched to the combination product, so there was a shortage because the company that makes it hadn't planned for such a boom in demand.  Conversely, the maker of the older drug of choice may have trouble making ends meet when their market share dries up over night.  Sometimes drug companies make the case that they charge more for their blockbuster drug(s) so the income can support less profitable drugs or R&D for new drugs that might make life infinitely better for some patients.  It's not really clear if this is true, but maybe it is. Drug companies like to keep their financing something of a mystery on purpose.

Solutions to this problem:
1. National health plan or state plans that cover everyone so there's no insurance market pressure for drug companies to cut deals with insurance plans so some drugs are covered while others aren't.

2. National unified pricing of drugs based on value to patients when drug becomes a generic, rather than generic makers underbidding each other until the price they offer is lower than the costs of making the drug and the last generic maker in the market quits making it or limits supply sharply to try to raise the price.

3. More frequent review of large national formularies to ensure the most effective medications are the ones patients are getting (VA, looking at you here) and better formulary design so many drugs in the same class are allowed if the problem untreated costs more than the drug to treat it. Example: there are about 20 different medications called ACE inhibitors that are used to lower blood pressure.  Not everyone responds well to the one that's most effective for the population as a whole, so it's important to be able to try a different one after the most effective or cheapest is tried and fails because the cost to insurers of untreated high blood pressure are so much more than the cost of the drugs.  Same goes for statin drugs that lower cholesterol.  They are expensive, so many insurance plans will only pay for one specific drug, but if the insurers considered how much treating complications of high cholesterol are, perhaps they'd allow more choices for those who tried one first and it didn't work out.

Philosophizing

Today was a great day.  Being in school I don't get all that many really great days, so today was exciting.  We went to see my very favorite musician in concert and I got to hear him sing all my favorite songs. It was delicious.  By "we" I mean the spouse and me.  We only drove an hour and a half one way to get there, but it was worth it.  We've gone on Valentine's Day concert trip extravaganzas to more exotic places, like Iowa in a blizzard.

Much of the reason I love this musician so much is his lyrics.  Today it dawned on me that I love these lyrics because they hit my philosophy on life on the nose.  It's about now, and making the most of now, and loving those in our lives who need it, and telling them so.  Life is about dreams and being surprised at where you end up and enjoying it anyway.  Life is about making mistakes and learning from yours and others'.

Now that I'm a parent, and I've had a little practice at it, I've developed a parenting philosophy too (in conjunction with the spouse, of course). It is as follows, stolen from Diane Duane's excellent book "So You Want to Be A Wizard":

In Life's name and for Life's sake, I say that I will use the Art for nothing but the service of that Life. I will guard growth and ease pain. I will fight to preserve what grows and lives well in its own way; and I will change no object or creature unless its growth and life, or that of the system of which it is part, are threatened. To these ends, in the practice of my Art, I will put aside fear for courage, and death for life, when it is right to do so -- till the Universe's end.

Parenting is certainly an art, not a science. No two children are the same, and no two pieces of art are the same either.  So the long and short of it is that I'm not in charge of growing children, or raising them. I'm in charge of giving the kid the opportunities to grow for herself and tell her when she's growing in the wrong direction (whiny tone, lookin at you).  If she's not destroying anything or hurting herself or others, then whatever. I'll let her play and climb stuff and roll in the mud.  Casual parenting, if you will.  I'll drive her to karate lessons but I won't walk her into the class. It's her choice to be there, and if she chooses not to participate, so be it.


I read too many mommy blogs, hey like this one... oops... and so many moms seem so deeply committed to being so in control of their kids' learning.  It just baffles me.  We are not here to confine and define the world for our children. We are here to remind them to put on a coat in the winter before they go play outside, and what to do if a stranger grabs them, and to drink orange juice if they have a cold.  We're here to hug them after they fall down and then remind them to dust themselves off and get back to playing, not to put on so many protective pads that they never skin their knees.  There is no way I can keep an eye on my kid every moment every day that she is little, and I refuse to do it.  She needs to be as self-sufficient as possible for someone her age because some day she will grow up and I want her to know how to help herself.  If she doesn't start now in the small ways she can, she will never learn. 

So I let her go. I let her use scissors without watching her every move.  I make her ask nicely before she gets a cookie.  I send her out to play in the yard alone for hours, after I put sunscreen on her (still too little to do that alone).  Yes, someday something awful might happen.  Unless she knows how to handle little disappointments and trials, she will be totally lost if it does.  Something awful might happen when I'm inches away.  I trust that life is mostly good, that we should prepare for the worst but assume it will never come to pass and live life without fearing the worst.  I have seen the worst life has to offer, and it doesn't happen to everyone or even most people, thank Heaven.  The worst is the exception, not the rule, so let's all have some fun.

Prescription drug abuse

So I work in a community pharmacy.  This means drug addicts and probably faked prescriptions.  I'm not talking about addicts to illegal drugs, I mean the folk who are addicted to oxycodone and vicodin and the rest (ritalin comes to mind).  They come up with some very creative reasons they need their refill early every month, or they switch doctors and doses mid-month, every month.  Or they're just mean and nasty to the pharmacy staff all the time, coming in with a prescription and asking every 3 minutes if it's ready even though we said it would be a half hour.  Then once they leave, they claim they are short pills and want them replaced for free. Right this minute.

The solution to all of this? No idea.  There are some things that could help, however.

I think having every doctor around set up a pain management contract with each patient would help.  This is a document that the doctor and patient sign, saying that the patient will only go to that doctor for pain meds and will go to only one pharmacy to fill prescriptions.  One copy is for the doctor's office, one for the pharmacy, one for the patient.  In it the patient promises not to pester the pharmacy or doctor's office for unneeded refills, and if they do, the pharmacy will stop filling their prescriptions and the doctor may stop seeing them and will cancel all refills on all medications, plus report them to law enforcement as a potential abuser.  Usually there's some kind of schedule of how often the patient needs to be seen and if they need to see some other doctor, some kind of permission system.  Yes, it's kind of a pain in the neck.  Yes it seems limiting and cruel to patients.  But for patients who are really in pain it makes sure they get the medication they need without the addicts getting in the way.

The other solution is having a prescription database that collects information about each prescription for a controlled substance so if someone turns up at the pharmacy and doesn't seem like they're in pain but demands a vast quantity of morphine without billing insurance, the pharmacy can look to see if that person has had a similar prescription filled elsewhere recently.  The looking part is key however.  If pharmacies are only required to submit data to the registry and aren't required to look at it to verify no prescription abuse, it doesn't really do all that much good.

Of course, I also like to blame doctors, because hey. Someone has to pick on them.  Some doctors are far too free with their pain prescriptions for people and they make no effort to wean them off pain pills (ok, ok, tablets) after an incident where they needed pain relief.  I disapprove.  If every person who walks in the door gets a 30 day supply of vicodin taking 1 every 4 hours for "back pain,", that's a little bit much. Bad patient care. Perhaps laziness. Perhaps they also hate being pestered by the junkies (probably yes).

Whatever we do, we need to do more.

On writing

Once upon a time, there was me, stuck in some tiny town, miserable.  And out of nowhere there was a ray of light when I heard about a high school with a dorm (because my perfect cousin had gotten in, and I clearly could do anything she did, right?).  This was a Tuesday, I am sure, because then time was told according to my mother's skewed clock and it was perpetually Tuesday.  3 years of Tuesday.  In less than 10 days there was an application deadline, so I rounded up stuff I'd written and sent it in on a whim, figuring I had at least given it a shot.  I'm not sure I told anyone I was applying.

In the realm of fate, here's where I'm sure: that on the drive to the interview I somehow magically got, I heard a new song on the radio and loved it. When I arrived the current students were singing it quietly to each other, then louder and louder until the hall echoed and someone popped out from behind a closed door to just glance at them, resulting in a giggle fit.  Leaving I was sure I'd get in, but I wasn't sure I would go.  Then things at home went from a mess to a fiasco and I was sure I'd go, so I did.

I spent a year just writing, then most of a half a year writing before I moved into editing and not being able to write.  It felt like a part of my soul was missing, so I took some college classes to try and get it back.  I read some amazing books and met some cool people, but I was so distracted with life spinning out of control and me desperately clinging to any old thing I could grab that I missed out on listening to what I was called to do with myself.

So here I am, with this blogging project, a million miles from that moment where I trusted my intuition even if I didn't trust myself.

And here I am, trying to wrap my head around a part of me I was sure was dead and gone but as it turns out was growing sneakily while I looked the other way.  So while the goal was/is/probablywill be to stay in the realm of life, you may have to suffer through some fiction now and again.  Fair warning officially given.

I was thinking about how stories have such a different quality and different meaning when they are about health and healthcare.  Before, it didn't matter if a story was the truth, it mattered if it was true.  Tim O'Brien said of war stories that "It comes down to gut instinct. A true war story, if truly told, makes the stomach believe."  If someone rattled on for 20 minutes about the awful car accident they were in, and how much pain they are in now, and all that jazz before, it was a story and the story had its own life.  Now as I move toward being a pharmacist, the story can't ever be a story that's true in that same gut-punching way that has nothing to do with the facts.  I don't get to listen to the whole story anymore, I just ask for the facts and please leave out the entire saga because there are 14 other people who have questions and concerns that I need to deal with right now.

Hopefully in the long run, some of the truth of life can catch what's true in a different light so I can see it again.

What services SHOULD you get in a pharmacy?

With all the recent to-do about the Susan G. Komen foundation defunding, then re-funding Planned Parenthood, a lovely video of Stephen Colbert talking about the consequences of expecting people to get their healthcare screenings elsewhere has been making the rounds of the internet oversharing sites.  In it, there's a clip from Fox News about how if you can't get your preventative health services from Planned Parenthood anymore, stuff like your blood pressure checked, breast exams, Pap smears, you could just get them somewhere else, like Walgreens.  This really begs the question of how many health services should you get in a pharmacy anyway?

I have this feeling that most people don't know what they're getting from a pharmacy anyway, so here's a list.

• Prescriptions checked by a medication expert to catch all the goofs your doctor/their e-prescribing software/the computer makes before they hurt you (or maybe kill you).
• Medication management services, where if you have more than one (or sometimes more than 2) chronic conditions, you get a pharmacist appointment at least twice a year to go over the multitude of medications you take
• Shots: flu shot, Shingles shot (that you can't get in a clinic, sorry), pneumonia shots for old people, and in some places all the shots you need to travel abroad and some childhood shots like the one that prevents tetanus, diphtheria, and pertussis (whooping cough)
• Free help with your insurance, sometimes for hours at a time, so you get your medications in a timely fashion
• Free blood pressure screenings (Fox news got it right!)
• Free answers to any question about a health problem that doesn't require you to see a doctor immediately (weird rash, cough, runny nose, upset stomach, dry eyes, red eyes, contraception via condoms or Plan B, nasty looking boils and cysts and warts, scary diabetic ulcer on your leg, etc.)
• Free advice about whether to see your doctor, and how soon, if the nearby speedy health clinic is busy (which is always)
• Free advice about what happens if you take medications together. At great length. Every night of the week because apparently taking 3 prescriptions is scary and you need to call just to check that it's still all right.
• Free advice on how much of any OTC medication to take/give your sick child who's yelling in the background very loudly
• Free advice about taking any medication long-term and what the side effects might be
• Free help finding any product in the pharmacy that you could possibly want
• Free ordering of almost any product we might sell in the pharmacy but don't have in stock (but not a douche bag, sorry. Apparently our suppliers don't carry those, sir.)
• Free transfer of your prescription to any other pharmacy in the country, or FROM any other pharmacy in the country.
• Free help with your durable medical goods if the pharmacy sells those, so fitting your elastic stockings, adjusting the height of your cane or walker, and putting on ice spikes to your cane or walker
• Free (or very low cost) classes teaching you about something health-related like how to manage your diabetes, how to take care of your high blood pressure, etc.
• Free medication identification when you accidentally spill all 14 bottles of prescriptions and OTCs together on your kitchen floor

While adding breast exams and Pap smears to the list is unlikely, aside from expanding how many people get medication management, I don't see that there's much more we can do.  Maybe every pharmacy gives a wider range of shots.  Notice all those free things on the list?  Those take up a lot of time that the pharmacy staff could be using to do things that the pharmacy gets paid to do, but out of a professional snese of duty to patients, the pharmacy staff do them anyway.  Just remember that the $25 you paid for your $300 bottle of medication is also paying for all those free things that take up time, so please don't complain so much.  But you do need to see a doctor/nurse practitioner/physician's assistant sometimes. Yes it costs money. Yes you have to plan ahead to make an appointment.  Grow up, Americans.  Not everything should be as fast and easy as getting McDonalds for supper.