Thursday, 29 March 2007

Intrinsa

I smell naughty drug companies. Drug companies in the United Kingdom are not allowed to promote POMs (Prescription-only medicines) directly to the general public. Personally, I think that is a good policy. Travel to the US and watch television for any length of time and you will soon be bombarded with adverts for medications to treat high cholesterol, NSAIDs, Antihistamines, Viagra. Drug companies are smart, they would not advertise directly to the patient if it was an ineffective use of their marketing budgets. There are some wonderful drugs, but you have to worry about the percentage of the general public who are capable of weighing up by themselves what medication they need. I particularly like the high-speed"maycausedrowsinessanddiarrhoea" side-effects message at the end of such adverts.

That does not happen in the United Kingdom. Here the most exciting advert will be for an overpriced compound for reducing ear wax or a proprietary cough medication that, "nothing works better than." I'll stick with nothing then thanks.

So, how does big pharma get around this lack of POM advertising? Oh, that's easy. All they do is write a press-release and send it out to the newspapers and agencies. I have seen these PR pieces and I have seen finished articles which seem to be complete "cut and paste" jobs. Surely journalists aren't so lazy as to just copy out a PR piece and stick it in the lifestyle section? Read some lifestyle sections and even "proper" medical sections and one starts to think otherwise.

Intrinsa is a new drug indicated for "the treatment of hypoactive sexual desire disorder (HSDD) in bilaterally oophorectomised and hysterectomised (surgically induced menopause) women receiving concomitant estrogen therapy." To you and me that's women who have low libidos as a result of their hysterectomy. It was released last week by Procter and Gamble and I've already been asked by patients about it.

This piece was printed in the Daily Mail last week too. To those of you outside the United Kingdom The Daily Mail is a tabloid newspaper from the "Immigrants are stealing our jobs, lowering our house prices whilst possibly killing Princess Diana and causing cancer" genre. It's not a paper you would be proud to read. Can you see any mention of what the drug is actually licenced for? Lots of references to "The female Viagra" and HSDD but no real mention of it only being licenced for the group above. It reads as if anybody wanting it can go and ask their doctor for a prescription- and good luck with doing that by the way. Somehow I don't think your doctor will be that interested. Unless maybe you take the article with you after circling it with green ink.

So, the formula to get around the ban on promotion seems fairly easy. Release a product, send press releases to lazy journalists, maybe offering them the usual freebies. As a result you can get your product into the public domain for virtually nothing . Also you can generate demand for a product to treat a hotly-debated condition that may or may not exist. The PR companies get paid by Big Pharma, the newspapers fill pages. The only person that loses out is the patient. You would be a fool to base a health choice on a newspaper article. Unfortunately there are lots of fools around. Don't let yourself be "spun" by health-related articles in newspapers. Remember why said article is there, and who wrote the press release.

Tuesday, 27 March 2007

Mistakes, misteaks, misstakes....

Okay, I dispense maybe 10,000 items a month. So, even if I hit an error rate of 0.1% that'd be quite a lot of errors. 0.01% would mean one error a month. One error a month, I wish!

Firstly, it depends on what you call a mistake. Any mistake that I notice in the dispensary before the prescription is dispensed does not really count. If the drugs have not got to the patient, then no harm has been done. Now the person whose medication I am dispensing is probably watching me, so the trick is to redispense the item without the patient noticing that you nearly gave him enemas instead of eye-drops.It's a skill..

Mistakes tend to fall into various categories.

  1. Right drug, wrong quantity. This is probably the most common error. It's also the easiest to resolve and the one least likely to land you in jail. Some drugs are packed in twenty-eights, some are in thirties. Some are in strips of ten, some fourteen, some fifteen. Most things are blister packed, we don't dispense a lot from bulk like they seem to in the US. So yes, if I'm in a hurry, half-asleep or having to answer the phone, then I might have miscounted. It will not have been deliberate, I really do not get cheap thrills by doing the monkey-dance around the two aspirin 75mg tablets that I shortchanged you.
  2. Wrong drug, right quantity. This is the embarrassing one. Hands up any pharmacist who hasn't inadvertently dispensed, or at least picked up the packet of, Allopurinol 100mg instead of Atenolol 100mg. Same maker, same pack design, same strength. same initial letter so next to one another on the shelf. Only problem is that one is used for prophylaxis in gout and one for, normally, hypertension. Probably the type of mistake most likely to cause harm to the patient.
  3. Right drug, wrong strength. This tends to happen when the orders are put away incorrectly. a 100mg packet gets slipped in amongst the 50mg and no one notices. It sits there and normally I'll notice when I check the prescription against the drugs. That's normally, not always. I suspect this happens a lot with "little white tablets"and nobody ever notices. A short-term overdose/underdose does not normally cause the patient too many problems. In fact give the patient 10mg Diazepam instead of 2mg and they'll probably be back with their friends too..

It's always a tense few moments when somebody brings back their drugs complaining that I have made a mistake. Normally it turns out to be the doctor's or the patient's fault. Sometimes it will have been another pharmacist's fault. (and I always feels slightly relieved when I realise that I was not actually working the day the mistake was made) But, I'm not infallible sometimes the mistake will have been made when I was on duty. I'm human, I make mistakes. If a tech picks up the wrong drug and I don't notice when I check it, then it is still my responsibility. It's always fun being ultimately responsible for someone else's mistakes! It's a bit like being God, but without the omnipotence or the omnipresence.

Now it is the point where I have to apologise profusely. It's counter intuitive but the people whose prescriptions have the smallest mistake make the biggest fuss. I had a gentleman take one iron tablet instead of a folic acid tablet (wrong strength, wrong drug- not sure how that mistake happened apart from both drugs beginning with "F") He had to "take three days off work because he was so upset."

Compare this with the elderly gentleman who my trusty colleague accidentally gave a sedating antihistamine to instead of a non-sedating one. (wrong drug, correct strength)He was quite drowsy for a week and had to stay at home. But, when the mistake did come to life we got a cheery. "oh well, no harm done, everybody makes mistakes!"

If you tell your doctor you are allergic to penicillin, then tell me too. Don't pretend that you aren't and then complain that your lips have gone blue and you are taken "something called Co-Amoxisomething". That's a special trick drug name without a -cillin ending that contains a penicillin- and no they don't make it in a raspberry flavour.

Many patients will notice the mistake and inform you. Some will notice the mistake and take the tablets anyway, even after realising that this month their tablets are ten times as large, a different colour and have a different name on them. People are strange.

So, today's message is pay attention to your medication. Make sure you know what drugs you are taking, in what dose, and for what condition. Check your prescription, but don't assume that the mistake is the pharmacist's, or you will look stupid when it turns out to be a mistake that you made. And don't tip your drugs out on the counter and check them on the spot. Would you drive your car out of the garage and then flip the bonnet up to check everything was okay?


Monday, 26 March 2007

Thinking Blogger Award



I've been tagged for the "Thinking Blogger Award" by The DrugMonkey, for this post. The rules of the meme can be found here.

Drugmonker's blog was the first I cam across that gave a sense of life at the sharp-end. There are plenty of blogs about new drugs, new dosage forms, etc. Of course these have their place, but it's good to find a well-written blog from somebody in similar shoes to mine.

The rules :-
Should you choose to participate, please make sure you pass this list of rules to the blogs you are tagging. I thought it would be appropriate to include them with the meme.The participation rules are simple:
1. If, and only if, you get tagged, write a post with links to 5 blogs that make you think,2. Link to this post so that people can easily find the exact origin of the meme,3. Optional: Proudly display the 'Thinking Blogger Award' with a link to the post that you wrote.


Okay, I might struggle to rustle up five blogs that make me think, but I will try.


  1. The Angry Pharmacist:- For this post. I know it seems trivial, but smelly patients open a whole can of moral worms- Does the patient know they smell? Should someone tell them that they smell? Should I tell them that they smell? Would it be rude to open a window?
  2. Fingers and tubes in every orifice:- For this post. Patient's relatives who want "everything done." A thought-provoking post. When to say "okay, that's enough" and potentially a decision we all may have to make.
  3. The Girl with the Blue Steth:- For this post. The Girl realises that some people are jerks for many reasons, but mostly just because they are jerks!
  4. Street Anatomy:- For this post. Always a beautifully illustrated blog, but this post contained some vaguely work-related posts from one of my favourite modern artists.
  5. The Little Black Duck's Quackometer Blog. For this post. Television commercials making bogus claims for shampoos, (makes your hair 59% shinier,etc.) cosmetics (reduces the apperanace of wrinkles? What does that mean?) and especially medications make me angry far more than they should.The LBDQB bursts many bubbles beloved of Daily Mail readers. Magnets soothing menopause anyone?

Feel free to opt out. I'm not a fan of memes or chain emails either!

Saturday, 24 March 2007

Bad name of the day (part two)

Jinx, as a name, for a girl!

jinx (jÄ­ngks) n.

A person or thing that is believed to bring bad luck.
A condition or period of bad luck that appears to have been caused by a specific person or thing.

Possibly not the best name for a child. Not a bad name for a Bond villain, or as a word in Scrabble. Don't be too surprised if your child grows up to hate you for that preposterous moniker.

Friday, 23 March 2007

Drug Reps

The pharmacy in which I work isn't exactly in a salubrious location. So, anyone who turns up reasonable presented is either lost, or a drug rep. I'm not completely sure of their titles now-they used to be Drug Reps, then they all started getting business cards with "Regional Pharmaceutical Manager", "Territory manager" or "Business Development manager" printed on. But if it looks like a drug rep and smells like a drug rep, then a drug rep it will be.

I estimate that approximately 8o% of the reps that I see are female. Of those 80% I reckon about 75% would score highly on the "I would" scale that single men use to rate females. Well, some single men! I am sure it is no accident that these well-groomed, highly-polished, large-breasted women are sent out to see both general practitioners and pharmacists. As a species, at least around here, we are predominately male.

It all starts pleasantly enough with, normally, a gift. Maybe some pens or possibly a packet of Post-it notes. Once you take the gift you almost feel obliged to talk to the rep. They will then come in and put their overlarge briefcase onto the dispensary floor. If you are a female rep it seems to be obligatory to do this whilst bending over very slowly. It's also seeming obligatory to leave one more button on your blouse undone than is decent. Attractive woman, hint of cleavage, I think I see the plan. Then it is smiles, lots of smiles, maybe a little bit of arm-touching to make you feel special, as is if they almost like you. You might even get to the point when you think about asking them out on a date. You have absolutely no chance, but you think you might ask anyway.......

They will surreptitiously scan your pharmacy shelves in the hope of seeing a shelfful of their product. Then they will normally tell you that "Dr Baker has said he is going to start using it." Maybe Dr Baker did, maybe he didn't. I'm guessing he just nodded his head to get his freebies and get rid of the rep. Then they will ask how their product is doing and which doctors are prescribing it. The answer to that is "I'm not telling you and you know that I'm not meant to give you that information". Maybe they will spot a parallel import of their product and do a little scaremongering about the quality, possibly forgetting that the recent counterfeit batches of Lipitor, Viagra, etc. were not parallel imports..

Next is the bullshit. Why product X is better than product Y. Sometimes there is a genuinely innovative new product. More often than not it is another "me-too" drug. Another ACE inhibitor, another COX-II inhibitor (hey, where did they all vanish too!!) Maybe their product is a whole 20p a month cheaper. Next comes the data. You'll possibly notice at this point that the data is normally unpublished. Check the references and you will find it is often listed as "Data on file, Big Pharma Ltd." Or, it will be a very small study with wide p values published by their own company. Me, a cynic? You think? Occasionally, but less so nowadays you will notice that the axes on the graph aren't to scale and/or don't go to zero. This is a bit naughty and exaggerates the scale of any differences in the data.

Don't get me wrong, they are normally nice enough people earning an honest living. Just don't place too much store in the information that they give you. It is just all a bit seedy. Why not be honest, come in wearing lingerie with my free pen between your bosoms. I'll pull it out with my teeth, tell you anything you want to know that I legally can, and we'll cut out all the crap. Then we can both go on out way having learned something. You will have learnt that pharmacists and doctors routinely lie to you, and I will have learnt that the amazing pen you gave me doesn't have any ink in it.

I feel a post coming on. Photographs of my ten best drug-rep gifts! Or maybe the ten best drug reps?

Say No to Drug Reps
Say No to Drug Reps (UK Version)

Confused patients




"my doctor changed my prescription from Ramipril 10mg to Losartan 50mg, but he seems to have given me a much stronger dose, should I be worried?"

Now I get to have the conversation I've had hundred of times as a pharmacist. 10 mg of Drug X isn't necessarily equivalent to 10 mg of Drug Y. It seems a fairly easy concept for anyone with a reasonable educational background.

I spend ten minutes trying to explain it as an analogy. The best analogy I could come up with on the spot was fruit. Grapes are small so you have more of them whereas you'd only need a small piece of melon. I know, it's a rubbish analogy but it's the best I could do? Any ideas for a better one received with thanks, as it's a conversation that I have fairly regularly. Normally it's along the lines of a patient saying, "The Paracetamol are 500 mg and the Aspirin are only 300 mg so I'll take the Paracetamol as it's stronger."

The patient departed with the words "Well, I still think I'm taking five times as much I need to, so I think I will go back and see my general practitioner"

Hopefully he'll have more luck with his explanation than I did. Maybe he will have a better analogy.

Tuesday, 20 March 2007

Bad name of the day.

Neo and his sister Trinity. Presumably his parents were fans of "The Matrix Trilogy" rather than scholars of Greek. Maybe we should be grateful that they didn't enjoy "Lord Of The Rings"

Noah takes a photo of himself every day for 6 years.

I know, I know. This post has nothing to do with pharmacy. It's just a simple idea, with an impressive piano track. I found it strangely moving. I think I'm getting sentimental, I need to get back to work!

Music is here

Noah's website is here

Normal service will resume shortly.

Sunday, 18 March 2007

Twenty ways to make me mad.

I'm normally a fairly happy chappy, but do any of these and I'll guarantee to make your prescription go to the back of the queue.

  1. Talking on your mobile phone-Your mum might be interested to hear that you have an infection and a sick note, but I'm not and neither are the other customers in the pharmacy. Please do not expect us to give out your medication and counsel you whilst you are talking to someone else.
  2. Looking at your watch whilst sighing and/or drumming fingers-Sure, I can dispense faster but I might give you someone else's medication or the completely wrong medication. Would you really prefer that to waiting an extra five minutes in your busy, busy life? In fact, I notice from your prescription that you are unemployed- you must have such a busy life, I apologise.
  3. "Can you check you have this in stock before I sign it?"- You are an idiot and you are going to have to sign your prescription anyway. I already know if I have the item in stock, I do not need to check. If you annoy me then I'll pretend I don't have your item, especially if it's raining. Then I'll do a little dance of joy as I watch you squelch along the road
  4. "Do you do prescriptions here?"- The 30cm high "PRESCRIPTION" sign is a good indicator that we are a pharmacy, just as a "BANK" sign is a good indicator that a bulding may be a, er, bank maybe?
  5. If you start any conversation "I know you aren't a doctor, but....." or "You probably won't know this, but......." then I am going to be annoyed.
  6. Aspirin is a medicine, the liquid you take for your indigestion is a medicine. So, when I ask you what other medication you take the answer is not "Nothing"
  7. If Jim's pharmacy down the road sells Kaolin and Morphine then go and buy it from Jim. I do not sell Kaolin and Morphine because it does not work. Telling me that "it always works for me" isn't going to change my mind. Diarrhoea normally lasts for a few days whether or not you take anything to treat it. Your n=1 study does not interest me.
  8. Do not try and talk to me whilst I am dispensing. I am your pharmacist, I am not your friend. I really do need to concentrate on what I am doing. Just because you can see my head does not mean my head can see you.
  9. If you think I've made a mistake then please double check. Ninety-nine times out of a hundred the thing you are missing was not on your prescription. I do not very often miss items off your prescription completely. Far more likely that you forgot to order them. Wait, you are not infallible either?
  10. I do not live in some sort of weird communal Big-Brother-style house with your doctor. Sure, your doctore looks a little like me, but he isn't my big brother. We really don't meet for a chat about you every Wednesday. Assume I do not know what he has told you and you him.
  11. If you are an attractive, busty female than waving your breasts at me isn't going to make me jump you up the queue. Yes, I'll possibly have a look at your breasts, as it'd be impolite to refuse such a generously offered gift. But really, waving your boobs at me whilst handing me a prescription for Metronidazole 2g Stat isn't going to float my boat.
  12. Do not complain that prescriptions now cost £6.65 per item whilst smelling simultaneously of Cigarettes,alcohol and McDonalds. You might not understand the word irony, but we do.
  13. If you need an item for a certain date then do not wait until that day before bringing in your prescription. I really do not have 56 packs of Ensure chocolate and 56 packs of strawberry in my secret cupboard.
  14. My dispensary does not have elastic walls. I cannot keep every strength of every possible medication. Sometimes I might need to order it. If I do it'll be here the same afternoon if you bring me the prescription in the morning. You really will not die if you go one day without your HRT. Well, you might, but only if I shoot you. Rolling your eyes is not going to help.
  15. If you won't tell me your address then I won't give you your medication. I realise that it is printed on the prescriptiuon, but I need to check that you are the correct "John Smith"
  16. If you shout at me and/or threaten to kill me after work then I will remember. Sure, try and creep back in and be nice, but I will remember the time you threw a packet of Salactol at my head because I would not give you a refund.
  17. If you have a prescription for hosiery then I will need to measure your legs. Thigh-length hosiery means I'll need to measure your thighs. Please wash your feet and wear some underwear. Also, try not to wear four layers of clothing. Your pharmacist doesn't want to see your smelly crotch and have to touch your hobbit-like feet.
  18. Please do not tell me that "My Nicotine-replacement therapy didn't work." Of course it worked, you are just an idiot with the will-power of a small child. Anyway, wasn't it you that told me ten year's ago that "Smoking has not done me any harm". How do you like using those Combivent inhalers?
  19. I cannot swap the medication that you do not want this month for one that you do want. I am not going to swap your Propranolol for a box of Ramipril even if they do come in the same coloured box. I guess I could do, but I'd get struck off. The only other thing I can do is juggle and no one will pay me to do that full time.
  20. If you have been to every other pharmacy in town and they do not have the item in stock them I'm guessing I will not have it in stock either. If it's something you really need then you have my sympathy. If it's just because you want "purple tablets that smell of straweberrys" then I'm probably not going to ring around other pharmacys for you.

I am really not that grumpy, really I am not. Well, only sometimes! Be polite to me and I'll return the favour. There is also a "Twenty ways to make me happy" post to come at a future date.

Saturday, 17 March 2007

Shaggy Blog Stories.





A collection of 100 short humorous pieces from the UK blogosphere. All profits from the sale of this book will be donated to the Comic Relief charity. Contributors include Richard Herring, Andrew Collins (BBC 6Music), Emma Kennedy, James Henry (Channel 4's "Green Wing"), Abby Lee (Girl With A One-Track Mind), Catherine Sanderson (Petite Anglaise), Zoe McCarthy (My Boyfriend Is A Twat), novelist David Belbin, Anna Pickard (The Guardian), and a diverse selection of some of the UK's most talented bloggers.

It's only £8.96, and £4.64 of this goes to Comic Relief. All of the pieces were generously donated for free. The perfect gift for Mother's Day. It'll just arrive a little late. :)

More details here.

Thursday, 15 March 2007

The Great Football Giveaway.

More information here

Okay, so I am possibly not the most compassionate person in the world. Then again, the video above shows what a difference even a modest £10 football can bring. You would not catch me kicking a football in real life, but it's heartwarming to see a little African fellow chasing after a ball. Go on, it's £10 and you can Gift Aid it too.

Wednesday, 14 March 2007

Bad name of the day

Bad name of the day:-Tineisha. Okay, you might get away with calling a child that name if you are a black, hip-hop star. But really, it's not the best name for a white baby when you live in the UK. Do you want your child to be beaten up?

Sunday, 11 March 2007

EHC customers



So, following on from my previous post. we supply EHC at zero charge to any female patient that asks and who fits the criteria. It's a service that our PCT funds-some PCTs do, some do not and some only supply it free to teenagers, not adults. (As adults are responsible and do not have irresponsible acts of unprotected sex!)

I think we've been supplying it for about three years now. The youngest patient I have supplied it to was 12 and the oldest was 49. The current record for the quickest presentation is a girl who managed to get dressed after unprotected sex, drive to the pharmacy and speak to me- in under twelve minutes. I was impressed, but maybe she had sex in the car-park, or in the local park.

Some patients are mortified and you can see them inwardly squirming as I ask them about their sex life. Then again, 90% of people are relaxed and quite happy to answer the questions I need to put to them.

The first few times I asked the questions I was a little embarrassed too. Now I think it's quite hard to faze me. I've heard about women having secret affairs who don't want their husbands to find out (and he won't find out from me, but the bruises on your arms might give you away) through to girls who come in together having slept with the same guy at the same time. Yes, I know, my life is boring compared to that too.

It's heartening that so many teenagers bring their boyfriends with them. The boyfriends normally sit outside looking vaguely nauseated. Presumably at the thought of being a premature father. (Which is still a possibility as EHC isn't 100% effective). We also have had girls coming with their mothers, their dads and most commonly their mates.

My favorite EHC consultation was with a Polish lady who did not speak English very well at all. Her answer to "How long ago did you have sex?" was-

"It was about for ten minutes and I liked it very much, thank you"

Polish people are so polite. How long her "sex session" lasted was not really something I need to know. I did eventually get the answer I wanted, but only after describing sex with a combination of hand gestures, sketches and mime whilst pointing at my watch.

Saturday, 10 March 2007

Why is the morning after pill called the morning after pill?

Did you know that the morning-after-pill can still be effective for pregnancy prevention if given within three days of unprotected intercourse? This, despite a name that seems to imply the pills work only the morning after. That's why calling this medication the "morning-after-pill" is technically incorrect. They are actually known as emergency hormonal contraception pills, or EHC for short. EHC can actually be effective if taken within 72 of unprotected intercourse and sometimes up to 120 hours.

The confusion is probably a result of the proliferation of medical information on the internet, whereby many of these sources still propagate myths about emergency contraceptive pills.

TM is a 23-year-old who just been dating a guy for the past month. They had unprotected sex 3 days ago. TM is worried about getting pregnant and wants to know how to prevent it. She has the following concerns:

Can an emergency contraceptive pill be used even though she is not taking it the morning after unprotected sex?
A clinical study published by von Hertzen et al in 2002 showed that EHC is effective if taken within 120 hours of unprotected intercourse, so it is possible for TM to take the pill at the time indicated (72 hours). However, in the same study, pregnancy rates were slightly higher among women who started treatment more than 72 hours after unprotected intercourse. Therefore, TM would need to be beware that the earlier the dose is taken, the more effective the therapy will be. She also needs to understand EHC is never 100% effective, and the effectiveness varies with how many days she is into her menstrual cycle.

How does EHC work?
EHC contains a hormone that acts to prevent pregnancy. This works by inhibiting ovulation, fertilization of an egg, and/or implantation of a fertilized egg in the uterus. They function in a similar manner to the regular daily oral contraceptive. It does not cause an abortion contrary to the popular urban myth.

What if the unprotected intercourse happened more than 3 days ago?
An IUD can be inserted into the uterus up to 7 days after unprotected intercourse. This intra-uterine device functions by preventing the implantation of a fertilized ovum, and having a direct toxic effect on the sperm, before fertilization of the ovum. However, a doctor must confirm TM has no medical condition that bars her from using it, and also be responsible for inserting the device for her. This device can also cause side effects such as vaginal bleeding and uterine cramping.

TM wants to go to her general practitioner for a prescription for oral contraception. It is midnight now and the clinic is closed. She knows there is a 24-hour pharmacy in her area. She has the following questions:

She learns that in the United Kingdom, EHC has recently become a pharmacy medicine and customers can now buy EHC in retail pharmacies without a prescription. So, she asks whether she can get any pharmacist to sell her EHC?

It is true that EHC is now a non-prescription medication. However, in the UK it is available either as a traditional over-the-counter medication, or via what is called a Patient Group Direction. (PGD) TM needs to be aware that the pharmacist will go through a more thorough interview with her if she does not have a prescription from a doctor. This is because a doctor would already have assessed if EHC was suitable for the client before prescribing it If a person goes directly to the pharmacist, this assessment now becomes the responsibility of the pharmacist. If a sale is made then the cost will be approximately £25. If it's supplied under a PGD then it would normally be free. (At least it is in my PCT, others vary.)
In contrast, if TM has a prescription from a doctor, she can have the EHC dispensed by any pharmacist. She does not need to pay any fee as contraceptive prescriptions are exempt from prescription charges.

TM decides to get EHC in the pharmacy, which has an EHC-trained pharmacist. What happens during the one-on-one consultation with the pharmacist?
First, the pharmacist brings TM to a private and quiet area for counselling. Next, they go through the emergency contraception form. The pharmacist will ask TM her name and postcode, then ask her when the first day of her most recent menstrual period is, to make sure TM keeps track of her cycle. This way, if her period does not start within 3 weeks, TM will be able to see her doctor or do a home pregnancy test, since pregnancy could have occurred. Secondly, the pharmacist will record the date and time of the unprotected intercourse to determine if an effective treatment can be given within the 72 hour timeframe. The pharmacist will question if the exposure is due to a failure of another birth control method, and offer other effective methods if necessary. Then, the pharmacist will explain how EHC works. The pharmacist will also inform TM that EHC, not being 100 percent effective, is for emergency use only. This is to encourage the use of regular birth control methods, such as taking oral contraceptive pills, which are more effective. After this, the pharmacist will tell TM of the possible side effects of EHC - these include nausea and vomiting and early or late menstrual period. TM could take an over-the-counter anti-nausea medication, such as Prochlorperazine to relieve nausea and vomiting; and she would have the knowledge to expect her period to possibly be a few days early or a few days late.
After that, the pharmacist will remind TM that EHC offers no protection from sexually transmitted diseases.

Under what other circumstances are referrals needed?
If TM inquires about regular birth control methods, she should be referred to a doctor for assessment. Also is TM is taking other medications, such as some anti-epilepsy medications or suffers from any other medical conditions, then a medical referral may be necessary.

What happens after the counselling?
After the counselling, both TM and the pharmacist sign the form, which stays in the pharmacy. Then, the pharmacist supplies the EHC, but does not normally have to witness TM taking the medication. The pharmacist also gives the “How to use emergency contraceptive pills patient information” handout for TM to take home, as well as a small supply of condoms. TM does not have to take the condoms if she lives with her parents, doesn't want anyone to find them, etc.

TM wonders whether the pharmacist can disclose her use of EHC if her parents request about it?
All pharmacy staff are obligated to keep clients’ information confidential unless the clients give consent to release it. So, even her parents cannot access her medical information. If a client is under sixteen then the pharmacist would normally recommend that she discusses things with her parents.

Half an hour later, she phones the pharmacy and says that she has vomited. What should she do now?
If she vomits within three hours of taking an EHC, she should come back to the pharmacy for another dose. It is likely that she has not absorbed the medication.

See, it isn't that embarrassing. Plus, it's free. Certainly cheaper than a mini-me.

References:-

Von Hertzen H, Piaggio G, Ding J, Chen J, Song S, Bartfai G, Ng E, Gemzell-Danielsson K, Oyunbileg A, Wu S, Cheng W, Ludicke F, Pretnar-Darovec A, Kirkman R, Mittal S, Khomassuridze A, Apter D, Peregoudov A; WHO Research Group on Post-ovulatory Methods of Fertility Regulation. Low dose mifepristone and two regimens of levonorgestrel for emergency contraception: a WHO multicentre randomised trial. Lancet. 2002 Dec 7;360(9348):1803-10.

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Friday, 2 March 2007

Prescription Charges.

The yearly prescription rise, from £6.65 to £6.85 an item is fast approaching. from April 1st it'll be a chorus of:-

"Has it gone up again?"
"Is this to pay for your new car?"
"It's disgusting!!"

Okay, many drugs do cost pennies a box, but the mean value in our pharmacy is about £13 an item. Remember it's £6.85 whether you have 15xAmoxicillin Capsules 250mg or the latest super-duper anti-TNF medication at £700 a box.

I guess the current exemption system make little sense. If you are epileptic you get all your medication, even if completely unrelated to epilepsy, for free. If you are asthmatic you have to pay for all of your items. If you have Hypothyroidism then congratulations, you'll be exempt. If you have Hyperthyroidism then hard luck, that'll be £6.85 for your Carbimazole please.

Everyone should pay a set price per item. Say, £1 an item. That's affordable, even if you have many items a month. It might also stop the patients that go to their doctors to get Paracetamol Suspension, Paracetamol tablets and head-lice treatments.

So, £1 an item whether you are old or young, rich or poor, hypothyroidic or hyperthyroidic. Sounds fair? It won't ever happen. There are far too many vocal OAPs who would complain and far too many Chavs who would rather spend their Income Support on scratchcards than their childrens' medication. It's such a big potential vote loser for any government that I cannot see the current system ever changing very much. Well, not with a new Labour-leader due and a General Election not too far away.

Joan Beaker



Joan Beaker smells. Joan Beaker smells quite badly. Does she have some incurable fungating skin infection? No, she doesn't. Does she not wash herself properly? Well, maybe, but that isn't the reason.

The reason that Joan smells is because she doesn't keep her medication in the refrigerator. As a consequence of this, her medication degrades quite quickly and doesn't work. She has had the same medication for many years.
So, why doesn't she keep her medicine at the correct temperature?

"I keep food in my fridge, not medicine, are you stupid or something? Why would I keep medicine in the fridge"

One can but try.

Thursday, 1 March 2007

Something for the weekend


Bloody generics!

Many popular drugs were discovered so long ago that they no longer have any patent protection. That means any generic drug company can decide that they will make their own version, and they do.

This happens with the most common drugs. That’s things like Bendroflumethiazide, Atenolol, Ramipril, Simvastatin, etc. Common sense would suggest that each company would make their version of the drug the same shape, the same colour and with the same tablet markings as all the other companies that make it. What happens is Company A may decide they really want to put their blue Ramipril capsules in a non calendar-pack and without any markings. Company B decide to put them in a calendar pack, with a white “10” marked on each red capsule.

It does get confusing, especially as our suppliers send whatever they have on their shelves. It’s a little annoying, but when one realises that each capsule contains the same amount of the same drug, it doesn’t matter what colour they are/what sort of box they are in/whether they are pentagonal or hexagonal.

What is far more annoying, and happens on a daily basis, are patients that insist that the Blue capsules work “better” than the red ones. Or the blue ones make them sick whilst the red ones do not. Or they prefer hexagonal tablets to round ones as they don’t stick in their throats. You can easily spend five minutes, with other patients tapping their feet with impatience, trying to explain that they are identical and will have exactly the same effect.

“No, I’m not trying to poison you!” but I often wish that I could.

It is at this point I reach behind my counter and pull the lever which opens the secret trapdoor. This plummets the annoying patient to a certain death. We don’t really have one of those, but we should do.

Of course you can track down that elusive supply of blue capsules. If you do that you are certainly a better man than I. Do it one month and that very same bozo will be back month after month to insist you try and track down those strangely hard to find boxes of APS Ramipril capsules.

Losing one's drugs.

I have a patient who I shall call, because it’s his name, Mark. Mark comes to our pharmacy every week and gets his prescription for Diazepam 10mg dispensed.

Approximately every six months Mark will get burgled and someone will steal his Diazepam. It’s very strange that a burglar will break into his house, find a 8cmx1cmx4cm box of Diazepam, but overlook the television, video and the rest of his possessions. Not that I am cynical or anything!

He also has the unfortunate habit of losing his tablets, or getting mugged on his way home and having them taken from him. I have noticed that people never lose their hypertension medication or their inhalers, they only seem to lose drugs with a street value [Current street value of Diazepam 10mg-£1 a tablet]

What does his doctor do? Well, his doctor gives him another prescription for Diazepam, just like that! I often think that if I had some magic beans one of the Doctors in my surgery would buy those too.

Having said that I do like Mark. He’s a pleasant, polite chap whose likeness to Gollum from LOTR is spooky to behold. He also has the endearing quality of counting the number of tablets we dispense for him, just in case we try to rip him off! All only slightly marred by having the pale and waxy skin of the long-time drug abuser. Think Trainspotting.

I’m hoping to arrange a date with him for one of my staff. But she might just be a little too picky.

Malaria

I had a patient today who had been told by the receptionist that she could buy anti-malarials over the counter. Which is true, sort of. You can buy Proguanil (Paludrine) and Chlorquine (Avloclor) fairly cheaply. The problem being these are only recommended for relatively few places as the malaria mosquito has become resistant to this drug combination in the less desirable, fly-blown, parts of the world.

Where was the patient going? A seemingly around the world trip including parts of sub-Saharan Africa that I would not personally visit even if accompanied by armed guards. She “could” take the combination of the two drugs above but it isn’t a recommended treatment regime and she’d possibly get malaria and die. So, I bounced her back to the doctors for a private prescription. Maybe a nice prescription for Malarone or Lariam?

Or maybe, if the doctor really hates the patient, he will give them some Doxcycline- which means she'll have to stay out of the sun in case she has a reaction to the sunlight whilst taking it. Oh dear, no tan to show her friends!

So, the moral of the story. When you visit your surgery don't take travel advice from the receptionist, or the cleaners. Try for a GP. If you cannot find one of those ask a Nurse.

Stupid customers. (Part One of many)

Stupid Customers:-

Me: “Hello, Bill’s pharmacy”
Customer: “Hi, could you tell me what your phone number is please”?
Me : “It’s 01234 56789”
Customer: “Thanks, er, could you write that down for me?”
Me: Er, “Well, I could but you wouldn’t be able to read it, would you?”

Thank heavens for computers.





Fortunately, I qualified just as computer-generated prescriptions were becoming standard. Now, probably 99% of prescriptions are computer-generated and printed. The only ones handwritten tend to be the ones issued by dentists. and the occasional prescription left by a General Practitioner on a home visit.When I qualified I guess it was 50% handwritten and 50% printed (Normally by dot-matrix printer with the oldest, most faded ribbon imaginable).


At least now I'll probably know what your doctor intended. Whether we give you that, or mix up Slow-Potassium with Slow-Sodium (You know who you are) is a different matter


Ten points for anyone who can decipher this. I can just about work it out. Er, I think!

Little Jimmy


Okay, “little Jimmy”, your imaginary son, is ill. You know it’s viral and that he will not need antibiotics.

Would you:-

A -Phone for an appointment with your family doctor, make a special trip into the surgery, wait for your appointment, explain your concerns to your GP, trundle to the pharmacy and hand in your prescription and then wait ten minutes for your prescription for 99p worth of Calpol suspension to be dispensed?
(That is exactly the same Calpol suspension that you can buy over-the-counter in any pharmacy. In fact, as Calpol Suspension is a General Sales List (GSL) medicine, it is the same Paracetamol suspension that you can buy in just about any shop- Tesco, Sainsburys, and your friendly petrol station.

B-Walk into the pharmacy and buy a bottle of Calpol for 99p and avoid all of the above?
You’d choose B, right? How much time would you have to have on your hands to choose option A? But that is exactly what many people do.

Why do they do that? Well, that way they will not have to spend 99p of their own money. Instead they will spend/waste about ten times that amount of NHS money. (The doctor’s time, my time, the ingredient cost for the Paracetamol).

Plus, people in this town seem to have way too much time on their hands, something I’m slightly envious of. Then again, I do have a job which is one explanation why I would not waste hours of my time to save one whole pound.

Now, I am quite sure that some people think the medicine from the pharmacy is special. Surely my Paracetamol is more powerful as I measure it nicely into a small bottle and attach a label. No, it’s actually exactly the same!!

It’s the age-old problem that people do not attach value to things they do not pay for themselves. Cost=zero, demand=huge. People would rather spend their money on jumbo packs of turkey-twizzlers and scratchcards.Calpol seems to be the cure-all of choice here. It is only Paracetamol but it magically manages to help children sleep, stops diarrhoea, stops constipation, helps with wind and cures coughs too.

Do you not love the placebo effect?

An explorer on the Moon.

I live and work in an unprepossessing town in Warwickshire. The town itself is perfectly pleasant, the only problem being some of the people living here. I am not sure if it is something that I do to attract them, but the majority of my patients seem to be slightly dim.

I am not entirely sure whether it is genetics, alcohol, drugs or a combination of all three. Feckless, reckless, overweight, pale and waxy-skinned would be a fair description of an average patient.

Oh yes, impatient too. They certainly would not want to wait ten minutes for a prescription being egocentric to the point of seeming not to notice the six patients waiting in the queue ahead of them.

“It’s only tablets, why does it take so long?”
“I’m parked on a double yellow line, can you do it quickly?”
“All you do is stick a label on the packet.”

Yes, that is really all I do. Feel free to come and try It yourself.

It is a very bad habit, but I tend to put the prescriptions for people that complain about the wait to the back of the prescription pile. Ten minutes isn’t that long. Did you not sit and wait for twenty minutes in the surgery? Did you complain to your doctor about the wait? No, thought not. By all means try the next pharmacy down the High Street, but that is ten minutes down the street and they will take twenty minutes to dispense your prescription.

One would normally assume that the people around you are similar to oneself. Not here, it’s like being an explorer on the Moon.

So, it begins.

So, it begins!

Not sure about what, why and how often I'll post. Probably when I'm bored and don't have anything else to do.

Everybody exists, but people have been anonymised and names changed to protect their identities. All comments are of REAL made-up patients at a completely FICTITIOUS pharmacy. The names have been changed to protect the innocent, who aren't really guilty because they don't really exist.