Saturday, January 14, 2012

Pharmacy Phun

Veterinarians are always getting harassed about drugs. People want us to prescribe drugs for their pets in inappropriate ways (antibiotics for a virus, or pain medicine in the name of the owner instead of the pet so that it can go onto the owner's insurance. as if!). People want us to dispense drugs directly from our office so they don't have to schlep somewhere else and wait for it, or so that they can get the special veterinary-only formulas that aren't available at local pharmacies. At the same time, people think we are evil and greedy for charging "so much" for the medications we dispense, even though our markup is, quite frankly, bupkes - especially for the more expensive drugs. So they ask us to write a prescription for a non-veterinary-only drug that requires one to look up what size/strength of the medicine is available for people and/or to figure out if it's even something most pharmacies carry - but heaven forbid we want to charge any actual money to cover the time spent on that. Dispensing is really lose-lose, except of course for the pet who needs to start on something right away, without waiting for to ship it from Outer Buttlandia... on the whole, I gotta say, I prefer prescribing. What else? Oh right. People want to steal our drugs. Veterinary hospitals get broken into frequently by losers who don't like the Special K you can buy at the grocery store. People abuse our trust by bringing in pets with diseases requiring long-term treatment with opioids or benzodiazepines, and then diverting the drugs we dispense or prescribe either into their own selves or onto the street. And then there are the "friends" who think "yo, so - you can probably get all the Vitamin V you want, right? Can I get some too?" is appropriate cocktail party discussion. So, pardon me for being a little cynical about the whole veterinary pharmacy situation.

This brings me to the issue of prescribing. And please, don't say "prescribing human drugs." Drugs are drugs. There are drugs used in humans and not in animals, drugs used in animals and not in humans, drugs used in humans and dogs but not cats or pigs, drugs used in humans and cows but not horses or sheep, they are all drugs, and none of them are human (last I checked.) Prescribing is fine, I don't mind do it, in fact I sometimes like doing it because often, it teaches me something (I have to do a little research (epocrates FTW!) to find out what strength something comes in, what the vehicle is, how it's absorbed in a given species, etc - a little brain exercise can be nice). But, for some reason, it's really common to run into a problem with the pharmacist.

Don't get me wrong. I generally love pharmacists. I appreciate their education. They aren't just pill-counting techs - they are experts in these medicines and how they work and interact in the human body. Most, however, have little or zero education about the pharmacokinetics of commonly prescribed veterinary drugs in the species for which I am prescribing. This does not seem to stop the ones around here from accusing me of malpractice and/or simply changing the Rx without telling me!

Common pharmacist errors with veterinary prescriptions include:

-dogs getting thyroid hormone supplementation: pharmacists frequently tell the client the vet MUST have made a mistake and is dangerously overdosing the dog. Trust me: we're not overdosing the dog. Humans just happen to require much smaller doses than dogs happen to require.

-telling us they don't have amoxicillin suspension 25 mg/ml, but they can swap it out for 125 mg/5 ml "if that's ok with you!" WTF? This one happens FAR too frequently and no one has ever adequately explained to me why this happens. I always thought this mistake could only be attributed to pharmacy techs, but I have had two licensed pharmacists pull it on me, so, I dunno - there's gotta be some reason, but I don't know what it is. I wonder if the Angriest Pharmacist could maybe drop by and explain why this one error is so common? [side note: I love the Angriest Pharmacist!]

-trying to sub in a timed-release formula for a dog (whose transit time is different enough that this is not good)

-telling the client the insulin we are telling them to get for their cat is too expensive and they should change to some cheaper (inappropriate) stuff.

It can be very frustrating. Some of my colleagues have offered CE classes at pharmacy meetings to try to cut down on some of the more common errors that classically trained pharmacists make with respect to veterinary prescriptions. That's probably a lot more productive than bitching about it on the internet is. I can bitch about it on the internet in my PJs, though, so there is that.


  1. My degree is in philosophy, so why can't they sub out amoxicillin like that?

    My vet actually does most of their own dispensing, since they are a combination of 24hr emergency hospital and regular care facility. Definitely makes my life easier. I love that they already know my animals and have their records when we have had to come in with a real emergency. Rattlesnake bites, blocked urethras, exciting stuff.

  2. Claire, the 2 amoxicillins are the same (25mg/ml=125mg/ml). No need to ask, because they are not really substituting.

    My peeve is when I say that this is a veterinary prescription and the reply is, "Is the patient a dog or cat?". Since when am I limited to dogs and cats? Why assume the species?

    1. Okay, that's what I thought! The algebra looked fine to me. I did take 4 semesters of calculus, so I figured there was just something particular that I didn't know.

  3. Something important to remember when getting veterinary Rx-es from human pharmacies is that some drugs have to be name brand. This is due to their absorption. I tell the owner why and try to put the explanation on the Rx pad or let the pharmacist know when I am calling, just to be sure that the pt gets the right drug. I don't like it when the pharmacist subs generic even though I requested a label name drug and I also really hate getting an irate phone call from a client because the pharmacist said I just gave them the expensive stuff.

    I can say, with conviction, that there will be some really tragic problems if human pharmacies start carrying veterinary name brand drugs but don't arm themselves with education. There are several pharm D's that I have worked with that did this very well. I have known some awesome pharmacists, especially those that compound drugs, that make a point of going to veterinary specific CE. There is a big difference in knowing what a drug will do in a human versus what that drug does in cats, dogs, turtles, birds, mice, hamsters, snakes, etc.

  4. Target has already started carrying veterinary label only drugs and I'll tell you from experience, they aren't sufficiently trained for it. I would beg any pharmacist dispensing vet only drugs to have a Plumb's handy or SOMETHING!

    Thankfully, we have developed a decent relationship with the local Target pharmacist and he's good. But there are others... oh my... The concentration thing never fails to confuse the hell out of me. IT'S THE SAME!!! I also enjoyed when a pharmacist gave my patient 100mg doxycycline capsules when the directions were "1/2 tablet by mouth every 12 hours". How they gonna do that, dude? Use some common sense.

    Or the million times they've asked me for whatever number it is MDs have for insurance stuff. I had a pharmacist refuse to dispense a medication (metronidazole) until I either gave her that number or my DEA number. Clinic policy is no DEA number unless it's a controlled substance. I finally just had to give it to her because I had better things to do that day than sit on the phone and argue but it was frustrating. Won't be calling anything in there ever again.

    I have definitely also lodged a complaint when a pharmacist told a client the thyrozine thing. Of course, the fact that our clients would believe the pharmacist over us is disheartening. I understand they are well trained when it comes to the medications I use and they obviously have a different way of referring to things but that doesn't mean I'm wrong.

    1. I have had pharmacists catch mistakes that human doctors have made in prescribing- a number of times. Between medications for my family and for my home health care clients, there have been several mistakes by physicians. Because of this, if a pharmacist tells me that there might be an error in type, dosage, or compatibility of a drug prescribed by a vet, I'm going to call and ask the vet about it.

      This isn't a lack of trust in the vet so much as the realization that vets are people, and people sometimes make mistakes.

  5. My favorite personal story was when a colleague wrote an Rx for Hydrocodone 5 mg. Apparently that was on backorder, or for all I know maybe human pharmacies don't stock it, so the pharmacist just dispensed Vicodin (hydrocodone 5 mg/acetominophen 500 mg). Yeah, because those are the same thing!!! The dog was a pom, and this was a massive overdose of acetominophen. The thing that REALLY gets me, is the pharmacist will call over such nonsense as the amoxi concentration cited above (agree this happens WAY too often) but they don't call to clarify this???

    Owner didn't even notice or realize the difference, she just happened to call to ask a question about the dog. We began discussing the drugs and if there was any improvement, etc. when owner happened to mention the Vicodin. I was like "WHAAAA???" After 45 minutes of back and forth between myself, the pharmacy tech, and the pharmacist, they finally admitted to their mistake.

    All of the above complaints, both in the original post and in the comments has also happened to me, and they all drive me nuts. I must say, the author of the blog has alot more respect for pharmacists than I do, but that also stems from many experiences of pharmacists not knowing their stuff when it comes to human drugs, as well. Also, only once was a pharmacist actually able to answer a question I asked about a particular drug.

    All of these reasons is why I am scared to death if this proposed legislation to make writing an Rx for all drugs is passed. If you think we have problems now, we have only seen the tip of the iceberg.

    Follow the link to read about the Fairness to Pet Owners act, and to get the contact information of your representatives in Congress. Relaying stories such as these, illustrating that the passage of this act is dangerous for pets, is the only chance we have of defeating this bill.

  6. Ohhh... Hydrocodone/Homatropine vs Hydrocodone/Acetaminophen. Been there too. Got a dog the latter to get him through a day or two while we tracked down the former. Adjusted dose accordingly for my sweet portly yorkie friend. Find out that, in our area, only Walmart sells Hydro/Homat. Great. Call it in there. Ask concentration of Hydro in the mix and dose accordingly. Except they give my patient Hydro/Aceta. Thankfully the owner is savvy enough to notice that the two bottles she had said the same thing but with different doses so she didn't give either for a half a day. But if my patient had died or, at the very least, had serious side effects, would Walmart have paid for that? Bet not.

    1. I'm sure Walmart would not have paid, and in fact, it would probably be the vet whose license would be in jeopardy and who would get sued first. If you documented clearly and could prove it was a pharmacy error, you should be OK, but not before going through a ton of headache!

  7. I live in a small town and we have a nice small town pharmacy that is run by two pharmacists. Both of them are our clients. I love that. They will call over the things that they don't know and admit they don't know. Plus they are ever so patient with me when I call with the what do haves, dosages, carriers, etc questions that I have. And they will match Walmart prices. Therefore, I don't have to deal with Walmart hardly ever anymore. Sometimes a little town can be a good thing.