by Tony Guerra, Pharm.D.

We have a hiring freeze. Call us in a couple of months. We have a position, but it’s in a small town. Do you need benefits? How much experience do you have? Did you do a residency?

These aren’t supposed to be answers to our interview questions as pharmacists. We’re supposed to be able to fog a mirror and get a job. We should get to negotiate for a higher salary with a nice sign on bonus where and when we want. What happened to the good old days? You know, last year.

Supply and Demand

As the United States population has grown older and heavier, the demand for prescription medications has skyrocketed. Working to fill the need, chain pharmacies have gobbled up independents and kept their doors open later (many overnight), requiring greater levels of staff. As HMO’s, hospitals, clinics, universities, mail-order services, and the military all need pharmacists, they have been willing to pay handsomely for them.

At the same time, women have entered pharmacy in far greater numbers than ever before, many opting for part time positions or taking extended leaves to raise children. Complicating things further, when bachelor’s programs were phased out in favor of Pharm.D. programs, a year’s worth of graduates were lost.

All of this created an historic shortage of labor. State pharmacy schools could not keep up with demand, so the private schools started adding pharmacy programs at a rate of almost two per year (up from one every three years). In 1990, there were 74 pharmacy schools operating in the United States. Today, there are 103 with an additional nine in pre-candidate status. As salaries begin to stagnate or worse—drop, this may end up as a game of musical chairs, forcing a number of pharmacy programs to close their doors as quickly as they opened.

Tony Guerra, Pharm.D.

What does any of this have to do with finding a job you’re passionate about? To put it simply, you must work smarter to get it. If a PGY1 could have landed you a faculty spot before, then now you may need a PGY2 to get that same position. You may need to know a couple of people at the college or at the place you want to work. You may need to take a job that you don’t like as much so that you can build the skills and relationships to get exactly what you want.

But I want it now!

I understand. The truth is you can have it now, if you are willing to go outside the box.

I ask residents, “What are you going to do after your graduation or residency?” Nine times out of 10, the answer is, “I don’t know.”  Like being an Olympic athlete who has worked their entire life to win a gold medal, you will stand at the graduation platform thinking about the moment rather than what might satisfy you in the future. But there are actionable steps to arrive where you want to be.

Step One – Decide what you love to do on the most basic level.

Do you want to teach? Lead? Write? Advise? Manage? Whom do you love to help? Kids? Adults? Students? When you close your eyes, where do you see yourself smiling at work? By answering these questions, you can start moving in the right direction.

A pharmacist herself, my wife loves being the trusted advisor. Whether with family or patients, she loves to sit down and help people because she is a talented listener. With this in mind, she focused on becoming a diabetes expert through a program at Drake and in her practice. After showing a local free clinic how she could help them, they offered to create a 16-hour position due to the great work she had accomplished with diabetic patients. Because her passion was in line with her work, an opportunity was made.

Step Two – Volunteer.

Too many people ask for something then expect to get it, as if getting the career of your dreams is a one step process. The real order of service is to give, then ask, then receive. Since I wanted to teach and didn’t care if I got paid, I volunteered in a middle school math program. Later, I got paid to tutor, proctor, and teach test prep at Kaplan. It wasn’t a pharmacist’s salary, but their training program was great. After that, I volunteered to teach in pharmacy courses at the University of Iowa.

Each succeeding experience has made me more confident and more able. When the opportunity finally arose to teach a full-time course at a local community college, I was accepted right away. Yet, all of this began in a public school classroom with the willingness to give.

Step Three – Build your own practice.

The job you make for yourself is the job you’ll love. The day I left retail and started my own business, I was scared. But once I bought my own health insurance, I realized it wasn’t that bad and the freedom is amazing.

While I certainly had responsibilities to my customers, I could schedule them around other things in my life. I could coach in the afternoons, take trips with my family, and spend evenings at home. I was there for people when they needed me while building deep relationships one-on-one instead of trying to do the same through a plate glass drive-through window.

Building your own practice is life changing. It’s like going to a restaurant and ordering from the à la carte menu and getting exactly what you want.

Step Four – Start Now.

If you haven’t already, soon you will see the real impact of this economy. There are likely to be two kinds of responses. The first: you can cling to a job that you may not like out of fear of the unknown. The second: you can go forward, today, and start building a practice that you love. Involve the friends you missed while you were on that lonely pharmacy island.

Entrepreneurship is back in a big way. It can be your ticket to the work you love. Take the smallest step right now by writing down what you want. My own mission is to “build a service business so I can train in the mornings, teach during the day, coach in the afternoon, and be with my family and friends nights and weekends.” Write yours out, and it will become a reality.

Plato said, “Necessity is the mother of invention.” But, just having a good idea is not enough. Transitioning an invention from idea to marketable product takes something more—an entrepreneurial spirit, as well as a little confidence.

Three Washington State University PharmD candidates have taken an idea, their entrepreneurial spirit, and the confidence gained from winning the 2006 NCPA Pruitt-Schutte Student Business Plan Competition and launched a much-needed product for pharmacy students.

Flash Forward is a company that produces flash cards of the top 250 drugs. Jason Doss had the idea for the cards in his first year of pharmacy school. “I knew I was going to have to make flash cards for class and I wanted to make it easier by purchasing a set of flash cards instead,” he said. Not finding any for purchase, he realized that there was a need that was not being met.

Doss and Corinne Gavrun were members of Washington State’s winning team of the business plan competition, along with Josh Fancher and Daniela Beilic. Linda Garrelts-MacLean was the team’s advisor.

“The experience of having written a business plan convinced us that it was possible to start a business and succeed,” Doss said. So, in the fall of 2007, Doss and Gavrun joined with fellow pharmacy school student David Villeneuve to launch Flash Forward. Doss is the company’s chief executive officer. Gavrun serves as chief financial officer, and Villeneuve is the chief technology officer.

“The NCPA Business Plan Competition inspired our entrepreneurial spirit and motivated us to take action,” Gavrun said. “After our competition win, we were eager to start up a business that we could run in our spare time while completing our last two years of pharmacy school.”

The trio used lessons learned from the business plan competition in developing and launching Flash Forward. “We went through a process similar to the one we did for the competition,” Gavrun said, “brainstorming creative ideas, assessing idea feasibility, researching the market potential, developing a product prototype, and writing a business plan.”

Not wanting to just produce cards like those students make for themselves, the team spent time developing the cards and including extra features to make them stand apart. “We spent a while researching and designing the look of the cards. We wanted to make sure that the cards would be functional and easy to use for students,” Doss said. “We believe that it is important to put out a quality product that is going to help students and we wanted to get it right.”

Flash Forward is selling sets of the flash cards to pharmacy student organizations, which in turn can sell them to raise funds. The sets include cards for the top 250 drugs to account for differences in top 200 lists and to bring greater value to their customers.

Now that the team has successfully launched the business, they are not content to sit on their laurels. They continue to work to evolve the company and improve their product. “We’ve got some great ideas for the future,” Doss said. “We are developing supplemental cards for specialty areas of pharmacy, as well as updating the cards to reflect the new top 200 lists. We are also in the process of updating our Web site (www.PharmacyFlashCards.com) to get a newer look and take online orders.”

Equipped with the experience of winning the business plan competition and successfully launching Flash Forward, the trio continues to look for new opportunities where they can use their skills. In the summer of 2007, Doss began working for the Community health Association of Spokane (ChAS), a clinic for low income/no income patients in Spokane, Washington.

ChAS leadership was aware of the NCPA business plan win, Doss said. So, they asked him to write a business plan for opening an anticoagulation clinic. “I wrote it in December and January, and presented it to ChAS, and they were very happy with it. They are now in the process of training pharmacists and will be opening the clinic soon,” Doss said. For more information, visit www.PharmacyFlashCards.com.

“This article originally appeared in the June 2008 issue of America’s Pharmacist, published by the National Community Pharmacists Association, Alexandria, Va. Reprinted with permission.”

Nuclear pharmacy is a specialized practice area in pharmacy that involves compounding and dispensing radiopharmaceuticals to be used in various nuclear medicine procedures.  Unlike radiology, nuclear medicine is a fantastic tool for assessing physiology (function), as opposed to only structure and anatomy.

It is a unique niche within pharmacy and this article will provide an overview of the specialty area, including common radiopharmaceuticals and procedures used in nuclear medicine, as well as the role of a nuclear pharmacist on the healthcare team.

From a business perspective, the industry’s current standing includes nuclear pharmacies which are either institutional (and cater to a single medical center), or commercial.  Centralized commercial pharmacies are contracted by hospitals/clinics to provide radiopharmaceuticals.

Today, there are only a few major radiopharmacies: GE (formerly known as Amersham), Covidien (formerly known as Tyco or Mallinckrodt), and Cardinal Health (which bought out Syncor, among others), as well as a few smaller independents.

Tc-99m and Compounding Radiopharmaceuticals

Technetium (Tc-99m) is by far the predominant isotope used; it is an ideal diagnostic tracer and is used to compound the vast majority of radiopharmaceuticals.

To put it very simply, Tc-99m is obtained by eluting a molybdenum generator: a vial of saline is placed at the entry point of the generator, with an evacuated vial on the opposite end (encased by a heavy tungsten shield).  The negative pressure draws the saline through the generator, and a sodium pertechnetate eluate is produced.

Depending on the amount of activity needed for the run (and the number of doses the pharmacy will send out), several generators are hit throughout the course of the day.  This Tc-99m elution is then used to compound the majority of kits in the pharmacy. Since Tc-99m has a relatively short half-life (approximately six hours), logistical reasons require local preparation of the drugs.

In a laminar airflow workbench (LAFW) with an L-block for protection, multidose vials of the various radiopharmaceuticals (also placed into tungsten vial shields) are compounded using specific amounts of Tc eluate and saline.  Each drug kit has very particular compounding steps and procedures, which may include heating, venting, etc.

The pharmacist then hands the prepared multidose vials with corresponding prescription labels to technicians, who (in their own hoods) safely draw up unit doses into syringes with the help of a leaded glass syringe shield.  Due to the lead/lead glass composition, these are relatively heavy, and require dexterity and practice to use properly.

The technician draws the volume indicated on the prescription label, and then verifies the activity by placing the syringe into a dose calibrator.  The calibrator will indicate the current activity of the dose, as well as what it will read at the desired assay time indicated by the customer (i.e. 72 mCi now, and 30 mCi at 08:00).

Each unit dose (syringe) is placed into a lead-shielded “pig”, labeled, capped, and placed into a case to be shipped out to the hospital or clinic.  When the dose arrives to the customer, a nuclear medicine technician/physician will verify the activity in their own calibrator, and administer the dose to the patient.  After a set amount of time, the patient is scanned and the images are interpreted.

In addition, prior to doses leaving the pharmacy, quality control by chromatography is performed on each and every kit that is prepared to ensure the drug is sufficiently bound to the isotope, there are no impurities, etc.  USP sets certain percentage requirements for each drug to pass QC, and each company may set even more stringent internal requirements (i.e. 95% purity or above to pass).

Radiopharmacology and the Common Procedures in Nuclear Medicine

Relatively speaking, there are really only a small number of radiopharmaceuticals and nuclear isotopes available.  This permits nuclear pharmacists to become true experts in their practice.  Approximately 80% of radiopharmacy is diagnostic; however, there are some fascinating and effective therapeutic drugs that we compound as well.

The following list does not include every radiopharmaceutical available, but will give you a good taste of what is available.

• Cardiology: this is the bread and butter of nuclear medicine. The major agents used are Thallium-201, Tc-99m Sestamibi (Cardiolite®) and Tc-99m Tetrofosmin (Myoview^TM). They are useful in myocardial perfusion imaging (i.e. comparing a ‘rest’ and ‘stress’ image to identify ischemia/infarction), avid infarct imaging (to detect damaged myocardial tissue post-MI) and cardiac function studies (to determine how well the heart is pumping via LVEF). These studies are a great tool for guiding a patient’s course of therapy; helping to determine whether they may need open heart surgery, catheterization, or strictly risk management with lipid control, and so on.
  

• Brain imaging: Tc-99m Exametazime (Ceretec^TM) and Tc-99m Bicisate (Neurolite®) are agents used to screen for tumors, detect metastases, detect intracranial injury, identify seizure foci, and even aid in determining legally defined ‘brain death’.
  

• Skeletal imaging: Tc-99m Medronate (MDP) and Tc-99m Oxidronate (HDP); are radiotracers with a bisphosphonate structure used to assess bone trauma (i.e. fracture imaging), distinguish osteomyelitis from cellulitis, evaluate bone cancer/multiple myeloma, paget’s disease, and so on.

• Treatment of pain due to bone metastasis: This is a good example of where nuclear medicine is used in treatment rather than strictly for diagnosis. Sr-89 Chloride (Metastron®) and Sm-153 Lexidronam (Quadramet®) can be far more effective than traditional therapy in helping cancer patients suffering from excruciating pain resulting from bone mets.

• Liver/Spleen imaging: Tc-99m Sulfur Colloid is essentially a radioactive particle that is phagocytized by the RES. It is used to image for hepatitis/cirrhosis, high LFT’s, liver tumor, trauma, abscesses, etc., where ‘cold spots’ (dark areas) in the image indicate an abnormality.
  

• Lymphoscintigraphy: small doses of filtered Tc-99m Sulfur Colloid are injected during surgery to locate lymphatic drainage patterns, guide oncological surgeons, and to identify the location of a sentinel node. The sentinel node (first node downstream from the tumor) can then be sent for biopsy to determine whether the cancer has metastasized>

• Hepatobiliary imaging: Tc-99m Mebrofenin (Choletec®) is used for gallbladder imaging to differentiate between acute (oftentimes caused by gallstones) and chronic cholecystitis. In acute cholecystitis, the gallbladder will light up in the scan, but does not for chronic disease.

• Renal imaging: Tc-99m Pentetate (DTPA) and Tc-99m Mertiatide (MAG-3) are two radiopharmaceuticals used for renal function imaging (i.e. quantifying GFR or tubular secretion), whereas Tc-99m Succimer (DMSA) is used to assess structure/anatomy of the kidney. These agents are useful in patients with renal obstruction, renal HTN, tumor, trauma, and so on.
  

• Pulmonary imaging: VQ scans are done to differentiate between a pulmonary embolism (lung clot) and chronic obstructive pulmonary disease (COPD). A perfusion test (using Tc-99m MAA) is generally done first. If the results are abnormal, the ventilation portion of the study (using radioactive Xe-133 gas or aerosolized Tc-99m DTPA) is performed. Normal ventilation will then indicate that the patient has a high probability of having a PE, whereas abnormal ventilation points to COPD.
  

• Thyroid imaging and treatment: since the thyroid gland naturally takes up iodine in order to produce thyroid hormones, administering radioactive iodine is a logical step in order to assess function (uptake) of the thyroid, as well as image or treat thyroid cancer. Thyroid uptake/function studies are performed by administering I-123 or I-131 NaI, which are useful in the diagnosis of hypo-/hyperthyroidism. Thyroid imaging can also be performed to assess ‘hot’ or ‘cold’ nodules on the thyroid; as well as whole body imaging, to look for metastatic tumors during follow-up of thyroid cancer. Thyroid therapy is a classic example of how nuclear medicine is used for treatment purposes. I-131 NaI is administered in higher activities to treat hyperthyroidism, as well as ablate the gland after surgery to mop up any remaining cells.
  

• Infection imaging: Ga-67, which is similar to iron, is passively localized to a site of infection and is an excellent choice for chronic infection imaging. Radiolabeled white blood cells can be an effective option in patients with an acute infection, inflammatory bowel disease, fever of unknown origin, osteomyelitis, soft tissue abscess, skin graft infection or diabetic foot ulcer. A hospital will send us a syringe containing a sample of the patient’s blood. In the pharmacy’s blood room (a completely segregated area from the remainder of the pharmacy), a needless procedure is used to extract the patient’s white blood cells. The leukocytes are then tagged with radioactive In-111 or Tc-99m Exametazime (Ceretec^TM). The patient’s own radio-labeled WBC’s are then sent back to the hospital where they are re-injected into the patient, and scanned to localize the site of infection.
  

• Monoclonal antibody imaging/therapy: this could quite possibly be the future for nuclear medicine, as there are so many possible applications for monoclonals. There are a only a handful of agents available now: In-111 Capromab Pendetide (ProstaScint®) to image prostate cancer, and In-111/Y-90 Ibritumomab Tiuxetan (Zevalin^TM) or I-131 Tositumomab (Bexxar®); however many more are in production. Zevalin^TM and Bexxar® are effective treatment options for patients with non-Hodgkin’s lymphoma.

• PET: is another fascinating area of nuclear medicine. F-18 FDG (”radioactive glucose”) is produced at a facility with a cyclotron, and is used to detect areas of the body undergoing high metabolism (i.e. epilepsy, cancer) relative to normal tissue. Since PET looks at the disease on a chemical level, you can identify the disease much sooner than when using other imaging modalities.
  

Authorized Nuclear Pharmacist (ANP) Training

As can be expected, the training necessary to become a nuclear pharmacist is very extensive.  About 200 hours of didactic training, and 500 hours of hands-on experience are required to practice under a pharmacy’s RAM license.

There are a few ways to go about getting this and becoming an “ANP”: 1) Attend a pharmacy school that has a nuclear program, which is completed during the PharmD curriculum (i.e. Universities of Arkansas, Oklahoma, New Mexico, Tennessee ).  Option 2) Once already a pharmacist, privately pay for training (i.e. through NEO).  Option 3) Pursue a nuclear specialized residency (i.e. SUNY or Walter Reed) or Option 4) and this is probably what most people do; begin working for a nuclear pharmacy company.  They will generally pay pharmacist salary while you do your training, and provide the training as well.

Typical Day at a Nuclear Pharmacy

Most pharmacies will typically have between 1 – 3 set “runs”.  A typical day at my pharmacy begins at around midnight when the night pharmacist arrives; they will then begin to hit the generators and start compounding the first run.  Technicians and drivers will begin to trickle in; doses are drawn (including FDG brought in from a cyclotron) and packed up.  First run is out the door and on its way to customers between 04:00 – 05:00.

The pharmacist and technicians then have some down time to clean up, log all of the kits prepared during the run into the computer, grab a bite to eat, etc.  Second run then starts at around 06:00; a second pharmacist arrives at around 07:00 as this is when the phones start to pick up with same day add-ons from the customers.  Second run is out the door by 08:00.  A third and fourth pharmacist arrive at 08:30.  One of them will generally be designated to work on the bloods; another will help answer the phone, take orders, deal with customer service issues, etc.

Third run compounding (which is usually pretty light), begins at 10:00 and is out the door by 11:30.  I-131 capsules will need to be compounded at some point during the day as well.  Throughout the morning and afternoon, we’ll field phone calls ranging from STAT add-ons to clinical questions (i.e. pediatric dosing, altered biodistribution, questions about drug selection, and so on).  The rest of the day is generally spent setting up for the next night: order entry, drawing any doses (i.e. Thallium, which has a long half-life) that can be drawn the day prior.  Prescription labels are printed, double-checked and any products needed for the next day are ordered.  So, as you can see, the daytime hours are generally spent getting ready for the following night.

The closing pharmacist locks up sometime around 17:00 and is on call for the remainder of the night.

Radiation Safety

Radiation safety and proper handling of all RAM is at the forefront of the training we receive.  Employees are required to wear ring badges (to monitor extremity exposure) as well as a body badge at collar/thyroid level (to monitor whole body exposure).  Rings are monitored weekly, and badges monthly, to assess each employee’s radiation exposure.

The US government has set limits (i.e. 5 REM/year for whole body exposure, 50 REM/year for extremities).  In addition, companies will oftentimes have even stricter limits than these, and will assess each individual as necessary if their exposure approaches action levels.  Most of the times, this will entail adjusting ones compounding techniques to ensure practice of “ALARA” principles.  Each pharmacy will also have a “Radiation safety officer” (who may or may not be a pharmacist), and they are responsible for overall safety at the pharmacy: monitoring air concentrations, training personnel, and keeping employees under all federal/company radiation guidelines.  Pregnant women can officially declare their pregnancy to the company as well, and will receive an additional fetal badge to be worn near the belly.  She will have even stricter limitations to restrict the amount of radiation exposed to the child.

Advantages of Becoming a Nuclear Pharmacist

As mentioned earlier, this is a very specialized field and there is a general appreciation for the training/education a nuclear pharmacist has received.  As you read in the description of a typical day in the pharmacy, (barring any problems), the pace is generally pretty relaxed with some lag time, especially at night.  You become very close with your staff (technicians, drivers, administrators) and get to know your customers very well.  You are treated as a professional and they value your input and services.  After you’ve gotten enough hours under your belt, you’re also able to become board certified (BCNP) if you so desire; nuclear pharmacy was the first specialty area established by the BPS.  There’s definitely opportunity for job growth through management.  Nuclear pharmacy is a neat balance between clinical pharmacy, physics, chemistry, math, management, business/sales, customer service, current issues like the application of USP <797> across the industry; there is a little bit of everything for everyone.

Disadvantages of Becoming a Nuclear Pharmacist

The reality is, we deal with radiation and biohazardous material on a daily basis.  We are however, provided with the training on how to deal with this properly, and it is in your own interest to do things by the book.  Over-night hours are another stickler for some people.  A fully staffed pharmacy though, will permit pharmacists to rotate their shifts.  It may be possible that you will only have to work the opening shift one week out of every four to six.

Specializing in this field also requires us to keep up with “regular” pharmacy.  Many times, hospital/retail pharmacists will not know what Cardiolite® is, but nuclear pharmacists rarely talk about the new factor Xa inhibitor anticoagulant either.

Many people ask me whether it’s difficult to find a job as a nuclear pharmacist. The answer is: no.  It’s not hard to find “a” job; there will always be a demand for a well-trained specialist, however, unlike retail pharmacies, you’re not exactly going to find a nuclear pharmacy on every corner.  As a result, it may take a little longer to find “the” opening you want, in the specific city/state you’re interested in.

Thank you for your interest in this topic; hopefully this article will spur further discussion of nuclear pharmacy and nuclear medicine on the SDN Forums.  It’s a fascinating specialty practice that allows pharmacists to excel and provide valuable diagnostic and therapeutic options for our patients.

I encourage all students who are interested in the field to take an elective at your school if one’s offered, sign up for a nuclear rotation, or even contact a nearby pharmacy to shadow a pharmacist for a day.

Since October is National Pharmacists Month, now is an excellent time to examine the evolving role of pharmacists in the modern health care system. The profession of pharmacy is going through a period of vast development and change. Instead of being tied solely to the product of medications and dispensing, it is diligently recreating its image into an increasingly cognitive practice.

Pharmacists have become such an integral part of the health care team because they have the unique advantage of being among the most accessible health care professionals. As patients come in once a month to refill a prescription, the pharmacist tends to be the professional that they see the most regularly.

Unfortunately, due to the mandates of insurance companies, physician visits are growing shorter and shorter these days.

If a patient presents for an acute condition during a physician visit and that condition is addressed and cared for, there is generally little time left for the management and care of any chronic conditions. It is in the management of such chronic conditions that the cognitive services offered by pharmacists can be useful.

Chronic medical conditions are not uncommon across the country. Focusing on the Medicaid program alone, approximately 30 percent of recipients have a diagnosed chronic medical condition . Not only are these chronic conditions physically taxing for the afflicted individuals, but they also have significant financial impacts for the Medicaid system. Approximately 83 percent of spending for Medicaid is dedicated to people with multiple chronic conditions . As a result, new strategies have to be developed to deal with this sizable issue. In the state of Iowa for example, one strategy to combat chronic conditions is through a program called Pharmaceutical Case Management (PCM). A collaboration between physician and pharmacist, a patient is identified as being at high risk for potential drug interactions and/or adverse drug reactions based on the disease states and number of medications being taken. Through an interview and consultation process, pharmacists can thus help manage the long-term care of chronic conditions in an effective way.

Begun in 2000, the Iowa Medicaid PCM program has allowed pharmacy to take on a new role for patients. By looking at the pharmacy dispensing system and refill history, a patient is identified for eligibility. In order to qualify for the Iowa PCM program, patients must have one of 12 different chronic disease states and also be on four or more chronic medications. Additionally, they must not reside in a long-term care facility. When a patient is identified, eligibility for the program is verified by Iowa Medicaid which will pay for the services provided. After this step, the patient is contacted to come into the pharmacy for an interview. To enable the pharmacist to get a better understanding of the patient, a simple patient history form is filled out discussing disease states, hospitalizations, and common background questions. The interview then proceeds by reviewing the background paper, the medications, and the refill history of the patient. The goal of a PCM interview is to identify drug therapy problems such as:

1. dose too high
2. dose too low
3. wrong drug
4. untreated condition
5. drug therapy for unidentified condition
6. drug interactions with other drugs/food/labs
7. adverse drug reaction and/or inappropriate compliance

Following this interview, a SOAP note is sent to the physician involved in the care of the problem. There is variety in how SOAP notes can be written. Some pharmacists like to focus on one patient problem at a time, while other pharmacists identify all the problems in one SOAP note. The SOAP note is documentation of the interview and also enables the pharmacist to communicate with the primary care physician and relay information from the interview to the physician.

The most intriguing portion of the Iowa Medicaid PCM program is that is based in a community pharmacy setting. Traditionally, community pharmacy has been driven by dispensing functions. However, as pharmacy continues to grow and expand services (especially cognitive services), PCM is going to be an increasingly important program. As mentioned earlier, community pharmacists are the most accessible health care providers for some patients. By providing this service in the outpatient and community settings, the focus can remain on the management of the chronic condition rather than being involved in the patient’s immediate hospital care needs.

With this new program comes special considerations for the practitioner as well. In order to provide PCM services to Medicaid patients, pharmacists must have completed one of two training modules. Either they must be a Doctor of Pharmacy graduate, or they must complete a training program through Iowa Center for Pharmaceutical Care (ICPC). The pharmacist then has to complete an application and submit five patient care SOAP notes completed in the past six months.

The Iowa Medicaid PCM program reimburses pharmacies for providing not only the initial interview but also any necessary follow-ups. Initial interviews are reimbursed at $75 with preventative problem follow-up assessments reimbursed at $25. The preventative problem follow-ups can be done once every six months. If a problem is identified, problem follow-up assessments can be completed and reimbursed at $40 per occurrence, up to four times in a 12-month period. If a new problem is identified, this can be reimbursed two times per year. In this way, the program is designed to provide long term follow-up and maintenance for the patient while truly managing the patient’s chronic condition.

As PCM is a new service provided to patients enrolled in Iowa Medicaid, the program has been evaluated with significant results having come out of the review. During the study period, pharmacists identified 2.6 drug related problems per patient. The most common recommendation of pharmacists was the addition of another medication, such as a beta-blocker or aspirin for a heart attack patient. While Iowa Medicaid paid a total of $94,170 for PCM services,there was no net increase in the health care utilization costs or charges for patients who received PCM services versus those patients who did not receive them.

By helping to manage the chronic conditions of eligible patients, the Pharmaceutical Case Management program has great potential to positively affect the Medicaid population. As health care continues to evolve and become more team oriented, pharmacists are going to be asked to take on more responsibility in the care for patients. Pharmacists in the community setting are poised to help manage patients at great risk to adverse events due to their medications. By demonstrating their success to both insurance companies and the greater medical community, hopefully services such as PCM will continue to grow.

1. Agency for Healthcare Research and Quality. Accessed Sept. 20, 2008. Available at http://www.ahrq.gov/qual/medicaidmgmt/medicaidmgmtint.htm
2. Agency for Healthcare Research and Quality. Accessed Sept. 20, 2008. Available at http://www.ahrq.gov/qual/medicaidmgmt/medicaidmgmtint.htm
3. Iowa Medicaid Pharmaceutical Case Management Program Final Report December 2002. Accessed Sept. 20, 2008. Available at http://www.iarx.org/Documents/PCM%20Final%20Report.pdf.

While some associate prescription drugs with expense and inconvenience, others seek out the drugs, lying to get prescriptions, and buying pills illegally. Such “drug seeking behavior,” familiar to medical professionals when it involves Ritalin, OxyContin, Xanax, or any number of drugs noted to increase productivity, sink patients into an opiate-induced haze, or sedate those wishing to evade the stresses of life, abuse of anticonvulsants, antipsychotics, antihistamines, and others, represents a new frontier of drug abuse.

One of the more well-known and well-documented drugs of abuse, diphenhydramine is an antagonist to the H1 receptor, which seems, given its over-the-counter status, to be innocuous. Like many sleep aids, including the more recently developed Ambien, the drug was at first touted as having low associated risk of dependency (1). However, there has been much evidence to the contrary.  In low doses, the drug has its indicated sedating effects while in larger quantities it can produce a euphoric high and possible associated hallucinations (2). Diphenhydramine is particularly desirable as it is cheap and requires no prescription. Thus it is especially hazardous to adolescent populations unable to obtain more hard-core street drugs.

Some newer drugs, including Seroquel and Neurontin, have also demonstrated abuse potential. Seroquel, an atypical antipsychotic familiar to psychiatrists as a treatment for schizophrenia and bipolar disorder, is known on the streets as quell, Suzie Q, baby heroin, and, when combined with cocaine, a Q-ball. In the latter example, Seroquel replaces heroin in the usual cocaine-heroin speedball recipe (3). The abuse potential is thought to be due to its sedating effects, most likely secondary to histamine H1 receptor antagonism. There is much anecdotal evidence to bolster this theory as one patient reportedly took the drug to “mellow out” and another compared the drug to clonazepam.

Drug seeking and Seroquel abuse have been particularly problematic in prison populations. One report on the Los Angeles County Jail states that about a third of those prisoners seeking psychiatric help may be malingering to obtain Seroquel. Knowing that the drug is used to treat psychosis, prisoners mimic these symptoms, often reporting that they hear voices (4). Such drug-seeking behavior has also been noted outside of the prison population, including the case of one man who stole his girlfriend’s Seroquel. In another case, a patient who was prescribed the drug legitimately, for bipolar disorder, resorted to taking more than his prescribed dose.

While Seroquel has received much recent attention as an insidious drug of abuse, other drugs outside of the usual stimulants and benzodiazepines have been noted to have abuse potential. Neurontin, used to treat both epilepsy and neuropathic pain, has recently been noted as a potential drug of abuse.

The drug is known also to have a sedating effects with an accompanying high similar to that produced by marijuana (5). This is somewhat less well-documented. One patient, known to have a history of alcoholism, reported that it reduced his cravings (6) and another patient resorted to drug-seeking behaviors (5). Both experienced withdrawal symptoms upon cessation of the drug.

Abuse of diphenhydramine, Neurontin and Seroquel illustrates the point that doctors must proceed cautiously when dealing with patients who appear to exhibit drug-seeking behavior towards drugs not normally known to be abused.

(1) Roberts, K., Gruer, L., Gilhooly, T. Misuse of diphenhydramine soft gel capsules (Sleepia): a cautionary tale from Glasgow. Addiction. 94; 10, 1999.

(2) Halpert, AG., Olmsead, MC., Beninger, RJ. Mechanisms and Abuse Liability of the Anti Histamine Diphenhydramine. Neuroscience and Behavioral Reviews. 26, 2002

(3) Waters, BM., Joshi, KG. Intravenous Quetiapine- Cocaine Use (Q Ball). Am J Psychiatry 164:1, 2007.

(4) Pierre, JM., Shnayder, I., Wirshing, DA., Wirshing, WC. Intranasal Quetiapine Abuse. Am J Psychiatry. 161:9, 2004

(5) Vigneau, CV., Guerlials, M., Jolliet, P. Abuse, Dependency, and Withdrawal with Gabapentin: A first Case Report. Pharmacopsychiatry. 40, 2007.

(6) Pittenger, C, Desan, PH. Gabapentin Abuse and Delierium Tremens Upon Gabapentin Withdrawal. J. Clin. Psychiatry. 68:8. 2007.

This February, SDN introduced the first admissions guide for pharmacy school applicants. The Student Doctor Network Pharmacy School Admissions Guide aims to help prospective pharmacy students make an informed career decision and to guide them through the school selection, application, interview, and admissions processes. The 140 page guide contains perspectives from a wide variety of students and practitioners who share their advice and real life experience and other helpful features such as a mock interview outline, an overview of the profession, and recommended reading links. To order a copy of The Student Doctor Network Pharmacy School Admissions Guide, please visit Amazon.com.

Table of Contents

• An introduction to pharmacy as a career
• An overview of professional duties
• Required training, education, and licensure
• Career and employment opportunities
• Preparing to apply to PharmD programs
• Choosing your potential schools
• Prerequisites to admission
• Building your qualifications
• Required examinations
• Financing your PharmD
• The PharmD admissions process
• Preparing your application
• Letters of reference
• Personal statements
• Interviews
• Responding to offers of admission
• Reapplication
• Recommended reading for prospective PharmD students
• Real students, real answers
• Practitioner interviews

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Scenario
An 18 year old male presents to the ED where you are working at about 3 am after being at a “rave.” The patient is staring off into space, clenching his jaw, and trying to hug the nurse as she starts an IV. The nurse has difficulty starting the IV due to patient’s dehydration. You notice his pupils are enlarged and he is tachycardic, he grabs your pen light and stares into it and moves it around in circles. His body temperature is elevated. Would you know what substance was most likely the cause of this patient’s condition?

Background
Club drugs take their name from their association with raves, all-night dance parties typically hosted in unremarkable locations such as warehouses. Party-goers, known as “ravers” often supplement this sensory barrage with a variety of mind altering substances, hence the name “club drugs.” It is important for those in the medical profession to recognize the presentations of various drug-related syndromes in order to provide the best treatment. We also need to be able to communicate with patients about their drug use. Test your drug knowledge on the following words and phrases (answers are at the end of the article):

• Skin popping
• Foxy methoxy
• Chasing the dragon
• Robotripping
• K-hole

If your response to reading over this list is a blank stare and a furrowed brow, read on. Yes, medical students need to get hip with what the kids are doing these days. Not only is it crucial for those occasions when your family and friends turn to you as the resident medical guru, it’s also on the boards!

So without further ado, let’s review the commonly abused drugs and some of their features that you may be tested on, pimped about, or just generally exposed to during your medical training.

Alcohol is one of the most commonly abused substances, and therefore one of the substances you should be the most familiar with – preferably not because you are drowning your sorrows about that last exam in a bottle of cheap whiskey. Alcohol is a CNS depressant that appears to act mainly as an agonist on GABA receptors and a blocker at NMDA receptors. It is more correctly referred to as ethanol or “EtOH” because there are other types of alcohols, including methanol (solvent alcohol), acetone (nail polish remover), and ethylene glycol (antifreeze). All these are part of the classic “MUDPILES” acronym for anion gap acidosis, because they are metabolized to ketoacids.

Useful Facts

• One drink = 1 shot = 1 glass of wine = 1 beer, each drink should elevate the blood ethanol level by approximately 20mg/dL, and coincidentally, this is about the amount that is metabolized by the average person in one hour.
• You must be able to identify alcohol withdrawal, for two reasons: one, it often presents in hospitalized patients who have not revealed that they are dependent on alcohol, and two, it can kill you. Therefore, when a patient on the wards (or in a board question) becomes tachycardic, agitated/tremulous, diaphoretic, and hypertensive, if you are the only one on the team to think of ethanol withdrawal, you’ll look like a superstar. Classically (in a board question) the patient will have been in the hospital for about 3 days, but in reality, onset can be as early as a few hours after the last drink. Another presentation that should raise your antennae is a patient with no history of seizure disorder who has a seizure after a day or two in the hospital. These seizures do usually have a brief post-ictal state, and are often accompanied by the other manifestations of ethanol withdrawal. Ethanol levels are likely to be negligible or zero, but should be drawn.
• The big names to associate with alcohol are Wernicke and Korsakoff – a.k.a Wernicke-Korsakoff syndrome, which is a result of thiamine deficiency related to alcoholism. Wernicke’s encephalopathy is ataxia, altered mental status, and ophthalmoplegia. It can progress to Korsakoff psychosis, in which patients cannot recall events and so they create improbable stories to explain what has happened. This is called ‘confabulation’. Many a medical student has been fooled by a confabulator. Remember – if a wild tale starts sounding way too wild to be true, you might be dealing with a confabulator.
• Fun fact: ethanol is the treatment for methanol poisoning, because it competitively inhibits methanol turning into formate. “Nurse, get this man a liter of IV tequila – STAT!”

Cocaine is another one of the most dangerous drugs of abuse to look for, especially since reportedly, use of cocaine has increased significantly among college students. Cocaine can be used in a number of ways – the important thing to realize about it is that as the cocaine is purified, the “high” is shorter and the addiction potential is greater. While chewing on a coca leaf can make a user feel mildly euphoric for a few hours, smoking crack cocaine gives the user a rush before they even have time to exhale. Cocaine use results in tachycardia, but also can cause dangerous arrhythmias, and can precipitate myocardial infarction through coronary vasospasm. The mainstay of treatment is benzodiazepines.

Ecstasy (MDMA) is probably the most famous club drug, popularly used at raves and dance clubs. It came to prominence in the 1960s and 1970s when it was used as part of psychotherapy, for which it appeared useful to facilitate communication as part of relationship counseling. It is a synthetic drug that is used in pill form. The pills may be colorful and imprinted with different logos and symbols. The most common concern for side effects of ecstasy is during its use at dance parties, when users may go for many hours without drinking enough water to stay hydrated. The combination of increased temperature and dancing can cause significant dehydration. Common effects include euphoria and increased appreciation of tactile stimuli, such as in the scenario presented at the beginning of this article. Ecstasy is unlikely to kill users and usually only results in death if combined with other drugs. Treatment is symptomatic.

Methamphetamine is known on the street as “speed” or “crank” – or just “meth.” A powerful stimulant, methamphetamine increases levels of brain dopamine significantly, resulting in increased movement and enhanced mood. Although methamphetamine is classified in DEA Schedule II, it is not widely prescribed. The vast majority of methamphetamine abused in the United States today is imported illegally or made in small, covert labs stateside. The process of making methamphetamine is very dangerous, utilizing toxic chemicals with a high risk of explosion. These illicit “meth labs” endanger both the users engaged in “cooking” the meth as well as neighbors and the environment.

Methamphetamine can be taken orally, by snorting, by injection, or by smoking. Tolerance and addiction are often rapid. Symptoms of methamphetamine use include wakefulness, increased physical activity, loss of appetite, rapid heart and respiratory rates, increased blood pressure and hyperthermia. Users may experience insomnia, anxiety, confusion, tremor, convulsions, aggression, hallucinations, memory loss and severe dental problems. Treatment for methamphetamine addiction is challenging and should include cognitive-behavioral therapy to help break deeply entrenched patterns of abuse.

Mushrooms have been known for their psychoactive properties for centuries. When you hear people referring to “shrooms” as a hallucinogen, they’re generally referring to Psilocybin mushrooms, also known as “magic mushrooms”. Mushrooms that contain the compounds psilocybin or psilocin cause users to have hallucinations and feelings of euphoria that last about 6-8 hours. Contrary to popular belief, the effects are not due to the “poisonous” nature of the mushrooms. In fact, the National Institute of Occupational Safety and Health’s Registry of Toxic Effects rates psilocybin’s toxicity at 641 (with 1 being most toxic), compared to aspirin at 199 and nicotine at 21. A person would reportedly have to consume his or her own body weight in psilocybin mushrooms to take a lethal dose. Not surprisingly, then, treatment is mainly observation and supportive care until the effects wear off. Psilocybin can be much more dangerous when used with alcohol or marijuana, due to increased amounts of risky behavior. Unpleasant side effects can include nausea and vomiting.

Heroin was marketed by Bayer from 1898-1910 as a cough syrup and as a cure for morphine addiction, until the public discovered that heroin is merely an acetylated form of morphine which is not only converted to morphine as it is metabolized in the liver, but also is approximately twice as potent. This brought bad press for Bayer. Heroin is well-known as a highly addictive substance which can cause withdrawal symptoms after just a few days of use. Its classic effects include CNS/respiratory depression and miosis (pinpoint pupils). Withdrawal from heroin, referred to by patients as being “dope sick”, results in numerous unpleasant symptoms such as malaise, nausea and vomiting, diarrhea, muscle cramping and aches. You may note that your patients also begin yawning as they go into withdrawal. Withdrawal can be abruptly precipitated by the use of naloxone (Narcan), an opiate antagonist. This can have the unfortunate effect of causing the patient to go from a comatose state to an agitated, “dope sick” state which can be followed by the patient’s rapid departure against medical advice to seek more heroin. For this reason it is advisable to titrate naloxone by using small doses. It is important to note that however unhappy those in heroin withdrawal may be, withdrawal from heroin cannot kill you. Heroin is most commonly injected IV but can also be snorted or injected subcutaneously. Heroin plus cocaine injected IV is known as a ’speedball’.

Ketamine is a dissociative anesthetic that is used in veterinary and human medicine. Classified as an NMDA receptor antagonist, ketamine induces a state known as dissociative anesthesia, in which signals from the conscious mind to other parts of the brain are blocked. Ketamine is primarily used in the induction and maintenance of general anesthesia, usually in combination with a sedative. Because it produces less respiratory depression than other anesthetics, Ketamine is useful in children and in emergency department patients with unknown medical histories. Besides its legitimate medical uses, Ketamine, or “Special K” is often used illicitly. Symptoms of Ketamine intoxication include sedation, hallucinations, a sense of bodily detachment, sensory distortions and unintelligible speech. No antidote exists and treatment is supportive.

PCP or phencyclidine is a dissociative hallucinogen that can be used either in crystalline or liquid form. In the liquid form, cigarettes or joints my be dipped in PCP then smoked. Its best known street name (though it has many) is “angel dust”. On a typical exam question, a patient will present to the emergency room with tachycardia, agitation, and potentially nystagmus or ataxia. The hallmark of phencyclidine on an exam question is that the patient will be engaging in highly violent behavior. The drug can cause behavioral disturbances as well as decreased pain sensation, the combination of these two factors increase the risk for violence.

GHB made headlines worldwide last month when it was revealed that the Chinese-made toy Aqua Dots was coated in a chemical that, once metabolized, converts into the “date rape” drug gamma-hydroxy butyrate. A massive recall and tons of publicity left many worried parents wondering, “what is this drug?”

GHB is known on the street as Grievous Bodily Harm, Georgia Home Boy or Liquid Ecstasy. It is a clear liquid that resembles water but has a slightly salty taste. Banned in the United States, GHB is nonetheless available for purchase on the internet or imported from other countries. Often sold in small bottles, GHB can be mixed with water or combined with other beverages to conceal its flavor. The ability to slip this substance into the drink of an unsuspecting victim, along with its sedative and amnestic properties have implicated GHB as a drug used in facilitated sexual assault.

The classic signs of GHB intoxication are CNS and respiratory depression, but GHB also has effects on other organ systems. Symptoms may include nystagmus, ataxia, seizures, vomiting, somnolence and aggression. Extreme CNS depression is most commonly observed in patients presenting to the ED with GHB overdose, but this CNS depression may resolve suddenly due to rebound effects from the drug. A patient may go from completely unresponsive to agitated and combative in a very short time frame.

Benzodiazepines or “benzos” are a class of prescription drugs with varying hypnotic, anxiolytic, sedative, anticonvulsant, amnestic and muscle relaxant properties. They are useful in the induction of anesthesia and the treatment of insomnia, anxiety, agitation, seizures, muscle spasms and alcohol withdrawal. Recreational users of stimulants may use benzos as a means of “coming down.”

Benzodiazepines exert their action at the GABA-A receptor in the CNS. Taken alone, benzodiazepines are considered very safe. When combined with other substances such as alcohol, serious or fatal CNS, respiratory or cardiovascular depression may occur. Symptoms of benzodiazepine intoxication include drowsiness, ataxia, confusion and vertigo.

Common benzodiazepines used in practice include alprazolam (Xanax), clonazepam (Klonopin), diazepam (Valium), lorazepam (Ativan), midazolam (Versed) and temazepam (Restoril). Rohypnol (flunitrazepam) is a type of benzodiazepine that is available in Mexico and Latin America and imported illegally into the United States. Particularly insidious are its amnestic properties and its tasteless, odorless formulation. These characteristics make “roofies,” as they are popularly known, a frighteningly effective tool in drug-facilitated sexual assault. The danger of this drug contributed to its inclusion in the Drug-Induced Rape Prevention and Punishment Act of 1996.

Drugs used for date rape such as Rohypnol and GHB can only be detected within a short time of ingestion on a drug screen, so if there is any question of their use, patients must be tested as soon as possible. Standard drug screens may not capture these chemicals; practitioners should make sure to specify the need to test for these drugs if their presence is suspected. This can be challenging as part of the drugs’ effectiveness is their ability to cloud the memory of their victims, leaving doubt about the events that transpired.

Answers to quiz:

• Skin popping is the street name for injecting drugs like heroin subcutaneously instead of IV. It’s a high risk behavior for abscesses and other infections.
• Foxy methoxy’s chemical name is N,N-Diisopropyl-5-methoxytryptamine (5-MeO-DIPT) – it really rolls off the tongue, doesn’t it? Foxy is a short-acting psychedelic that can be swallowed, snorted, or smoked.
• Chasing the dragon is a phase that originated in Hong Kong, referring to inhalation of fumes while heating heroin. It is linked to the development toxic leukoencephalopathy, the pathophysiology is unknown.
• Robotripping refers to tripping by drinking Robitussin or other cough syrup to achieve a hallucinogenic amount of the chemical dextromethorphan or DXM.
• A “K hole” is a term for the dissociative effects of ketamine intoxication.

What about our patient? Have you figured out what substance this young man has ingested? From his clinical presentation, the likely answer is MDMA. The big clues are: hugging (MDMA is often referred to as the “love drug”), bruxism (clenching of the jaw – one reason that ravers are often seen sucking pacifiers), increased body temperature and dehydration. This patient has probably been rollin’ (slang for being high on MDMA). Good job!

Resources

NIDA Info Facts: Methamphetamine
http://www.nida.nih.gov/Infofacts/methamphetamine.html

E-medicine: Club Drugs
http://www.emedicinehealth.com/club_drugs/article_em.htm

StreetDrugs.org
http://www.streetdrugs.org

Midwest Emergency Services: GHB
http://midwestemergencyservices.com/news/0405/ghb_intoxication.html

The issue is often framed as a question of patient rights vs. pharmacist rights, due to the public controversy over the emergency contraceptive “Plan B” which has unfolded over the past decade. However, the issue carries broader implications, extending to drugs intended for abortion or immediate post-abortion care, lethal injection for use in the potentially abused medications such as narcotics.

The stakes are so high for interested parties that states across the country have been pressured to take a position for or against pharmacists’ refusal to fill through legislation and policy changes. As of November 2006, five states (AR, CA, GA, MS, SD) have chosen to codify the right of a pharmacist to refuse to fill a prescription on moral grounds, while four (IL, MA, NC, PA) have passed legislation requiring pharmacists to fill or transfer certain prescriptions.¹

On March 23, 2007, Washington became the 5th state to take a stance against refusal to fill when their Board of Pharmacy amended policy to require that pharmacists make a good faith effort to fill any legal and medically appropriate prescription.² At the same time, the Board set standards defining and mandating professional behavior in cases when declining to fill is unavoidable. Specifically, pharmacists may not destroy or refuse to return a lawful prescription, violate patient privacy or rights under federal anti-discrimination laws, or intimidate or harass a patient.

Some states’ laws are broad in scope, applying to all medications, while others apply only to certain controversial prescriptions. Unfortunately, in each of the states mentioned above one group loses out, with the needs of either patients or objecting providers remaining entirely unaddressed.

For patients wishing to fill a controversial medication, the inability to access a willing healthcare provider is a barrier to care. Sometimes that barrier can be overcome by simply seeking out an alternate care provider. In other cases, no alternate is available. Some patients may be unable to access an alternate due to personal limitations such as transportation, insurance coverage, finances, prior time commitment to an employer, or lack of knowledge about where and how to access alternate care.

As with emergency contraception or pain medication, timely access to medication may be crucial, so a temporary delay may be undesirable, despite the presence of other accessible medication providers. Regardless of the feasibility of seeking care elsewhere, many patients are simply upset that a third party would have the power to refuse to fill a valid prescription when they have a legitimate medical need.

Often, refusal to fill is an issue of professional discretion, basic moral freedom, or practice of religion. Some practitioners feel that they should be able to decline any prescription for any reason because imposition of any limitations would impinge upon their professional discretion. This is a legitimate concern, as even legally written controversial medications may be inappropriate due to medical contraindications.

Others feel that because their license is on the line every time they fill a prescription they should be the one to decide when not to fill a medication. Independent pharmacy owners and those who have chosen to practice in religiously affiliated healthcare systems may be especially adamant about the right to determine their own scope of pharmacy practice, limiting it to those items which they can dispense in good conscience.

A mandate to participate would harm some practitioners, forcing them to choose between religious or moral convictions and their perceived professional duties. Where religious freedoms are denied, such legal statutes may be unconstitutional. Ironically, such laws could make lawbreakers out of otherwise good practitioners who refuse to stand down on the issue. The situation is especially frustrating for providers with religious or moral objections, as many entered the profession before the advent of controversial medication such as emergency contraception and are now confronted by a dilemma they could not have foreseen.

While some pharmacists are adamant about the right to refuse to fill a legally written prescription on moral grounds, there is no consensus on the issue within the profession. Many pharmacists disapprove of refusing to fill a prescription on moral grounds, citing that it is an unprofessional imposition of one’s personal morality on the patient. A handful believe that this offense is egregious enough to warrant dismissal from the profession.

Others support the right of a pharmacist to refuse to fill so long as the patient is able to obtain the medication elsewhere. It may be considered essential that the medication be provided by someone on-site, or acceptable to refer the patient to a provider at a different location.

To further complicate matters, individual pharmacists may be willing to accept some moral objections, but not others. For example, most pharmacists consider it not only acceptable but morally responsible to decline early refills on narcotic medication. For no definable reason, others may be willing to accept religious objections when it comes to abortifacients, but not when it comes to the emergency contraceptive, Plan B. The only uniting thought seems to be disgust and frustration at the negative media attention brought on the profession by the refusal to fill issue.

Refusal to fill will continue to be an issue until controversial medications are readily available to those who seek them. To those who see refusal to fill legislation as an easy fix – on either side of the dilemma – I submit that it is no fix at all. Only by making an abundance of willing providers available to the public can we truly eliminate this dilemma.

Instead of berating those who do not feel comfortable dispensing controversial medications, we should be working to improve the number of access points. Prescribers of known controversial medications can help improve patient access by suggesting to their patients at least one pharmacy that is known to stock and dispense the prescribed medication. If no local dispensing sites are known, in-office dispensing should be considered.

Pharmacists can help by making themselves known to key providers as dispensers of controversial medications and by placing themselves on provider lists where they exist, such as the national Plan B registry administered by Princeton University.³ Development of local provider registries by public health departments or public minded healthcare providers can also promote access to controversial medications.

Those of us who gladly dispense controversial medications need to step up and announce our presence. Only when the public knows who we are and how to access our services will the controversy be over.

References

1) Hopkins, Denise and Marsha Boss. “Pharmacists Right to Refuse to Dispense
Prescriptions Based on Moral Grounds: A Summary of State Laws and
Regulation.” Hospital Pharmacy. 41 (2006): 1176-1179.

2) “Professional Responsibilities of Pharmacists & Pharmacies.” WAC 246-863-095,246-
869-010. 2007. Washington State Board of Pharmacy. 27 February 2007.

3) Office of Population Research. “Emergency Contraception” 2007. Princeton
University. 4 April 2007.

While handwriting doesn’t play a major role in most peoples’ careers, in the medical field, it can mean the difference between life and death. Whether it’s a mix-up between Lamisil and Lamictal, Cerebyx and Celebrex, Zyrtec and Zantac, or Sarafem and Serophene, confusion over drugs with similar spellings and similar sounds accounted for 15 percent of all errors reported to the United States Pharmacopeia Medication Errors Reporting Program from 1996 to 2001. In fact, it’s such a problem that the Food and Drug Administration even appointed a panel of experts to review proprietary drug names—just to try to alleviate such confusion in the future.

But beyond drug name mix-ups, poor penmanship also accounts for many other errors. From 1993 to 1998, a total of 52 deaths resulting from drug name errors were reported. And according to the Institute for Safe Medical Practices (ISMP), in the year 2000, indecipherable or unclear prescriptions resulted in more than 150 million calls from pharmacists to physicians asking for clarification—a time-consuming process that could delay important treatments, as well as lead to injury or even death.

These mistakes could also cost those involved. In 1999 in Texas, a jury awarded a woman $450,000 because her husband died from taking the wrong medication due to his doctor’s poor penmanship and the pharmacist mistakenly giving him the incorrect medication as a result.

“Reading prescriber handwriting is an acquired art,” explains Anna Peck, who is both a pharmacy student and worker. “Much of the ability to decipher prescriptions comes from pre-exiting knowledge of drug names and sig (shorthand) codes. Someone who practices in a retail setting may not be able to read messy hospital orders and vice versa.”

Peck says that last year, her state legislature (Wash.) passed legislation stating that cursive prescriptions are deemed illegible and must be verified by phone or fax, or simply rewritten.

“In the two weeks between the passage of the law and when word came around that the Board of Pharmacy was not enforcing it, I learned that forcing prescribers to write in block letters does not make crappy handwriting any better,” she added. “In fact, cursive is usually easier to read.”

At Cedars-Sinai Medical Center, the powers that be have offered special classes in handwriting for members of their medical staff. After contacting a firm that specialized in teaching people good penmanship, nurses and administrative staff were asked to help identify physicians who would most benefit from the class. The three-hour course was self-instructional and emphasized a cursive italic handwriting style, with tips on the correct position of the paper, the size of letters, the length of strokes, and how to hold the writing instrument.

Beyond penmanship pointers, the ISMP advocates the use of electronic prescribing tools that computerize the process of ordering prescriptions, which has been shown to reduce potentially harmful prescription errors, allergic drug reactions and excessive drug dosages. These computers also check for drug side effects, drug interactions and inappropriate dosages, among other errors.

But if a physician is planning to stick with pad and pen, experts recommend using caution when writing prescriptions or orders for drug products with brand names similar to other brand named drug products, generic names similar to other generic named products, or brand names similar to other generic named products.

While Peck has heard of one guy in Everett, Wash., whose handwriting was so bad that the state board restricted his prescriptive authority to typewritten or electronically generated prescriptions, she says, “Honestly, most of the prescriptions we get are ultimately legible, even if they appear messy.”

“I’d venture to guess that quite a few more mis-fills are blamed on ‘illegibility’ than are actually caused by it. Often, bad handwriting is used as an excuse for sloppy eyesight or other errors. A truly illegible prescription usually cannot be read at all and the prescriber must be contacted for clarification. Only rarely do we find that we truly misread one drug as another, one dose as another, or one sig as another, because the item was really ambiguous and that fact eluded us.”