Pharmacy for the Masses: Decoding Drug Info

all medical info is for informational purposes only and should not be taken as medical advice

[pharmacyforthemasses]

So this is a thing that can and does happen.

[altheterrible]

So I'm kinda videophobic but I was thinking of trying to make a tik tok about how no one understands health insurance in the United States and pharmacy pricing is a scam.

[pharmacyforthemasses]

I’ve been taking Dexilant for over a year now to treat chronic GERD and Barrett’s esophagus and my GP desperately wants me to stop taking it already because of the long term risks but I get really severe heartburn and stomach pain when I do and have bad stomach pain sometimes even when I take it. I have CPTSD so I’m constantly on alert and I know that’s making my GI symptoms worse. What’s your opinion on staying on Dexilant long term?

I mean, there’s risks to taking it long term and there’s risks to stopping it. Ideally you could get your stomach problems under control without the medication by changing diet, reducing stress, etc, but that’s not always feasible. 

It’s really up to you which set of risks you want to take. Personally, bodily comfort is my highest priority, so I would keep taking it. But that’s my risk assessment.

[pharmacyforthemasses]

Large Study Finds Trans Men on Testosterone at Risk for Blood Clots

Transgender men who take testosterone are at risk of developing erythrocytosis and future thrombotic events, especially if they smoke and ar

This is really important to know. Trans healthcare is not where it needs to be in this country, and many transgender folks are not informed of these kinds of risks because doctors aren't educated on cross sex hormones. Even this article is woefully unhelpful, it provides no clear guidance on what actions transmen should take if they have high hematocrits.

[altheterrible]

...are we just pretending that opioids don't exist now? Wtf?

[altheterrible]

You ever go to the pharmacy, and there's only one pharmacist and one technician working, and you’re pissy because you're only there in-person because you can’t get through on the phone, because they keep putting you on hold and then hanging up? Or, like, you know how there's three registers at the pharmacy counter but only one is ever open? You know how it always takes 45 minutes to “put 30 pills in a bottle”? You know how the pharmacy gave you the wrong medication once and almost killed you? You know how you had to wait over an hour for a flu shot while the pharmacist was “just standing there staring at a computer”? You know how you keep transferring pharmacies because they can’t ALL be this slow and incompetent, but they somehow are? You know how all these problems could be solved by having another pharmacist working? Too bad there's such a shortage of pharmacists that they have to be spread so thin!

I'm going to let you in on a secret. There is no pharmacist shortage. In fact, there's more pharmacists graduating every year than can find work.

The problem isn't a shortage, it's that the major pharmacy corporations have simply decided that your safety and convenience are less important than their profits. It used to be common to have 2 pharmacists on staff during a shift, now even very busy pharmacies only have a few hours a week where there's more than one pharmacist working.

There are certain pharmacy operations that, by law, only pharmacists can perform. This is because pharmacists are experts, we have doctorates and know more about medications than any other healthcare professionals. To maintain high standards of patient safety, in a pharmacy, only pharmacists can give immunizations, transfer prescriptions, perform final prescription verification, counsel patients, and a couple other things.

So if you only have 1 pharmacist working, they can get spread thin super fast, leading to long waits for “simple” things. Like, maybe it only takes 3 minutes for a technician to count out 30 pills, but if I'm on the phone with insurance, it could be another 20 minutes before I can verify the prescription is correct. It's not because we’re “incompetent,” it's because there's only one frazzled person who can perform that step. And the more frazzled that person gets, the more errors that happen.

Additionally, retail pharmacists don't get breaks, which is GREAT for patient safety. I used to work 12-hour shifts where the only chance I got to sit down was when I ran to the bathroom. I didn't get breaks. At all. Period. I couldn't be off the clock because the pharmacy would've had to have closed and THAT endangers profits. If I was lucky, I would get 10 uninterrupted minutes in a 12 hour shift to shove a granola bar in my face. So this increases fatigue, which further jeopardizes patient safety.

So next time you're at the pharmacy and it's taking forever, or they made a mistake, place the blame where it belongs and voice your dissatisfaction to the corporation directly. Send them a tweet. Ask why they chronically understaff their pharmacies. Ask them why corporate profit means more to them than patient safety. And then consider transferring to an independent pharmacy.

[pharmacyforthemasses]

Hello! Idk if this is too specific but I was wondering if you knew anything about opioid-induced hyperalgesia, and/or if you had any tips for minimizing withdrawal symptoms for someone who is trying to cut back on opioid medication use? I used to take 3 percocet daily and now I'm down to 1.5, sometimes just 1 a day (I take them by halves now), but after a couple days of just 1, I get agitated, restless, and generally uncomfortable. Any tips on weaning further while avoiding these symptoms? Thx!

So opioid-induced hyperalgesia, for the unfamiliar, is this stupid thing that happens where using opioid pain medication can paradoxically increase a patient’s sensitivity to painful stimuli. The human body never ceases to amaze, right? The exact mechanism of this useless phenomenon is not yet known, but we have 4 hypotheses about what could cause it:

• sensitization of peripheral nerve endings

• enhanced descending facilitation of nociceptive signal transmission

• enhanced production, release, and diminished reuptake of nociceptive neurotransmitters

• sensitization of second-order neurons to nociceptive neurotransmitters

Anyway, there are a few treatments that can help relieve OIH. One is reducing opioid doses. Adjunctive ketamine had been shown to be useful, as has adjunctive gabapentin. Finally, opioid switching may help, but this has not been conclusively demonstrated in studies.

Tompkins, D. A., & Campbell, C. M. (2011). Opioid-induced hyperalgesia: clinically relevant or extraneous research phenomenon?. Current pain and headache reports, 15(2), 129–136. https://doi.org/10.1007/s11916-010-0171

As for reducing withdrawal symptoms when cutting down opioid doses, that's going to be tricky with Percocet because it is short acting, so it's only in the body for a few hours. Once it's out of the body, withdrawal starts. Switching to an extended release opioid like Oxycontin would be your best bet, but that may not be practical. Have you considered asking about buprenorphine or methadone? These two opioids are used more for treating opioid addiction, but can be effective pain relievers that prevent withdrawal.

[pharmacyforthemasses]

What's your take on the validity of self diagnosis?

I really hate the word valid, yo.

Personally, I don't practice self diagnosis because I see no benefits to adding a diagnostic label versus addressing symptoms. That's just me, though; some people find diagnostic labels to be extremely beneficial for understanding their experiences. If self diagnosis is meaningful for you, then by all means, practice self diagnosis.

One important addition, though: always tell your healthcare providers when a diagnosis was done professionally versus self-diagnosed. If you don't make such a distinction, they may assume that since you state a diagnosis, you've undergone tests and procedures that you may still need to have performed.

[pharmacyforthemasses]

Send me your health and medication questions!

[pharmacyforthemasses]

I'm trying to decide what I want to do with this space.

I don't want to go into specifics, but my professional life just totally went up in flames 6 months ago and since then I've been pretty much over pharmacy.

But I don't want to delete the blog because there's a few good posts here that someone might find useful. And since Tumblr seems to have dramatically increased the limit on side blogs, I don't need to delete this blog to make space or anything, so I could just leave this here forever.

But, but, but, I hate abandoning things.

So my thoughts: Going forward, I could

A. lean more heavily on answering specific asks rather than on generating general information posts, which take significantly more work

B. Reblog more from other people to bulk up my content

C. Create general information posts about more than just meds, so like, diseases, interpreting lab results, getting your doctor to do what you want etc

D. Some combination of A-C.

[altheterrible]

Tw: medical abuse, medical incompetence, psychiatric medication, very brief mention of self harm, rant, I have sources but they're on my laptop and I do not have the patience for that tonight

I'm becoming quite anti psychiatry, which is quite funny to me as at one point, I intended to be a psychiatric pharmacist.

I've swung to being 100% against using antipsychotics for anything but psychosis, and even then, I think the doses need to be much lower than current practice. Doctors are prescribing seroquel for insomnia, like, that's so bad. Or anxiety. Antipsychotics have no clinical evidence of efficacy in anxiety disorders.

Clinical trial data indicate that with the exception of severely depressed patients, anti-depressants barely outperform placebo. In many trials, antidepressants DON’T outperform placebo. The medications for bipolar disorder tend to address depression OR mania, but nothing really treats both. And bipolar meds have so many contradindications, if you're taking lithium or lamotrigine, good luck taking anything else safely. Benzodiazepines cause serious cognitive issues, and withdrawal can be fatal. I’ve had fucked up experiences with benzos, and frankly I’d rather be anxious than have anterograde memory loss or pound 8 nails into my tibia. I say this as someone who has experienced anxiety so severe I physically couldn't leave the house.

God, what else…the side effects of antipsychotics are terrible. On the first-generation side, you have movement disorders like TD, akathesia, dystonia, etc. Drooling is common. Extreme sedation is common. On the second-generation side, you have weight gain, insulin resistance, metabolic syndrome, hyperlipidemia, eventually leading to heart disease, diabetes, and hypertension. Oh, PLUS all the movement disorders. There are some studies suggesting that antipsychotics shrink the brain. Clozapine can destroy your immune system. I put on 30 pounds taking Abilify, which was advertised to not cause weight gain. I still can't get my blood glucose under control. And I took 2 of the most modern, “benign” antipsychotics.

Don't get me started on idiots who decide to give dementia patients antipsychotics for “agitation.” Antipsychotics have a black box warning for increasing death from all causes in the elderly.

Then there's the fucking cowardice where doctors are afraid to use meds that DO work. My sister has ADHD worse than mine. Her doctor would only prescribe Wellbutrin and Strattera. Those didn't work, so she stopped taking them and now has NO treatment. She regularly forgets where she's driving and gets so distracted driving that it’s a miracle she hasn't caused an accident. I've had insomnia literally since I was 12 years old, but no one will prescribe Ambien or Lunesta. I've had success with gabapentin for insomnia, but now it's a controlled substance in my state and no one will prescribe that, either. All I get is trazodone, which upsets my stomach tremendously and doesn’t actually work. Right now I'm taking 2 Benadryl and a trazodone and I get maaaaaybe 5 hours of sleep a night.

Psychiatric medications are often more about control than patient relief. Especially if you’re a minor, it’s so rare for a psychiatrist to ask what your treatment goals are.

I just want to feel awake, and alive, and I want to spend less time every night staring at my ceiling. Is that so much to ask?

[altheterrible]

I saw a really misguided post awhile ago about how it's a bad, evil thing that generic versions of medications exist, and everyone should get the brand name version because it's always better and generics are just cheap knockoffs.

The thing is, generics aren't just cheap knockoffs, and having multiple manufacturers of a medication is advantageous. A med can be made in different dosage forms (syrup vs capsule vs tablet) in which the brand name doesn't exist, they can be made with different excipients (inactive ingredients) which is good for people with sensitivities, and they can actually contain more active ingredient than the brand name version (I think generics have to contain 80-120% of the amount of active ingredient found in the brand name version, but don't quote me on the exact percentages).

The most important features of generics are of course different dosage forms and different inactive ingredients, though. For example, lactose is a common filler in pills, but if you're severely lactose intolerant, you can't take a pill with lactose in the formulation. But chances are very good that another manufacturer has created a generic without that ingredient.

A lot of patients actually have a preference for a specific generic, even choosing it over the brand name version. Example: Certain brands of amphetamine salts (Adderall) are known anecdotally to be more effective than others.

While there's requirements for generics in terms of bioequivalence, generics often improve on the brand name. Generics come out 10 years after brand names, so that's plenty of time to perform market surveillance and figure out improvements. Maybe a certain generic formulation dissolves better, or is released into the blood more evenly compared to the brand name. Maybe it tastes better. Maybe the tablets are scored for splitting in a rational way compared to other versions (don't get me started on 2 mg alprazolam bars that are divided into 3 pieces instead of 4).

So, generics aren't inferior to brand name drugs. In some cases, a generic may be preferable over brand name, even before taking the financial aspect into consideration.

Speaking of finances, I know I didn't address the cost discrepancy that coerces patients into choosing generics. I think it goes without saying at this point that I'm strongly anti capitalist and believe in Medicare for all and healthcare as a human right. Cost should not be the deciding factor when choosing a drug manufacturer. That's evil Capitalist bullshit. I just wanted to establish that generics are not an inferior product, I'm sure I'll rant about prescription drug costs someday soon.

[altheterrible]

Tw: medical abuse, pharmacy staff being assholes, extensive discussion of controlled substance prescriptions, ableism. Long post, sorry.

Do NOT even get me started about how fucking hard it is to fill a prescription for a controlled substance.

As a pharmacist, I can absolutely confirm that a lot of pharmacists are on a power trip and enjoy inconveniencing patients who are filling controlled substances. The more assertive you are, the more they’ll push back. And boy, can they be petty.

From day 1 in graduate school, we are exposed to the attitude that patients who are chronic users of controlled substances are probably abusing their meds, and the best treatment goal for everyone is to stop using controlled substances ASAP. These meds are shown in a morally dubious light.

We are taught to treat all controlled substance prescriptions with extreme suspicion. We are taught how to identify forged prescriptions and we are carefully watched as we examine every single one. We are then instructed on “suspicious patient behaviors” to watch for that indicate medication abuse. These behaviors include things like consistently filling a controlled substance 2-3 days early, becoming irritated with staff if the medication is out of stock or an insurance issue arises, filling prescriptions at multiple pharmacies, filling multiple controlled substance prescriptions per month, the list goes on and on.

In fact, we’re encouraged to investigate the controlled substance use history of every patient filling a controlled substance. Every state has a database for tracking prescriptions for controlled substances, and these databases show what medication was prescribed, the physician, the doctor’s office location, the location of the pharmacy that filled the script, the number of pills prescribed, and the date it was filled. Furthermore, most states contact with a company that’ll take aaaaaall that data and generate something called an “overdose risk score” which is essentially a numeric representation of how likely a patient is to overdose on their medications. If your score gets too high, say goodbye to your medications.

So after we interrogate the patient and verify the script isn't fake (and btw, if a pharmacist has ANY reservations they don't have to fill a prescription) then we're supposed to verify that the prescribing doctor is properly credentialed. If that checks out, then we are supposed to scrutinize the prescription to make sure the doctor isn't overprescribing controlled substances. If a doctor writes for too many controlled substances, a pharmacy can stop accepting prescriptions from them. We are also encouraged to question if a prescription is for a higher than necessary dose or an unusually high number of pills. We know basically nothing about the patient's medical history, but we're encouraged to judge if they really need what the doctor wrote for.

So already, you can see there’s a ton of potential roadblocks on the patient side of things to filling these prescriptions. There's more, though, on the pharmacy side.

Pharmacies are limited in the supply of controlled substances they can order per month. If they're out of stock, you’re out of luck. There are very specific rules about transferring controlled substance prescriptions between pharmacies, and even if a transfer is possible, a pharmacy may refuse to fill a controlled substance script for a new patient.

If the DEA notices that a pharmacy is filling a lot of control prescriptions, they will investigate and the pharmacist can face sanctions even if every prescription filled was legal. So pharmacists are very reluctant to take control prescriptions from new patients.

Many states have laws about how much medication a patient can receive. For example, in Michigan, “opioid naïve” patients can only receive a five day supply of narcotic pain meds on their first fill, regardless of how many days the doctor wrote for—the patient also loses the remaining days’ medication.

So, to recap, pharmacists are trained to regard controlled substance prescriptions and the patients filling them with extreme suspicion. There are many, many hoops to jump through when you're trying to fill these medications. Acting assertive, speaking up for yourself, or becoming frustrated with the pharmacy’s reluctance to do their job will cause further roadblocks in the process. Even if you’re the perfect patient with the most unambiguous, uncontroversial need for a controlled substance, you may still be unable to fill your prescription due to legal barriers for which there is no recourse.

It’s SO FUCKING ABSURD. PATIENTS WHO ARE PRESCRIBED CONTROLLED SUBSTANCES ARE NOT THE SOURCE OF AMERICA'S DRUG PROBLEM. GRANDMA AND HER 60 NORCO 10S PER MONTH IS NOT THE REASON DRUG OVERDOSE DEATHS KEEP RISING. DENYING PATIENTS MEDICATIONS THAT WORK JUST BECAUSE THERE'S A POTENTIAL FOR ADDICTION IS LIKE TELLING PEOPLE THEY CAN'T DRINK WATER BECAUSE THERE'S A RISK OF DROWNING.

Ahem.

Clearly this is a pet peeve of mine. And I didn't even go into the shitty, unprofessional things pharmacy staff says about patients behind their backs.

Tune in for that next time!

[altheterrible]

FDA expands Boxed Warning to improve safe use of benzodiazepine drug

Includes potential for abuse, addiction, and other serious risks

[pharmacyforthemasses]

I have prescriptions for percocet for chronic pain and xanax for anxiety. Today my pharmacy wouldn't fill both of them and made me choose. How are they allowed to do that?

First, I know how frustrating it is when your pharmacy won’t fill your medication. I’ve been where you are and you probably handled it better than I did--I just flipped out and started screaming, so like, not my best moment.

So, here’s what happens when you try to fill an opioid and a benzodiazepine together. After the pharmacy technician inputs all the prescription information into the computer, the pharmacist needs to verify the prescriptions (make sure they’re for the right patient, they’re the right drug, right dose, right route, and right timing). If the verification step looks good, then the pharmacist submits a claim to your insurance.

This step is where 99% of problems in the pharmacy come from.

Benzodiazepines and opioids have a well documented drug interaction where the combination causes respiratory depression greater than either drug does alone. To reduce deaths and hospitalizations from respiratory failure, which are expensive, insurance companies started flagging this combination of medications. So basically, automatically, your insurance will cover one or the other, but not both.

Your insurance will then kick back one of the prescriptions with a code that basically says “Are you sure the patient needs both of these medications? Check with the prescriber to make sure.” So then we contact your physician. If the two drugs are prescribed by different doctors, we contact them both and let them know that this combination of medications has been prescribed and ask if they want to alter their prescription.

Most of the time, the doctor knows about the combination and is fine with it, and so we can input a code to your insurance that basically says “yes both of these drugs are medically necessary” and then both can be filled.

If the drugs were prescribed by two different doctors, sometimes they don’t know about the combination and decide to void or alter the prescription they wrote. Sometimes they are aware of the combination and are fine with it.

And sometimes, if your meds were prescribed by a single doctor but they’re incompetent, they doesn’t know that they’ve prescribed this combination and upon being told about it decides that the patient can only have one of the meds. The choice is often left up to the patient.

Without explicitly getting the doctor’s approval, we can’t fill both meds. It opens us up to huge liability if something does end up going wrong.

The pharmacist is just the messenger. You’re really getting fucked over by your insurance company and your doctor. It’s really important to make sure your doctor knows every medication you’re taking, even if they’re the one who prescribed them. If you have different prescribers--like a lot of pain patients have a pain management specialist and then a PCP--then make sure each of them has a complete medication history. Never assume your doctor knows what meds you’re on, because that can lead to surprises at the pharmacy counter.

[pharmacyforthemasses]

How does hormonal birth control fail? How can someone have the rod or be on the depo shot & still fall pregnant? I was lead to believe things like the rod and the shot were 'foolproof' as they didn't rely on you remembering to take a pill at the same time every day.

So, one thing that can happen is that you take another medication that causes the birth control to get metabolized too quickly. Usually the culprit is an antiseizure medication. Also, the shot and the implant can fail if they aren’t given/inserted correctly. The depo shot is supposed to be an intramuscular injection, if someone messes up and gives it as a subcutaneous injection instead, that will affect how long the drug will last. Finally, if you’re late getting the shot by a few days, you can fall pregnant in that gap.

[pharmacyforthemasses]

Anyone got any medication questions? I'll be around answering them tonight!