We recently busted someone who tried to fill a fraudulent prescription for Lortab. This was the first time I've been involved from start to finish in a fraud case. I won't describe the mistakes these crooks made, because I don't want a reputation as the blogging pharmacy student who divulges pharmacy's tricks of the trade for identifying fraudulent prescriptions for the benefit of inquisitive potential drug abusers, but suffice it to say, these people were rank amateurs. They did everything wrong, and it was a textbook case on identifying and thwarting prescription fraud. These were the kind of crooks who will get caught and arrested long before they successfully forge a script, if that's any indication how dumb they were.

I said I wouldn't describe the mistakes they made, which I won't, except for one exception to illustrate just how dumb these people were. The suspect had withdrawal shakes when presenting to the pharmacy. Yes, that's how bad they were, and they were only getting started. I guess they didn't realize pharmacists are trained to recognize the therapeutic effects, adverse reactions, and withdrawal symptoms of drugs, or they were too deep in the grips of withdrawal, and too desperate, to notice or to care.

Pharmacy may not always be fun, but it's never boring, that's for sure.

It ain't easy working retail. The vast majority of pharmacy patients I've served are no problem. A few are great, and a handful are your favorites. On the bell curve of the patient population, however, for every favorite, there is a very difficult patient. Don't mistake my choice of words as a weak vocabulary or unimaginative adjective selection. In the pharmacy setting, I'm a professional, folks, and I refuse to let my thoughts about any patient become negative in such a way that it would compromise my ability to treat them. As a medical professional, I don't care who you are; if you're my patient, you're entitled to a standard of care, and you'll get it, even if you pull a stunt like a patient recently did to a pharmacist I work with.

She's always been a difficult one, revving her engine in the drive-thru and peeling off through the four-way stop without stopping. I haven't begun relating the things she's said, but suffice to say, if you heard her, you'd think everyone in the pharmacy spent their day devising devious plans to make her day miserable.

To wit, after a recent change in her insurance plans, she was left without prescription coverage during the last week of the month. Those of us in the pharmacy are merely the bearers of bad news, a responsibility we loathe, because those are the times you see either the best or the worst in your patients. Whenever I have to relay such a message, I put myself in the patients' position and consider how I'd feel in such a situation, and go from there. I'm sympathetic, encourage them to call their insurance company, and often times have already called the insurance company myself to investigate.

Some folks understand we're not the bad guys. Some folks need to vent, and the pharmacy employee standing in front of them is way more accessible and timely than the insurance company's customer service line, so guess who gets it? That's right, the tech or pharmacist who just dropped everything else to try to resolve the situation with the patient's insurance company, or maybe someone who just started a shift and has no knowledge of the situation other than the handwritten sticky note on the receipt.

Anyway, our patient peeled out of the drive-thru, and the patient's insurance company called the pharmacy. The patient was on the other line, and the insurance company rep told the pharmacist, "We need to get her re-enrolled, and fast." I can only imagine what she said to the poor rep that persuaded him to call us at the pharmacy, because that's so untypical of an insurance company. So the pharmacist waited on the line, resubmitting the prescription claim multiple times until the rep properly re-enrolled the patient so that her claims no longer rejected, and she was able to fill prescriptions before her policy's official activation date.

Apparently, the patient wasn't aware of the pharmacist's assistance. The next morning, the store manager told the pharmacist she had filed a tearful complaint against him, and threatened to take the matter to corporate. She claimed he was refusing to fill her prescription and had been very rude. You know, I was there all three times she came through the drive-thru window, and the only person who had been insulting, the only person who had raised their voice, the only person who had rolled up their car window and turned up the volume on their radio while the other person was trying to speak, was the patient. The limit of the pharmacist's confrontational behavior was to offer to transfer the patient's prescription to another pharmacy of the patient's choice when it became apparent she could not be satisfied.

So, here is what I would ask of you. If you go to the pharmacy someday and they tell you there's a problem filling your prescription, please keep a few things in mind:

• Your pharmacy does not tell your insurance company what to do. It's the other way around.

• The advice we give you is sound advice. If we could have resolved the issue, we would have done so before you returned to the pharmacy. If you're having an insurance problem we can't resolve, odds are, you've had another problem at some point we were able to resolve without you ever knowing about it. We deal with insurance and prescription problems every day. We're not just drug experts, we're insurance experts, too.

• The pharmacist and other employees derive their livelihood from dispensing medications. They need you and other patients to put food on their tables. Without you, they don't get paid. Therefore, it is in their best interests to help you get your medicine.

• Your insurance company derives its livelihood from limiting healthcare expenditures. When problems arise with the cost of your medicine, or you're told your medicine requires something called a "prior authorization" from your physician, it's your insurance company, not us. Your insurance company is trying to keep your premiums low and make a profit.

• Do you blame the television reporter for all the bad in the world they tell you about on the evening news? Please don't blame us when we tell you there's a problem filling your prescription. Remember, if you don't get your medicine, we don't get paid.

• We're on your side, and want to help. It's a lot easier for everyone involved if you help us help you.

A retired pharmacist transferred his wife's prescriptions to my pharmacy and became a new customer. It took about two weeks, thanks to the Medicare Part D "doughnut hole," to make him an unhappy customer. He told us she was in the Medicare Part D "doughnut hole," the gap in the Medicare prescription drug plan where members are responsible for 100% of the cost of their drugs. I added his wife's medical info into her profile, and the pharmacist called the other pharmacy to transfer the prescriptions.

To soften the financial blow of the doughnut hole, the customer split the timing of his wife's prescription refills to be two weeks apart. So, he refilled half at the beginning of the month, and the other half at mid-month. This really distressed me. This guy was a pharmacist, so I knew he had lived a comfortable lifestyle, and now in retirement, he was struggling to keep the cost of his wife's medicines within budget. I can only imagine what seniors go through who have to take expensive medicines and didn't have pharmacists' salaries.

Before the customer left, I told him some Medicare Part D plans didn't have a doughnut hole because they charged higher monthly premiums. In all the confusion when the program was new and no one understood the details very well, a lot of folks didn't understand what a godsend a plan without a doughnut hole could be. So, since he knew his wife would hit the doughnut hole every year, it might be to their advantage to pay higher premiums and spread the cost over the entire year to avoid the financial shock of paying full price in the doughnut hole. He seemed to understand this, thanked me, and said he would call 1-800-MEDICARE to price out the available plans.

Since the Medicare Part D doughnut hole is complicated, this is an aside to briefly explain it. The doughnut hole begins when total cost of drugs reaches $2,250 and ends when the member has paid $3,600 out-of-pocket costs in any year. Depending on co-pays, the doughtnut hole could theoretically last for as long as $3,600 (if the patient had no co-pays) or as little as $1,350 (if the patient paid full cost for drugs, which isn't a realistic example, because with a full cost co-pay, such a patient would always be in the doughnut hole)

The customer returned last week for the second half of his wife's prescriptions. Despite knowing his wife was in the doughnut hole, the sticker shock caught him by surprise... over $200. But what can you do? What he paid was actually a price his Part D provider had contracted with the pharmacy. In other words, the full price for his wife's medicines was even higher than what he paid, probably $300, but the insurance company had contracted a "volume discount" price for its patients, and this reduced price is what patients in the doughnut hole actually pay. He sighed on his way out, and said, "I know, I need to find a plan without a doughnut hole, like you told me the other day."

He returned a couple days ago with his $200+ receipt, complaining we hadn't given him the 10% senior citizen discount on his wife's medicine. We do have a 10% discount program for seniors, which does include cash price prescriptions, but since he pays a contracted price set by his insurance company, we can't give him the 10% discount, because that doughnut hole price is technically his co-pay, and discounting or waiving prescription co-pays is insurance fraud. So...

There was nothing we could do for this customer, except show him what the full cash price would have been without the contracted price, explain this contract price was greater than the 10% discount he would have received without a Part D plan, and explain we legally could not discount the price. The customer grumbled about hogwash and having to deal with insurance companies as a pharmacist for 50 years, and still having them stick it to him in his pocketbook after he had retired.

But at least he understood and calmed down after blowing off steam. That's a big challenge -- it's not easy to distinguish who just needs to blow off a little steam and will calm down once they know you sympathize with their situation, and who will continue to escalate to the point of making a scene by screaming in front of other patients and scaring them away, insulting you personally, and being escorted out by security. That's the hardest part of the job.

That crazy essay I wrote for my "Overview of the U.S. Healthcare Delivery System" elective.

Another semester of pharmacy school is in the books, my third, with 8 credit hours of "A's" and 12 credit hours of "B's."

There was a close call with my parenteral compounding lab practical. This is a bit difficult to explain unless you're familiar with USP <797> and compounding sterile preparations. Suffice it to say, no matter how nervous you are, when you take your lab practical on USP <797> sterile compounding procedure, and notice the isopropyl alcohol spray bottle is missing from your station, you shouldn't cross the buffer zone to retrieve a bottle from another laminar airflow workbench unless you've first gowned up and put on your gloves.

The "buffer zone" is a holy area of cleanliness in a sterile compounding pharmacy. A demarcation line separates the buffer zone from the rest of the universe. On one side of the line is the pristine buffer zone, ISO Class 7 air, and the laminar airflow workbench or "hood." On the other side of the line is the rest of the universe... unclean, dangerous, and full of bacteria, particulates, and pathogens. Mere mortals are allowed to cross into the buffer zone only after completing a sacred cleansing ritual which includes:

• scrubbing from fingertips to elbows with chlorhexidine gluconate, povidone iodine, or other suitable antibacterial chemical
  
• wearing low-shedding clothes (scrubs)
  
• resanitizing the hands with alcohol-based cleanser
  
• wearing a non-shedding gown over the scrubs
  
• wearing a hair cover and face mask
  
• placing shoe coverings over footwear while simultaneously stepping into the buffer zone (shoe coverings cannot enter the buffer zone if they touch the floor anywhere in the rest of the universe)
  
• resanitizing the hands again with alcohol-based cleanser
  
• wearing latex, silicone, or similar gloves
  
• sterilizing unsterile gloves with 70% isopropyl alcohol

So when I noticed the isopropyl alcohol spray bottle was missing from my workstation, I announced this to the instructor, noticed the extra 10 bottles in a neighboring unused laminar airflow workbench, and proceded to cross into the buffer zone to retrieve a bottle without performing any of the sacred cleansing ritual! I didn't realize the mistake until an hour later as I was driving home. This could have been a major point deduction, but fortunately, the instructor let it slide.

I'm writing an 8-10 page double-spaced essay paper for my graduate elective class, "Overview of the U.S. Health Care Delivery System." The professor requires 7 literature citations. A few hours of keyword searches on Medline and Lexis-Nexis turned up 83 articles, which I'm reading tonight to prepare to type the paper.

With so many other school-related things to worry about, I don't know why I'm investing so much time in an assignment that accounts for 20% of my grade in a class that I find ridiculously easy. With a modest amount of effort, I got a 100 on the mid-term exam and an "A" on my presentation. I wish my pharmacy school classes were so generous and forgiving, and if I spend too much time on this paper, I'm really going to bemoan that sentiment.

The paper will discuss the healthcare system's strategies for dealing with increasing prescription drug costs. One-third of the paper will discuss the present situation, the next third will discuss the "future per literature," and the final third will be my opinion. I'm going to divide healthcare recipients into three groups and discuss cost containment strategies of each: employer-provided insurance recipients, state and federal government-provided insurance (Medicaid and Medicare), and the uninsured (cash and drug assistance program recipients). So that's three sections (present, future, opinion) and three groups of recipients. If I devote one page to each combination of section and recipient, I will have a 9 page paper.

Seems reasonable enough... but must... fight... demons... of... analysis-paralysis... and... procrastination!!!

The other night, an 8 or 9 year-old boy walked up to the grocery store pharmacy counter where I work. The conversation went something like this:

BOY: Hey, how are you all doing tonight?

PHARMACIST: We're fine. How are you?

BOY: I was wondering if you could give me something to make me look this this? (Shows us a muscle magazine turned to a full page spread of some steroid-enhanced body builder)

PHARMACIST: (Temporarily at a loss for words)

BOY: As you can see, I'm rather small, so I was wondering if you had any protein supplements or drugs you could give me so I could look like this?

PHARMACIST: Well, we'd need a prescription from your doctor to give you anything that'd make you look like that.

BOY: Oh, okay. Good night! (walks away)

US: (after sharing looks of bewilderment, hilarity ensues)

For the record, I was extremely disappointed in the FDA's decision to delay a decision on Plan B's approval for OTC use. This is old news from August, but after hearing an interview with Dr. Susan Wood on her decision to resign from the FDA's Office of Women's Health, I wanted to mention it. The FDA should operate independently of the nation's political quagmire, but after delaying a decision on Plan B after its own advisors gave the go ahead, I find the FDA's decision disturbing. Dr. Wood is a personal hero for having the guts to resign.

To hear Dr. Wood speak about her resignation, listen to the New England Journal of Medicine's podcast.

A news item from last Thursday that caught my attention:

Investigational Diabetes Drug Linked to Increased Risk of Death, Strokes and Heart Attacks

CLEVELAND, Oct. 20 - Researchers here said today that the use of the investigational diabetes drug Pargluva (muraglitazar) doubles the risk of death, heart attack and stroke, and they asked the FDA to delay approval of the drug.

In an analysis that was released online by the Journal of the American Medical Association, Steven E. Nissen, M.D., and colleagues at the Cleveland Clinic said the FDA should not approve Pargluva until its cardiovascular safety can be proven in "a dedicated cardiovascular events trial."

[...]

Last month an FDA advisory committee recommended approval of Pargluva by a vote of eight to one, and two days ago the FDA issued an "approvable letter" to Bristol-Myers Squibb and Merck & Co., which are jointly developing the drug. The FDA letter asked for more data about cardiovascular safety.

Muraglitazar's mechanism is similar to thiazolidinedione (TZD) drugs such as Avandia (rosiglitazone) and Actos (pioglitazone). These drugs for the treatment of type 2 diabetes activate the PPAR receptor to increase insulin sensitivity. PPAR receptors are present on adipocytes, which may be related to the drugs' effects on blood lipids. Hyperlipidemia is common in type 2 diabetics, so the TZDs' effects on blood lipids (lowered triglycerides, increased HDL and LDL) may influence their use. Pioglitazone has more favorable lipid effects (pioglitazone doesn't increase LDL as much as rosiglitazone), but also causes more weight gain. Finally, TZDs may also cause edema and should never be given to patients with severe CHF.

Using TZDs and muraglitazar for their positive effects on triglyceride and HDL levels must be carefully weighed against their negative effects on weight, edema (CHF), and LDL. Is the net effect on the patient positive or negative? It may be negative for muraglitazar, and it will be interesting to watch how the FDA proceeds with its approval. The recent delay on a decision to make Plan B available for OTC use shook my faith in the FDA a bit.

The second round of block exams is complete, and my stint with GE is complete. I have some time to write this month's post, even as I keep nodding off while sitting in front of the keyboard and monitor.

I'm taking an elective class in UK's MHA/MPA program track. I'm not in the MHA/MPA program, but I wanted to polish my MBA with some healthcare management classes. The class is HA-601, Introduction to the Healthcare Delivery System. What's so striking is that I scored 100% on the 8 essay question mid-term exam, but A's are few and far between in pharmacy school this year.

The lowest scores are always on the CAPP (Contemporary Aspects of Pharmacy Practice) exams (mean scores are in the 70s), but CAPP has low scores by design. While the other classes teach us technical knowledge of pharmacy, CAPP encompasses the duties and responsibilities of the pharmacist, the skills we need to actually do our job, such as clinical practice standards, legal issues, patient counseling, compounding, IV admixtures, prescription errors, math, and other stuff like that. CAPP strengthens our skills with countless impossible/unreasonable challenges. So we ignore CAPP because it's supposed to be hard, and there's always a curve.

CAPP aside, the killer test this round was immunology, and that's the class consensus. Our immunology professor says we don't laugh at his jokes. He must be taking our "tough crowd" response personally, because he's mentioned it to enough people that it's starting to come back around to us through the grapevine.

I honestly believe he doesn't like us. Both times on test day, before handing out the exam, the professor has told us that he's writing more challenging exams this year that "will make you think." While handing out the second test, he went so far as to say, "This is a challenging exam. If you didn't study, you're going to be really pissed off." Even though I had studied, I immediately knew that I was going to be pissed off, anyway. Sure enough, there were multiple instances during the exam when indiscretion got the best of me, and I had several stinging thoughts directed toward the man.

It's been long time since I've written, eh? My second year of pharmacy school is underway, the first round of tests completed, and it's been busy. The second year is supposedly the hardest, and I'm currently working two part-time jobs. My exam scores suggest I have too many irons in the fire: one "A," two "B's," and a "C." I had a 4.0 last year, so these lower scores are hard for me to swallow.

As recognition for earning 4.0's in the first year, 5 people in my class, myself included, received a $150 therapeutics textbook from the pharmacy school student honor society. Our names were announced in front of the entire College of Pharmacy, so now I have an unshakeable reputation as a genius, or least a subgenius. My 4.0 and I kept a low profile last year, and now that we're public knowledge, I simultaneously have enjoyed a new respect by my peers and have been subjected to a few playful verbal jabs that sometimes have enough acerbity to be received on my end as more than joking. Someone later offered an unsolicited apology (by unsolicited, I mean I had not asked for an apology and had shown no indication I felt wronged or offended), so I guess there's more than mere playfulness on their end, as well.

I'm working 12-15 hours/week each for GE and a nearby pharmacy. The timing of the job offers was not optimal. GE is a short-term gig through mid-October that pays handsomely, so it was an offer I couldn't refuse. But since I had committed to work at the pharmacy before hearing from GE, I had little choice other than to "suck it up" for two months. So I work one or both days on weekends. And between classes and work during the week, I hardly get home before 9 or 9:30pm. That makes studying really, really hard to do.

Work and school demands are pulling me in three uncomfortable directions: 1) I'm unable to fully satisfy the needs of the GE project manager I'm working with, 2) I had to ask for my pharmacy schedule to be reduced after the October schedule had been made, and 3) my grades are falling. This is a classic "disaster waiting to happen" scenario, starring yours truly as a fool who's in way over his head and doesn't know it, whose worst mistake is continually telling himself "I can do this until mid-October" instead of doing what he knows in his heart he should do... which is stop the madness by quitting one or both jobs now, catch up on sleep, de-stress, and pull up those grades.

But I know I can do this.

I took a drug test at one of the 25 pharmacies I applied to earlier this summer. I had shaved, dressed in khaki pants and a polo shirt, and stopped by to sign the criminal background check waiver and take the drug test. The store manager said the results should be ready in about 3 days, adding, "I'm sure you won't have any problems."

I'm sure you won't have any problems.

I wish I had the stones to say "Ah, shucks - you probably say that to all the applicants!" And, of course, she doesn't, which made me feel discriminated for, the opposite of being discriminated against. I want to be absolutely clear on this: the company has done nothing illegal.

The pharmacy manager had never seen me before she called; thus, she made an employment offer based solely on my application, resume, and my status as a pharmacy student. The decision was based solely on qualifications, not appearance, race, gender, age, or religion.

Further, the store manager said this after a contingent job offer already had been made. If I had come to the store unwashed, unshaven, and wearing tattered clothes with bruises along the insides of both arms, as far as the store manager was concerned, I'd still have a job if my drug and criminal screens came back negative, although it might be in the stockroom out of sight of customers.

So, what's my point, then? I sat here long enough for the mp3 player to make it through three new age music songs as I tried to understand why her offhand comment has kept repeating in my head for the past three days. I wasn't personally offended. I was making small talk with her to break the monotonous silence as I filled out paperwork, so I shouldn't have been surprised by small talk about the purpose of our meeting in her office, even if it did walk the fine line of perfectly acceptable pre-employment conversation etiquette.

I guess my point is this: there is such a thing as positive discrimination, or being discriminated for instead of against, and even though we may not personally be offended by positive discrimination, it's not harmless. On the other hand, it's also known as favortism, and isn't a new concept, so excuse me for wasting the bandwidth.

That's a sarcastic title, in case you can't figure it out after reading this post for a bit. I had high hopes for the summer break after my first year of pharmacy school. I planned to work for peanuts as a pharmacy intern in a local hospital pharmacy. Measly pay aside, I would be better for the experience. Years later when I apply for a hospital pharmacist position, it would help me demonstrate commitment to a hospital environment.

Instead, I've written off the summer of 2005. The cynical view is that I've squandered it. The more positive perspective I struggle to maintain is that it has been an eye-opening experience in the frustrations of unemployment and learning how not to conduct a job search. I fell into a corporate I/T career right out of college, enjoying a more or less secure job for seven years. I now realize how fat, dumb, and happy I was, sucking the sweet teats of the corporate cow. The meager job-hunting skills I never had to develop after college have become rusty and even weaker than before, as if that were possible.

In the Lexington labor market there are two critical demographic features that do not work in the favor of a would-be pharmacy technician or intern. First, Lexington is a college town. Population 260,000 plus 33,000 college students equals perilous summer job hunting. Second, the 350+ pharmacy students and 33,000 college students saturate the pharmacy technician job market.

Job security and a pharmacist shortage were two of the reasons I changed careers. Escape from the looming threats of corporate downsizing and offshoring seemed like a good idea at the time. Pharmacists are "set" for life. What I failed to consider is that pharmacy students are not. The cruel irony is that I'm looking for work in a labor market where the ratio of labor supply to demand is so slanted that it makes the current U.S. I/T industry look like the late 1990s tech boom in comparison.

Talking to classmates in similar situations is small consolation. On the one hand, we support one another, and it's comforting to know I'm not alone, but it comes at the cost of realizing how truly scarce jobs are. We are so many sharks competing against one another in the hunt for one small fish.

A friend emailed earlier this summer. She wrote, "Hey dude, have you found a job yet? Because I haven't found anyone who is hiring. Which is kind of weird." Weird, indeed. She won an award for having the highest grades in our class. It happens to the best of us.

If I, a 30 year-old married to an optometrist, were up against a 21 year old self-supporting classmate freaking out about how to pay rent and groceries, I hope they would get the job. As much as the rejection of 30 pharmacies and temp agencies turning me down bruises my ego, at least I'm not starving or worried about getting evicted and living in a cardboard box.

If I could job hunt all over again, I'd start looking in March or April. Of course, that's exactly what I did. I went to the three local hospitals I knew were hiring and spoke to the pharmacy managers. They seemed upbeat, so I submitted applications, confident at least one would pan out.

A few weeks later, I saw the mugshot of the pharmacy director from pharmacy #1 on the 6 o'clock news. He had been arrested and charged with several felony counts of possession of a controlled substance. It surprised me, but after talking to the guy and seeing the pharmacy he managed, my reaction wasn't one of disbelief.

I had all but written off hospital pharmacy #2. My phone calls weren't returned, so I left my resume and cover letter on the hiring manager's desk and submitted an application. Over a month later, a pharmacist called to schedule an interview. I agreed to come in the next day, and the interview seemed to go well. When I called the next week to inquire on a decision, I found out both the pharmacist who interviewed me and the hiring manager were out of the country for three weeks. I left each a couple voice mails when they returned, but as before, my phone calls weren't returned, and I never heard from them.

The manager at hospital pharmacy #3 seemed reluctant to hire pharmacy students. In his experience, they didn't work enough hours during the school year. I thought I had eased his concerns. Apparently, I thought wrong. In hindsight, his smirk when I casually mentioned my 4.0 GPA should have tipped me off. As far as he was concerned, I was an arrogant ass too obsessed with grades to be bothered with working.

I didn't mention my GPA when I spoke to pharmacy managers number 4 through 25. GPA is relatively unimportant, now just an unnoticed factoid on my resume, a piece of paper they politely hold in one hand as they shake my hand with the other. A factoid that remains unseen, because once I walk out the door and turn the corner, they don't have to be in my sight for me to know what happens next. Before I get into my car and pull out of the parking lot, I know the resume has been tossed into the trash with all the reverence and ceremony befitting a dirty tissue, its eulogy a final sound of crinkling paper as it settles into its final resting place.

By the time it was obvious a hospital wasn't hiring me, the spring semester had ended, and with it had gone all the available intern jobs at retail pharmacies. In hindsight, I should have kept applying to pharmacies until I had pissed in a cup, completed the paperwork, and had a work schedule. I've learned there is an infinite chasm between someone saying, "Yeah, we're hiring! Do you have a resume?" and the first paycheck. A Richard Marx song popular in the 1980s comes to mind: "Cause it don't mean nothin' / The words that they say / Don't mean nothin' / These games that people play / No, it don't mean nothin' / No victim, no crime / It don't mean nothin' / Till you sign it on the dotted line."

Working in retail pharmacies may not be my first choice as a pharmacist, but by this point as an unemployed student intern, that preference for a future career choice seems increasingly remote and irrelevant. I'd take anything. I even applied at a pharmacy in a rough part of town operating out of a renovated 1960s-era drive-up milkshake and ice cream palace, complete with call boxes in the parking lot. But I didn't get that opening, either, because there are a lot of Mexican immigrant neighborhoods nearby, and I don't speak Spanish.

I got a hit at pharmacy #25. The pharmacy manager at a popular retail chain pharmacy in a nearby town greeted me enthusiastically. "You're a pharmacy student? That's great! Here's an application! Give it to K at the T Road store and she'll schedule your training."

Once again, I was lulled into a false sense of security and stopped submitting applications. Some people never learn.

Three weeks later, and they tell me my application is still pending the result of the criminal background check.

Four weeks after applying, I decide this is ridiculous and find the balls to drive to the store and check on the status of my application in person. If my application is sitll pending, I'm going to ask if they hired me erroneously, hired me even though they didn't need the hours. And if so, please pay me for my training hours, and let's move on.

The store manager tells me my background check cleared several days ago, and says he told the pharmacy manager I was good to go. I walk back to the pharmacy, but this is news to her - she says she was unaware my application had cleared, but in any event, she doesn't have any hours to give me right now, so "call K at the T Road store to find out which stores have hours."

Well, at least I didn't have to burn any bridges by asking if I had been mistakenly hired me when the store didn't have any hours. She came right out and told me so.

When I'm not driving around to pharmacies or temp agencies, I try to think of my summer unemployment ennui as a kind of sabbatical. I was going to study my lecture notes, meditate and realize some great universal truth and find inner peace for the first time in my life, or write a novel.

Ha! Novel, my ass. While I can't claim inner peace, I have developed some mad skilz waging starship battles in Starfleet Command 3. Rachel gave me Sims 2 for my 30th birthday, so the starships have been mothballed in spacedock the last few weeks. Some of my Sims 2 characters have the "write a novel" aspiration, kinda like I do. It takes a sim 27 hours of "sim time" to write a novel, which doesn't include sleeping, eating, working, or going to the bathroom. 27 hours elapsed time to write a sim novel, which doesn't seem that bad, except the average sim lifespan is 70 or 80 days, and when you consider that's like a year of a real person's life, well, that's just a long time. It doesn't help that I'm not a great storyteller, not even mediocre, my skills lie somewhere between bore and historian.

Yardwork and gardening has darkened my fair, pale skin to a fair, golden pale. If anything positive has come from my summer unemployment, it's been the satisfaction of tending a vegetable garden and compost pile. The summer began in a dry spell, which became a drought lasting until mid-July. Dedication and 250 feet of waterhose kept the garden watered for a month and a half until the rains came. The seemingly endless supply of squash, zucchini, and cucumber would not have been possible otherwise.

You start noticing the hybridized form of nature that exists in backyards and farms when spending so much time outside. For example, the rabbits lay seige to the garden in the late afternoon and early evening, but they don't eat much, scarring only a few cucumbers. I can identify about 15 weeds and grasses, and know of several weeds that are not only edible, but nutritious. Broccoli ripens first, followed by squash and zucchini, cucumber, peppers and tomatoes, corn, watermelon and cantaloupe. Fireflies peak in mid to late June. Grasshoppers hatch in early July. Japanese beetles like corn, but fortunately, not squash, peppers, or vine plants. And perhaps the cruelest irony of gardening: cilantro and tomatoes are great for making homemade salsa, but cilantro blooms and dies around mid-to-late July, just as the tomatoes begin to ripen. Honeybees are most active during early morning and late afternoon, and they almost swarm around squash and zucchini blooms, which close by late morning. The flowers of vine plants, like cucumber, cantaloupe, and watermelon stay open all day, and the bees always frequent them, but they won't bother you when you're picking vegetables if you give them some room and don't make sudden movements. Raccoons love corn, and they have an uncanny way of knowing it's ripe in the early morning before the sun comes up on the day before you were planning to pick it. The seed stems of Bermuda grass look like the TV antennas people mounted on their roofs in the 1970s and 1980s before satellite digital cable came along. The loud insect songs of the dog days of summer, complements of katydids and summer cicadas, begin around mid-July.

Much of what I've noticed doesn't seem overly exciting, now that I think of it. If I actually spent more time outside simply watching what was going on around me instead of pulling weeds and mowing, I might notice more of nature's awe-inspiring little quirks. I "turned over" the compost pile yesterday. The heat index was around 100 F, but I watched the bugs living in it for 15 minutes... beetles, centipedes, ants, and spiders. I spotted a tiny wolf spider (one of these jewels, only much smaller) moving around on the pile. It pounced on every passing ant, then kicked it away, unharmed. Amusing to watch.

So as my sabbatical nears an end, what do I have to show for it? More zucchini and cucumber than we know what to do with, but little on the philosophical front, I'm still agnostic, and have no ideas for the next great American novel. Ho hum.

"The number one cause of headaches? Everyday life."

Today I saw a TV advertisement from Bayer promoting one of it's aspirin formulations; I think it was Bayer Rapid Headache Relief, a rapid release aspirin formulation. I will argue why I think the information presented in this commercial is not only useless, but potentially deceptive to consumers.

The commercial makes a point: when you have a headache, you want fast relief. It then promotes the Rapid Headache Relief product, claiming it dissolves "5 times faster than Tylenol." The textual caption states the Bayer product has complete release in 27 seconds versus 133 seconds for Tylenol.

The implied (but unstated) claim is that Bayer Aspirin Rapid Headache Relief provides headache pain relief faster than Tylenol. This would be a great claim to make, because fast headache pain relief is the ultimate goal of the consumer. Why wasn't this claim stated explicitly? Because it's not true, and explicitly saying so would probably raise the ire of the FDA and McNeil PPC, the manufacturer of Tylenol.

Fact 1: Tylenol (acetaminophen) and aspirin cannot provide headache pain relief until they are absorbed into the bloodstream. The amount of drug in the bloodstream is measured by the "plasma concentration" or "serum concentration."

Fact 2: Tylenol (acetaminophen) and aspirin are both rapidly absorbed into the bloodstream. However, Tylenol (acetaminophen) reaches its peak plasma concentration in 10-60 minutes. Aspirin reaches its peak plasma concentration in 1-2 hours. Peak plasma concentration is the highest level of drug in the bloodstream, when the drug produces maximum effect.

Conclusion: Although the Bayer product dissolves 106 seconds before Tylenol, this is probably insignificant, because the 1 minute and 46 second headstart does not necessarily help aspirin get into the bloodstream faster than Tylenol.

There are three primary factors affecting how quickly an oral medication provides its effect: 1.) drug dissolution time (how long it takes to dissolve); 2.) drug absorption rate (how quickly the dissolved drug enters the bloodstream); and 3.) the drug's minimum therapeutic concentration (the lowest plasma concentration at which the drug produces its intended effect).

This commercial exaggerates the advantages of Bayer Aspirin Rapid Headache Relief. The advantage (rapid dissolving formulation) does not necessarily translate into overall better result (faster headache pain relief).

My number one pharmaceutical industry pet peeve: Factual but deceptive advertising. That's when a party with an agenda attempts to promote a product by omitting negative information or exaggerating the benefits of postive information. I'll give two cases.

First case, the promoter may discuss the advantages while omitting or marginalizing the disadvantages. This is not in the best interests of the consumer, because the promoter does not provide the consumer with enough information to make an informed decision. An example is what I call the gameshow prize effect. A contestant who wins $20,000 in prizes in a gameshow or contest can expect to owe $6,000 in taxes. If the prize is non-monetary (car, airline tickets, furniture), the winner must forfeit or liquidate the prize (assuming the winner can get more than 30% of the prize value, they're still ahead, but the sugar isn't as sweet as it once seemed). Another example is Eli Lilly's pulled Strattera TV ad.

Second case, the promoter claims the positive benefits of the product yield a better overall result. That's what I believe the Bayer Aspirin Rapid Headache Relief commercial does: faster dissolution does not necessarily mean faster headache pain relief.

There may not be a conscious decision to deceive, but the "agenda to promote" necessarily means the promoting party has a conflict of interest. In Bayer's defense, it has not claimed its rapid dissolving formulation is better than Tylenol. It has simply offered an alternative product to provide a more diverse selection of products to consumers. Bayer could rightfully argue it has improved the competitive marketplace for the consumer. I don't argue or take issue with any of that. I am simply disappointed this commercial makes it too easy for consumers to think its worth spending more money for this product on the false belief this formulation will make their headache pain go away faster than Tylenol.

Earlier this month I posted about prescription drug TV commercials and mentioned the Strattera video game ad. You will see this commercial no more. I noticed a lot of referrals for Google searches for "Strattera TV Ad" and found this:

The Food and Drug Administration warned Eli Lilly and Co. (LLY) Thursday about a television advertisement for Strattera, a drug used to treat attention deficit hyperactivity disorder, or ADHD.

[...]

It potentially broadens the use of the drug beyond the indicated patient population, while also minimizing the serious risks associated with the drug.

You can read the complete FDA warning letter here, but I've quoted the more salient points below. In my earlier post I used the Strattera drug commercial as an example to describe what I call the "pay no attention to the man behind the curtain" segment, and how this commercial for a drug to improve concentration in those who are easily distracted ironically uses over-stimulating and flashy visualizations to distract the viewer's attention from important facts about the medication. I'm pleased to see the FDA crack down on a misleading advertisement that overuses the "pay no attention to the man behind the curtain" marketing strategy.

Among other things, the FDA said in its letter to Eli Lilly:

The overall effect of the distracting visuals and graphics, including competing messages related to efficacy, and the competing audio message, is to undermine the consumer's ability to pay attention to and comprehend the risk information, thereby minimizing these risks and misleadingly suggesting that Strattera is safer than has been demonstrated by substantial evidence or substantial clinical experience.

[...]

The ad visually presents a person in a variety of situations as seen through the screen of a videogame, including: leaving the house; walking to his car; going back to the house for his car keys; looking into a shop; looking at a wristwatch; handing in a "Quarterly Report;" and sitting down at a desktop computer. These scenes are presented with a box that displays a descriptor or attribution for each behavior (e.g., "DISORGANIZED," "DISTRACTED," "TROUBLE FINISHING THINGS") and the word "penalty" beneath it.

[...]

The TV ad fails to clearly communicate the indication for Strattera because of competing visuals, graphics, and music that are presented at the same time as the information described above relating to the indication.

[...]

During the presentation of the various situations the character is engaged in, boxes with the words "SCORE" (including a running tally of numbers), "LEVEL 1," and superimposed text are shown. The text scrolls and flashes. The text, graphics, and voice-over are also accompanied by eerie sound effects. All of this distracts from the viewer's ability to process the visual information related to the product's indication. Similarly, there are numerous competing and distracting elements, such as a large SUPER that types out the word "RESTLESS penalty," a SUPER with the words "LEVEL 1" and "SCORE" which loses points every time a symptom is displayed.

[...]

The audio communication of serious risk disclosures in the "major statement" is minimized by the distracting visuals and graphic SUPERs, which combine to interfere with the presentation of the risk information. The audio presentation of risk information is accompanied by concurrent erratic camera movement, quick scene changes, and visual changes in point-of-view. The SUPERs scroll in and out and flash, and the "SCORE" is constantly moving (gaining points). The risk information is presented very rapidly in the audio.

Well said!

I've been paying careful attention to TV prescription drug commercials. First year UK pharmacy students work in a pharmacy during the month of May, and in my own pharmacy, I noticed several customers asking what we thought about a drug they had seen in a commercial.

It's a shocking trend. Direct-to-consumer (DTC) advertising by the pharmaceutical industry for prescription medications increased 5000% from 1990-2003. The average drug company spends 6 times more on advertising than R&D for new drugs. For me, it's the perfect argument for why unchecked capitalism is a bad thing. The pharmaceutical industry has determined the return on investment from advertising is much greater than it is for new drug research. You simply cannot argue such behavior is in the best interest of humanity and not the stockholders. In fact, hats off to the boards of directors in the pharmaceutical industry, because it is their fiduciary responsibility to ensure their companies operate in the best interests of the stockholders, and they have succeeded in that regard, if not to the detriment of the health of society.

My favorite DTC drug commercial is the video game style Strattera advert for Adult Attention Deficient Disorder (Adult ADD). It's like Doom without the BFG. Shown from the point of view of a male corporate employee who has trouble finishing tasks, focusing, and pleasing his boss, the man's "score" drops with his every act. In all probability, the poor guy could probably resolve his problems with one or more behavior modification strategies: take a vacation; stop working so much overtime; instead of watching Conan, turn of the tube and go to bed before Leno.

But in the American society, there's a pill for every ill, and for this corporate flunky, the pill is Strattera. His score immediately begins increasing, but in small increments.

My favorite part of the commercial comes next, what I refer to as the "pay no attention to the man behind the curtain" segment (apologies to the Wizard of Oz). Advertisements for prescription medications must include the most common and serious side effects and adverse reactions. When listing these adverse reactions, which can be worse for some people than the condition the drug treats, the narrator switches to fast talk mode. The visual component of the commercial becomes more engaging and captivating. The intention is clear: mesmerize the viewer with the vivid imagery so they pay less attention to the side effects.

In the Strattera ad, the corporate flunky is transformed into a career ladder-ascending all star. His score increases in exponential leaps and bounds. Everyone is smiling at him, applauding his every action. Meanwhile, the fast talking narrator is warning you about the potential for serious liver damage, that you shouldn't take Strattera if you have narrow-angle glaucoma, and to tell your doctor if you have high blood pressure, or any heart or blood vessel disease. The most common side effects include headache, constipation, dry mouth, urinary retention, problems sleeping, and sexual disturbances.

I'm sorry, but with a 17-27% incidence of headache, 4-21% risk of dry mouth, and 16% incidence of insomnia, not to mention 7% incident of erectile disturbance and 6% incidence of decreased libido, I'd be more willing to try non-drug therapies first, like going on vacation, working less overtime, and getting more sleep. I'd want to be convinced I had ADD before risking headache, dry mouth, and insomnia, any of which could further worsen, not improve, my ability to concentrate. But if you got caught up in that flashy imagery instead of carefully considering the side effects, you might have missed all that.

The next time you see a drug commercial on TV, pay attention to the "pay no attention to the man behind the curtain" segment. Note the visual hijinks to distract your attention from the side effects. It's a tried and true formula, and all recent drug commercials use it, with one exception:

Exception: the new Nexium commercial promoting its use for ulcer prevention in long-term NSAID use for arthritis and heart attack prevention. In the Nexium commercial, a couple in their 60s (Jenny and Jimmy) sit on a couch and talk to someone off camera, charming us with their playful banter. They list the three major side effects matter-of-factly: she says "headaches, diarrhea," and he jumps in with the third "and abdominal pain." No funny business. On the one hand, Nexium is fortunate to have one of the least problematic adverse reaction profiles on the market, so there's hardly reason to employ the "pay no attention to the man behind the curtain" routine, but still, I respect AstraZeneca's fresh approach.

Several reports of pharmacists refusing to dispense birth control medications, even contraceptive devices, on moral grounds have been publicized recently. I can't help but think that while this has only recently caught national attention, this behavior by pharmacists has been going on for much longer.

I am but a lowly pharmacy student one week away from completing his first year final exams, but I have a couple thoughts on the matter:

• The decision to pursue medical therapy belongs to the prescriber and the patient. The pharmacist may refuse to dispense only for safety reasons; that is, if the medication threatens the patient's health. Even so, the pharmacist is obligated to call the prescriber to discuss the therapy.

• I support giving pharmacists an "out" for moral concerns. If someone believes birth control is murder, don't make them an accessory. However, withholding prescriptions for time-sensitive medications, or even failing to tell the patient where the nearest pharmacy is or asking another pharmacist on duty to fill the prescription, is belligerent. Remember whose decision it is to pursue treatment.

• There is a legal loophole for pharmacists who do not want to prescribe a certain drug or brand of drug: don't stock the drug in the pharmacy's formulary. Then it becomes a simple issue of telling the patient that "we don't stock that drug here," and it's perfectly legal. For retail and community pharmacies, this decision is for the PIC (pharmacist in charge, the pharmacist in every pharmacy who assumes final responsibility for all pharmacy operations before the state board of pharmacy) and the store owner/manager. Of course, a pharmacy won't pull birth control from its formulary just for one pharmacist; a morally conservative pharmacist would have to find a similarly conservative independent pharmacy owner to make the formulary loophole work.

This semester our tests are a bit more hefty than usual. We have a total of three exam blocks (two exams plus finals) instead of the traditional four. The school changed the exam schedule this year so our spring break would coincide with the American Pharmaceutical Association convention in Orlando.

A few of the new strategies I've come up with this semester for taking block exams:

• Begin studying earlier. Try to wrap your noodlely noggin around that funky logic. Some friends and I even meet an hour before class to study... even between exam blocks!

• Hot Chocolate Pick Me Up. Hot chocolate (with marshmallows, of course) plus half a teaspoon of instant coffee for that late night turbo boost. Like many coffee aficionados, I keep my coffee beans frozen and grind them on demand for latte and vacuum-brewed coffee. I'm embarrassed to admit there is instant coffee in my home. I find it abhorrent, but sometimes you get into a compromising situation, and the aftermath of the scandal leaves you with a pound of instant coffee in your cupboard.

• Crazy Ass Conceptual Associations (CACA). Pun intended. Useful for learning the countless pharmaceutical and biological concepts presented during each exam block. For example, lyophilization is drug a freeze drying process to increase stability and reduce product weight. Need an "everyday" example of lyophilization? Instant coffee, an abhorrent product occasionally found in the cupboard that is reconstituted with water for convenient caffeine therapy.

  Another example is the behavior of red blood cells in hypertonic and hypotonic solutions. Hypertonic solutions cause RBC crenation; hypotonic solutions cause RBCs to swell. Although I rely on a conceptual understanding of osmosis and osmotic pressure to visualize the processes with vivid, often violent detail (when RBCs swell past the breaking point, their lysing can be beautiful; the shriveling of crenation is no less fascinating), making beef jerky and other dried, salted meats also works: rubbing on salt creates a hypertonic solution that draws water out of cells and crenates them.

Dear Pharmacy School Diary -

It's been well over a month, but last semester's lab practical tested two prescriptions. One prescription was compounded (capsule-punching prescription), and the other was paper only (solution).

Prescription #1:

An 81 year-old lactose intolerant patient presented the following prescription:

Inscription: Prednisone 0.007, Diphenhydramine 0.025
Subscription: DTD #2
Sig: Take T qam x 2 days
Refills: 0
Physician address: Pulmonary Clinic

I'm in a self-deprecating mood, so instead of detailing the compounding process, I'll list everything I lost points for and be done with it. The lab final was a bloodbath, but I got an A for the semester, so it's all good in the end. I made a lot of dumb errors, to be expected in a high-stakes, timed final exam.

Prescription Documentation:

• -1: no RX# sticker on prescription
• -1: no RX# written on prescription
• -1: amount compounded, dispensed, wasted not on prescription

Compounding Calculations and Methods:

• -1: "Product's Therapeutic Intent" on compounding form did not mention treatment of a pulmonary condition (prescription was from pulmonary clinic)
• -1: amount used, dispensed, discards not recorded in compounding calculations (that's right - one error can be penalized multiple times!)
• -1: "Product's Compounded Label Name" missing quantity (#2)
• -1: "Compounding Method" did not specify to re-zero prescription balance before weighing each ingredient
• -1: did not include "mix thoroughly" in directions for combining diphenhydramine and starch (I stated "triturate geometrically" without specifying trituration should be done thoroughly)
• -1: did not specify to "use gloves" when filling capsules

Patient Instructions / Counseling:

• -1: did not ask patient about other medical conditions when questioning about other prescription and OTC medication use
• -1: did not educate patient that prednisone reduces inflammation and diphenhydramine is an antihistamine
• -1: did not tell patient to avoid alcohol
• -1: did not tell patient to avoid OTC antihistamines
• -1: incorrect expiration date (30 days, not 1 year - this was a really dumb error)
• -1: instructed patient to watch for capsule changes/discoloration, but not what to do about it (don't take and call the pharmacy)

Product and Label:

• -2: wrong expiration/discard after date (again, a really dumb error on my part... and being double-penalized for it drives the point home!)
• -4: missing auxiliary label - "Store away from direct sunlight. Keep in a cool, dry place"
• -4: missing auxiliary label - "May cause drowsiness. Alcohol may intensify this effect. Use care when operating a car or dangerous machinery."

This prescription was worth 70 points. You can calculate my grade using the deductions above. It's not pretty! :-)

Prescription #2:

A 19 year-old female transferred from a long-term care facility presented the following prescription:

Inscription: Chlorhexidine Gluconate 1:200
Subscription: Dispense 1 liter
Sig: apply to acne pustules on back BID
Refills: 6

Prescription Documentation:

• -0.1: qs amount (not sure what this meant)

Compounding Calculations and Methods:

• -1: "Product's Therapeutic Intent" should have been "decrease bacteria count"; mine was "Topical antiseptic for acne." That's splitting hairs if I've ever seen it... but I got an A, so why complain?
• -6: This was a 0.5% chlorhexidine solution that should have been prepared in water; I prepared an alcohol solution because Remington's (reference book) said 0.5% solutions in water were erratically antiseptic, but ethyl alcohol solutions were more reliable. The red ink stated: "Use water. Do not want to use any pharmaceutically active ingredients that were not in Rx. Ethyl alcohol on inflammed skin would increase infection and pain."

Prescription Label:

• -1: missing "solution" in patient instructions (Apply solution to acne pustules on back 2 times a day.)
• -1: missing federal caution (Federal law prohibits dispensing without a prescription.)

This prescription was worth 30 points. Again, feel free to calculate my grade if you're interested!

I was never so glad to finish something as I was after the 3rd block exams, but that feeling of relief was trumped today by the relief of finishing the semester finals. Not because they were unreasonably difficult, but because:

• The stress is over.
  
• I can begin Christmas shopping.
  
• The days of getting up at 5:00am and going to school for a couple more precious hours of cramming are over.
  
• My wife doesn't have to avoid the alarm clock at 4:00 or 4:30am (the earlier it is, the longer it takes to wake up) by sleeping downstairs in the living room.
  
• The sun can melt the frost on the windshield instead of me scraping it.
  
• I can clean my half of the two-car garage and avoid frosty windshields altogether.

Having solid A's in all courses except for one weak A before finals is a mixed blessing. On the one hand, you know you're in good shape, because scoring in the low 70's to preserve an A is very attainable; even if you bomb the final, you slide by with a B. On the other hand, complacency combined with end-of-semester burnout has a deleterious effect on studying.

Somewhere in all those "one hand" and "other hands" is a feeling of guilt when you think of your future patients who won't benefit from that extra 5 hours of studying for the antibiotics final, because you forgot to tell them that Metronidazole has a severe antabuse-like reaction when taken with alcohol, and they went partying Friday night and spent the weekend with their head in the toilet. What's even more sobering (no pun intended) is the statistic our pharmacy law professor shared one day: a pharmacist kills one patient every 4-5 years.

In pharmacy, attention to detail is critical, because that's where the devil is.

Dear Pharmacy School Diary -

We walked into the lab and were handed a prescription and blank compounding notes in our seventh compounding lab. This was the mock practical to give us a flavor for the final lab practical worth 100 points.

A doctor calls for assistance dosing chlorpheniramine maleate antihistamine in a 6 year-old patient sensitive to the anticholinergic effects of some antihistamines. She wanted to give a dose slightly less than the average pediatric dose (2mg). Given are the patient's height (2' 8") and weight (57 lbs).

The original prescription:

Inscription: Chlorpheniramine maleate 4mg/5ml
Subscription: In simple syrup, 150ml
Sig: ss tsp q4-6h prn runny nose
Refills: 2

The plan: determine the patient's body surface area (BSA = 0.7 sq m) and recalculate dose accordingly. The adult dose is 4mg q4-6h and the average adult BSA is 1.73 sq m. (0.7 sq m)/(1.73 sq m) * 4mg = 1.62mg, so reduce the patient's dose from 2mg to 1.6 mg.

Next, change the sig from "ss tsp" (2.5 ml) to "2 ml" to yield a 1.6mg dose and note to include a dosing spoon and counsel its proper use to the parent.

(150 ml) * (4mg/5ml) = 120mg chlorpheniramine maleate needed in prescription. Fortunately, this is the minimum weighable quantity on a Class IIIa prescription balance.

Available sources of chlorpheniramine maleate are pure powder and tablets. The pure powder is freely soluble in water (1g per 4ml), so this prescription will be compounded as a solution. Triturate in a glass mortar and dissolve the pure drug powder in 2ml purified water. Add a portion of syrup to the mortar solution and triturate. Pour into an amber bottle pre-calibrated to 150ml and shake. Rinse the mortar with several portions of syrup, shaking the bottle after each rinsing. QS with syrup to the 150ml mark. Shake. Check for clarity. Label and dispense.

Finally, write the patient counseling instructions.

Dear Pharmacy School Diary,

Our sixth pharmacy school lab was another hand punching capsule exercise. A 52 year old woman presented a prescription for four 0.5 mg estradiol capsules to treat her osteoporosis. She also asked for OTC Lactaid, a hint that we should use starch as a diluent instead of the standard lactose. Her doctor gave her 19 capsules from his office and the below prescription for the balance of her monthly supply.

Inscription: Estradiol caps 0.0005
Subscription: DTD #IV
Sig: T qam: 23 days on and 5 days off
DEA#: AR3936745

The MD's DEA number was invalid, one of those "attention to detail" points we're supposed to catch. Sum the 1st, 3rd, and 5th digits. Sum the 2nd, 4th, and 6th digits, then multiply by two. Add the two results, and the "ones" digit should match the last digit of the DEA number. In this case, 3+3+7 = 13; 2(9+6+4) = 38. The total is 51, but the last DEA number digit is 5, so the DEA number is invalid. DEA#'s are only required for controlled substances, but even if there's an invalid number on a non-CS prescription, you'd better call the prescriber for the correct number, or the board of pharmacy inspector can fine you a minimum of $100 per offense. And in all probability, a BOP inspector in the state of Kentucky will do just that.

Apparently, many drug dealers and addicts will go to the trouble of stealing a pantone green controlled substance prescription pad or counterfeit their own, but can't be bothered with mastering simple arithmetic.

I remarked a couple of labs ago that eventually I expected us to prepare all the compounding notes and calculations on our own for labs. It finally happened. Although we wrote the prelab notes at home, this lab was done entirely on our own.

Estradiol is a steroid hormone; thus, it absorbs through skin and mucous membranes. I didn't want to grow breasts and sing soprano, so I wore gloves and a surgical mask. Actually, estradiol is expensive, so we were actually using an inert powder in its place, but we wore gloves and masks, anyway, to appease the instructor.

I used #3 capsules for this prescription. Eacj #3 capsule will contain 270mg starch. We needed to dispense 4 capsules, plus 2 for compounding waste, so that meant I needed to compound for 6 capsules (6 caps * 270mg each) = 1620 mg powder and (6 caps * 0.5mg estradiol each) = 3mg estradiol. Problem is, the minimum weighable quantity on a Class IIIa prescription balance is 120mg, so we had to use an aliquot to prepare the estradiol. I prefer to setup my aliquots as ratios:

(3mg estradiol needed)/(120mg aliquot) = (120mg estradiol powder)/(4800mg total powder)

To obtain the 4800mg powder needed, I geometrically triturated 120mg estradiol powder and 4680mg starch. I took a 120mg aliquot of this powder containing 3mg estradiol and mixed it with 1500mg starch to obtain the 1620mg of capsule powder needed for 6 capsules.

We gained a valuable nugget of knowledge about hand-punching capsules with starch: it's damn-near impossible. Unlike lactose, starch is a dry, free-flowing powder. Instead of packing inside the capsule after hand-punching, it falls back out. And when it does stick, you can't pack enough in there to be within the acceptable weight range.

Solution: pack the capsules horizontally with a spatula so the powder won't fall out. Don't let the lab instructor see you, because while this method yields a packed capsule of acceptable weight, it's considered bad practice and usually results in point deductions. Whatever. Either method yields safe and equivalent products. If it works, it works. I'd give the school a point deduction for not even allowing us to use primitive hand-operated capsule-filling machines, if I could.

Hand-punching capsules in pharmacy school is analagous to fire-making in army and marine survival training: every soldier's and marine's survival kit has a fire-making implement, but they have to build a fire by rubbing two sticks together to pass the survival training course, "just in case." Every pharmacy has capsule filling equipment lying around somewhere, even the ones that don't compound prescriptions. It's called "doing your time."

The third set of block exams is over, and I have never been so glad to put something behind me since the last time I said I've never been so glad to put something behind me. It has been the most stressful test-taking experience ever (but they tell me it gets even worse). Six classes, and studying for five of them is like studying for organic chemistry. Seriously, it's like every class in pharmacy school is on the same level as the hardest class you ever took in undergrad. My MBA classes don't even come close.

I was going to write a post after taking the tests and before getting the grades back, but this didn't happen for two reasons. First, I was too exhausted and slept, instead. Second, the UK Pharmacy professors are awesome and started returning grades the day after block exams were over.

But I knew exactly what I was going to say if I had written that post. I was going to tell you I knew I had done poorly on 4 of 6 tests. I had to guess at numerous questions and was certain of my answers for a handful of questions. Block 3's were "Come to Jesus" tests, and I was going to say that I needed to start studying at the beginning of a test cycle instead of one week before the tests... which is still true.

I finished blocks on Monday feeling these were dark times, indeed. I wasn't the only one. No one had been getting much sleep. Several classmates walked out of tests in tears. One guy was so scared, he called his parents every day the week before the exams; his parents drove to Lexington for the weekend because they were so worried about his well-being. Those are good parents.

Then we began getting our tests back. The first two exams were Physiology and Drug Design. I was prepared and confident for these. After the tests, I expected a B on the Physiology test and an A in Drug Design. I got a high A in Physiology and 100% in Drug Design. I was ecstatic with these, and as far as I was concerned, there was no rush for the other 4 tests, because they were blood baths, for sure.

By the grace of God, I dodged the bullet, and the blood bath never came. Somehow I pulled through. A in Antibiotics, tying for 3rd highest score in the class; this struck me as odd because I guessed at more questions on the Antibiotics test than any of the others. A in Pharmacy Practice. B's in OTC and Biochemistry. My average is an A in all courses except for a high B in Biochemistry.

I don't know what happened, but let me tell ya, what a relief.

Dear Pharmacy School Diary,

We compounded two prescriptions in our fifth pharmacy school lab. Completing both prescriptions in two hours was an exciting race against time in the hallowed halls of Lesshafft Lab.

The first prescription was for a foot powder, probably an antifungal powder for athlete's foot, but the MD didn't specify, so we were left to guess. A humble request to prescribers: include the therapeutic intent on the prescription; it helps the pharmacist counsel your patient and ensure proper dosage. Thanks!

Prescription #1
Inscription:
     Benzocaine
     Salicylic Acid aa 0.15 g
     Benzoic Acid 0.3 g
     Camphor 0.2 g
     Methyl Salicylate qs
     Talc qs ad 3 g
Subscription: M et Ft divided powders #5
Sig: Apply contents of one powder packet to feet ud qam

Multiply these amounts by 6 (5 powders plus 1 for compounding loss)

We reduced the camphor first, unleashing the smell of Vick's VapoRub throughout the lab. Pulverization by intervention is the technique of choice to reduce camphor crystals, but alas, we didn't have time to dissolve the camphor in alcohol and then evaporate it to leave behind a powdery camphor powder. So we triturated it in a glass pestle with limited success.

Camphor and salicylic acid form eutectic mixtures, so it wasn't necessary to completely reduce the camphor. Not since methylcellulose have we witnessed such a peculiar physical property. When certain solid compounds are mixed together, such as camphor and salicylic acid, the resulting mixture has a lower melting point than the ingredients (you'd expect the mixture's melting point to fall somewhere in between the melting point of the ingredients). If it liquefies at room temperature, it's a eutectic mixture. Add benzocaine for numbness and benzoic acid for antisepsis, and the eutectic is complete.

To this 4.8 gram eutectic mixture we added 13.2 grams of talc, which must be done gradually to avoid sending mushroom clouds of talc into eyeshot of the lab instructors as we triturated in our mortars. Talc mushroom clouds guarantee point deductions.

The mixture resembles very dry dough after incorporating the talc, more crumbly than adhesive. A few drops of methyl salicylate for a wintergreen scent, and the powder is ready for packaging.

We dispensed the powder in handmade powder papers (aka chartulae or divided papers). I wasn't sure I folded the papers correctly; I later found this video (complements of UNC). I think that's how I folded them. It's so difficult to find instructions for folding chartulae... it's such a rare dosage form and pre-folded papers are commercially available. Much like the apothecary system, folding charts is an obsolete practice propagated by pharmacy schools. Such old school practices make me think of pharmacy less as an allied healthcare profession firmly rooted in science, and more as alchemy. Read this witch's spell for breaking up a relationship. It bears a striking resemblance to working in the apothecary system.

Oh, well. Let's move on to the second prescription, in which we hand punched capsules. Hand-punching capsules is another thing pharmacists rarely do unless they work in a compounding pharmacy, but it's a convenient way to introduce the aliquots. Although aliquots are really quite simple with practice, there is no single "right way" to solve an aliquot problem, which makes them horrifying to the first year pharmacy student.

Fortunately, though, no aliquotting on this prescription because it was a placebo:

Prescription #2
Inscription:
     For Blind Study
     Lactose qs
Subscription: Dispense #5 caps
Sig: 1 po hs M-F during week 4
Label: Phenobarbital 8mg

Ah, yes, the old bait and switch blind study. This patient thought she was getting the study drug, but she walked out with a placebo. 8mg phenobarbital is a sub-therapeutic dose, anyway. 80mg would have been expected, but the MD confirmed 8mg was correct.

The goal of this prescription was to learn capsule hand punching. We used #3 capsules; each #3 capsule holds 280mg lactose. The prescription was for 5 capsules plus 2 capsules for compounding waste. 280mg x 7 capsules = 1.96 g lactose.

The instructor told us to add a few drops of food coloring to help her inspect the quality of our trituration. White specks in the colored lactose indicated incomplete trituration. Most people used blue (the school color). While it showed school spirit, blue also made it easy to see white specks. I used yellow food coloring to make any white specks nearly impossible to see. I aimed for a pale yellow powder, but it was radioactive yellow, instead. No matter - it's hard to distinguish white from any hue of yellow.

The instructor commented on my lemony powder, apparently pleased to see a color no one else had selected. I couldn't resist... with a toothy grin, I told her I chose yellow because it would hide trituration flaws. She smiled.

I got 10 out of 10 points for that lab.

Another four weeks have passed, and that means it's time for the third round of block exams! Giddyup!

The sheer volume of material is staggering, which I say before every round of blocks, but that's because each round is worse than the last. We are being ramped up, and how I wish we'd reach the peak of this mountain soon... but I hear second year is worse than the first.

It's much easier to be a pessimist than an optimist, or at least it is for me, because my emotional midpoint tends toward the more sullen side of normal. So I frequently remind myself that I intentionally left GE to pursue this. The choice was mine to make, and aren't I so lucky to have had several opportunities to change the course of my life. So when I catch myself wondering why I signed up for four more years of school in a Pharm.D. program, I feel kind of guilty complaining about the coursework, even though I'm mostly doing it out of jest and stress relief... especially when considering that less than 20% of pharmacy school applicants are accepted.

There is no greater empowerment than the freedom to chose one's own path.

Okay, enough pep talk. Let's list what's in this round of block exams so the immensity of it all can send me into a panic attack:

Physiology:


• Sensory Receptors
  
• Anatomy and Physiology of the Eye
  
• Somatosensory Receptors
  
• Chemical Senses (Taste and Smell)
  
• Vestibular and Auditory Systems
  
• Blood Brain Barrier and Cerebrospinal Fluid
  
• Spinal Reflexes
  
• Voluntary Movement
  
• Movement Disorders

  Antibiotics:
  

• Sulfonamides
  
• Fluoroquinolines
  
• Macrolides
  
• Aminoglycosides
  
• Glycopeptides (Vancomycin)
  
• Lincosamides (Clindamycin)
  
• Oxazolidinones (Linezolid)
  
• Nitroimidazoles (Metronidazole)

  Drug Design:
  

• Gastrointestinal Physiology
  
• Diffusion and Partition Coefficients
  
• pH and Effects on Ionization
  
• pH and Effects on Solubility
  
• Colligative Properties

  Biochemistry:
  

• Enzyme Kinetics
  
• Proteolytic Enzymes
  
• Enzyme Regulation
  
• Nucleic Acid Structure
  
• DNA Replication
  
• RNA Transcription
  
• Protein Translation

  OTC:
  

• Internal Analgesics
  
• Pediatric Internal Analgesics
  
• External Analgesics
  
• Antacids

  Pharmacy Practice:
  

• Legal - Board of Pharmacy
  
• Legal - Kentucky Controlled Substances Act
  
• Legal - Generic Drug Law
  
• Case Study - UTI
  
• Lab - Eutectic Mixtures
  
• Lab - Capsule Hand Punching
  
• Math - Dry and Liquid Aliquots
  
• Drug Information - Azithromycin, Ciprofloxacin, Clarithromycin, Doxycycline, Levofloxacin, Trimethroprim-Sulfamethoxazole

I'll be tested on all this Friday, Saturday, and Monday.

Yes, my friends, this is why I freak out every four weeks before block exams. Somehow, I have miraculously managed to keep all A's. But good luck can't last a lifetime unless you die young, and that's why I fully expect to lose some of those A's this weekend.

Okay, time to study. This may be my last entry for a few days.

The Student Doctor Network allows applicants to read and post their pharmacy school interview experiences. Includes comments, interview format, the applicant's overall impression, interview questions, positive/negative impressions, and things the applicants wish they had known ahead of time.

Dear Pharmacy School Diary,

A 3 year-old child with congestive heart failure presented a prescription for digoxin elixir in our fourth pharmacy lab. Unfortunately, the pharmacy was out of commercial digoxin elixir. Whenever the inpatient hospital pharmacy I volunteered at ran out of a medication, they attempted to procur it from another hospital pharmacy; the other pharmacies, in turn, called my pharmacy when they ran out of something. That's called "partnership."

The pharmacy school does not borrow medications from other pharmacies. No, sir. When we run out of digoxin elixir, we compound our own from triturated digoxin tablets, propylene glycol, carboxymethylcellulose, and cherry syrup.

Fortunately, the compounding procedure is printed on the prelab worksheet, and we calculate how much drug and suspending agent are needed and specify the proper compounding equipment to use. Each prelab has less information than the one before it. Eventually I expect to walk into lab, find a prescription and blank compounding form at my bench, and be wished all the best in preparing it. Since I want to be a pharmacist, this seems a reasonable expectation. Nevertheless, it terrifies me for some reason... perhaps because the lab instructor ruthlessly deducts points for minor mistakes, and with no printed instructions for guidance, mistakes are virtually guaranteed. Hmm, yes, I think that's pretty much the issue.

Digoxin was originally derived from the foxglove plant. Digoxin inhibits plasma membrane sodium and potassium ATPase pumps, thus acting as a diuretic and slowing the rate at which cardiac sarcolemma repolarizes itself to resting potential, allowing sarcoplasmic calcium ion concentrations to remain elevated, which prolongs and strengthens heart contractions. Unfortunately, the therapeutic dose for CHF is dangerously close to the lethal dose, so serum levels are carefully monitored and digoxin immune fab is used for overdose.

Inscription: Digoxin 10 mcg/ml
Subscription: 70 ml
Sig: T. tsp BID

First the calculations:

• Dose Check. When medication is prescribed to a patient, three or four people will check it: the prescriber, pharmacy tech, pharmacist, and nurse (if inpatient). Despite all this, mistakes do happen.

  Digitalizing Dose: 390 mcg, acceptable (within the 30-40 mcg/kg range for a 3 year-old child)
  Maintenance Dose: 100 mcg/day, acceptable (within the 25%-35% range of the digitalizing dose)

• 70 ml x 10 mcg/ml = 700 mcg digoxin needed. Digoxin solubility is unknown, so this will be a suspension, not a solution. 0.25 mg digoxin tablets are in the formulary, so three tablets were used. Three tablets weighed 370 mg and yielded 750 mcg of digoxin. 700mcg/750mcg = x/370mg; x = 345 mg of commercial powder needed.

• The suspension should be 1% w/v carboxymethylcellulose. 1% w/v in 70 ml = 0.7 g pure carboxymethylcellulose needed. Using 10% w/w carboxymethylcellulose stock, 10g/100g = 0.7g / x; x = 7 g of 10% w/w stock needed. The specific gravity of the 10% w/w stock is 1.251, so 7g/1.251 = 5.6 ml stock needed.

Next is the compounding procedure:

• Triturate three 0.25 mg digoxin tablets in a glass mortar to yield 370 mg commercial powder.
  
• Weigh out 350 mg commercial powder to yield 700 mcg digoxin.
  
• Combine commercial powder with 5-7 drops propylene glycol in a glass mortar. Triturate into a pasty mass, not unlike toothpaste.
  
• Add 5.6 ml of 10% w/w carboxymethylcellulose stock to the mortar in portions, triturating all the while. (My lab instructor would deduct a point for failing to mention the stock is measured in a 10 ml graduated cylinder, so I've mentioned it here out of paranoia).
  
• Carboxymethylcellulose is viscous stuff, so wash the graduate several times with purified water and pour into the mortar, flunky. Triturate for awhile; until your arm aches should be sufficient.
  
• Pour the mixture into an amber bottle calibrated to 70 ml with a grease pencil (one point will be deducted for failure to precalibrate).
  
• Rinse the mortar and pestle with portions of cherry syrup and pour into the amber bottle. QS to the 70 ml grease pencil mark. Swirl the bottle each time cherry syrup is added.
  
• Inspect suspension. One point will be deducted for non-uniform or unsatisfactory particle suspension.
  
• Print, initial, affix label (Digoxin 10 mcg/ml suspension in cherry syrup, 70 ml. Give 1 teaspoon by mouth 2 times a day.) to bottle, affix auxiliary labels (refrigerate, shake well before use), and affix prescription tape. One point will be deducted for any of the following infractions: patient instructions are not ended with a period, if numbers are spelled out, each extra or omitted auxiliary label, too much prescription tape, missing RPh initials, missing/incorrect dates (original, fill, expiration).

We also write patient counseling instructions on the worksheet in sentence form, as if it were a script for Act Three, Scene One of a play in which a parent goes to the pharmacy to pickup a digoxin prescription for their child and the pharmacist gives the following monologue in true Shakespearan fashion:

Pharmacist:


• Digoxin suspension has been prescribed to treat the child's congestive heart failure.
  
• Does the child have any known allergies to digoxin? Is the child taking any other prescription or OTC medications? They should be evaluated for digoxin interaction.
  
• Shake bottle well before use. Accurate dosing is important, so use an oral liquid measuring device instead of a household teaspoon. After dosing, refill the device with water and have the child drink the water.
  
• Give 5 ml (1 teaspoon) of suspension by mouth 2 times a day. Give doses at the same time of day. If a dose is missed, give it as soon as you remember unless it is almost time for the next dose. Do not give double doses!
  
• Digoxin may cause side effects. They are unlikely, but you should be aware of these serious side effects and notify the prescriber immediately if any of the following occur: dizziness, mental disturbances or strange behavior, nausea, vomiting, diarrhea, headache, or skin rash.
  
• Digoxin maintenance dosing must be carefully monitored by the prescriber. Have follow-up appointments been scheduled to assess the child's progress?
  
• Store container in refrigerator out of child's reach. Keep container tightly closed and protect it from light.
  
• Discard unused portion after 14 days, but if properly used, this bottle will last 7 days.
  
• This prescription is for 2 refills.
  
• Have a nice day and watch out for the pothole next to the sidewalk curb.

The upcoming antibiotics test is guaranteed to suck like the vacuum of space. Imagine a huge grid, like a chessboard, only much larger. Running across the top are the names of bugs; running down the side are names of drugs. Each grid block indicates the effectiveness of the drug on the bug, and why it is or is not effective. That's what we're up against.

The strategy is to recognize patterns. For example:

Each successive generation of penicillins and cephalosporins has increased antimicrobrial coverage.

But it's not that easy. Another pattern to recognize is that every pattern has exceptions... an anti-pattern, if you will. I refer to the anti-pattern of successive penicillin and cephalosporin generations as the "Role Playing Game Character Phenomenon": an RPG character can have intelligence, charisma, or strength, but never all three. In terms of antibiotics, drugs can have broad spectrums or resistance to bacterial resistance, but not both. While each successive generation of cephalosporins has broader Gram Negative activity, the Gram Positive activity decreases... and while each successive generation of penicillin drugs has a broader Gram Positive and Gram Negative spectrum, bacterial resistance develops more quickly.

Why develop successive generations of antibiotics? In a nutshell, because bacteria can take whatever chemicals medical science throws at them and still come out on top. But let's look approach the question from a specific drug class such as the penicillins.

The first commercial penicillin was Penicillin G, but like many innovator products, it wasn't perfect. Some of it's weaknesses (many of which also affect other penicillins):