Failure as guardians of the public health

You'll never know how easy it is to buy prescription drugs in community drugstores without a prescription from a medical doctor unless you have tried it. (You can even fake the name of the patient that the drugstore clerk writes on the receipt.) And you'll never know how severe the effects of drug misuse and abuse unless you have worked in a hospital...

It only means that the laxity in drugstores is a reflection of how we have failed as guardians of the public health.

Quote of the day

Will pharmacists be covered by the Medical Malpractice Act? Go to any drugstore today without a prescription and ask the person on the counter what is the best medicine for this and that and they will sell you something. While BFAD classifies a number of medicines as over-the-counter, every doctor knows that even aspirin taken for the wrong ailment can cause a patient to bleed to death or die of an acute allergic reaction.

Or if there should be a mis-dispensing of drugs at the drugstore,who shall be liable the doctor because of his handwriting, or the drugstore clerk? It is an open secret that many drugstores are running only on the 'borrowed licenses' of pharmacists. Only a few drugstores can produce the 'pharmacist on duty' on a bright and sunny day within one minute.

- Erwin L.Espinosa, MD on his article "Legislation and the law of unintended effect" dated September 16, 2002

Considerations in generic dispensing

Michael L. Tan had written an article entitled "Generics again."* Although it was written last year, I have read it only last September. Nevertheless, I still sent the editor my feedback on the article.

Here's my feedback:

Dear Sir,

While it is true that the Generics Act of 1988 requires that consumers be informed of the choices available to them in the selection of drugs with the same active ingredient (generic name of the drug), there are cases when the dispensing pharmacist should be cautious in doing so for reasons that may have undesirable effects to the patient.

This is because, based on bioequivalence studies, there are certain drugs made by different manufacturers that do not produce the same blood levels (bioavailability) and subsequent effects to the patient.

For example, here in the Philippines, Appendix T of the latest edition of the Philippine National Drug Formulary (vol. 1 6th ed., 2005) contains a list of "Drugs Requiring Stict Precaution in Prescribing, Dispensing and Use Because of Bioavailability Problem and Availability in Philippine Market in Several Brands/Manufacturers; Prescription Must be Filled According to the Specified International Non-proprietary Name (INN) and Brand Name (B)."

I would say that if a patient was already started with a certain brand of drug that is included in the list, it is safer to stick to that brand than to obtain varying levels and effects because of switching from one brand to another brand. It may be helpful also to consult first the prescriber before attempting to change brands.

Of course, an informed consumer can start with a cheaper and still effective drug if pharmacists provide the information required of them under the law.

Two of the drugs you mentioned in your aritcle (atenolol and propranolol) are included in Appendix T of the PNDF and better control of hypertension may be achieved if only one brand of those drugs is to be taken as maintenance therapy.

Also, R.J. Taylor (a pyschiatrist), in writing to the Australian Prescriber (vol. 28 no. 4, Aug. 2005)**, said that "we should remember that we are NOT just prescribing the active ingredient when we prescribe. There is the issue of varying particle size and varying excipients that may make a difference." As an example, he mentioned that "I once had a pyschotic patient with lactose intolerance and I had to work to identify which brands (or even which strengths of the same brand) of antipyschotics were lactose free." (Lactose is used as a base in some prescription drugs and over-the-counter medications.)

Indeed, there are excipients (and other pharmaceutical ingredients) added to the active component (the drug itself) to produce a drug product (i.e., drug + excipients) that sometimes make the difference. Some of these excipients may produce allergic reactions to susceptible patients which explain why some patients are "hiyang" to certain brands of drugs having the same active ingredient.

I am also in support of the Generics Act but these are two of the exemptions which I think should be remembered in choosing cheaper generic drugs over certain expensive branded drugs."

pinoypharmacist's note: I have limited knowledge in pharmacokinetics and biopharmaceutics. If there is anything that is not correct regarding my understanding of the subjects, kindly inform me. It shall be greatly appreciated.

_______________________________

* http://news.inq7.net/opinion/index.php?index=2&story_id=53269
** http://www.australianprescriber.com/upload/pdf/articles/695.pdf

What's wrong with an official receipt and a piece of paper?

One of the drugstores that I have recently reported to the Regulation Division I of the Bureau of Food and Drugs had issued me an official receipt with a different address of the drug outlet (probably that of the other branch) for prescription drugs which I purposely purchased without a prescription. (This was not the first time I have encountered such malpractice.)

On another occasion, the same drugstore issued me just a piece of paper as receipt for my purchased medicines. So, aside from reporting this drugstore to the BFAD, I also reported to the Bureau of Internal Revenue through no-or-complaint@bir.gov.ph. This is where complaints on non-issuance of Official Receipts (OR) by business establishments are being reported to the BIR.

Quote of the day: On deterioration of pharmacy's social standing

"Regrettably, most of those who use pharmacy to advance their own aims and many pharmacists have as their mission the accumulation of wealth. Once taken up, that goal obscures every value the professional holds dear: standards of excellence are eased to accommodate profit potentials, the sense of responsibility to community and profession is undermined, rules of conduct are relaxed, efforts by management to ease entry into its educational system become apparent, and its social standing begins to deteriorate."

- R. David Anderson

Not without a prescription

I was on my way home from the supermarket last Monday morning when I met a kababayan along the way.

She asked me if I can buy a certain drug product for her hypertension in the hospital pharmacy where I work since the price there is cheaper.

I asked if she had a prescription and she replied, "Wala. Kilala ka naman doon."

I learned that the last time she had a check up and diagnosed with hypertension was 2 years ago. Since then, she has taken the drug product every time she feels dizzy which she thinks is due to hypertension.

I advise her to consult a doctor again and assured her of my assistance to buy her medicine if she already has the prescription.

Quote of the day: On implementing pharmaceutical care

"Are pharmacists willing to provide pharmaceutical care and do they have the capabilities to do so? In fact, many pharmacists have been providing elements of pharmaceutical care for years, but they may not have been consistent or systematic in doing so, or they may not have been documenting their patient care activities. Individually, each practitioner must address his or her own degree of willingness. Implementing pharmaceutical care is not easy, and pharmacists need to establish their own motivations for providing pharmaceutical care to their patients. This effort can be extremely challenging; yet by taking small steps forward, pharmacists can overcome many obstacles to converting their practices to the new philosophy."

- Randy P. McDonough

Source: Intervention to Improve Patient Pharmaceutical Care Outcomes.

Journal of the American Pharmaceutical Association. Vol. NS 36 No. 7

(July 1996) 453-466.

A forwarded message about MedExpress

This is a forwarded text message sent by one of our interns:

IT'S ALL ABOUT TIME!
Have your medicines delivered right at your doorstep!Just give us a call at (02) 6343333...
Our on-line licensed pharmacist will take your call...
Another first from MedExpress, the 3 in 1 drugstore!
Breakthrough services for your ultimate convenience...
Pls. pass this message and let your friends experience the MedExpress services...
MedExpress also offers the following services:
1. Patient compliance program
2. Confidential medication profile
3. Medication counselling
4. Daily dose pack

MedExpress also caters walk-in and drive thru customers, just give us a call at (02)6343333 and know more about us.

Quote of the day: On type of pharmacist of the future

"What type of a pharmacist do we want to graduate?... The pharmacist of the future should not only be knowledgeable, creative, and an effective communicator but also be a motivated professional ready to learn new concepts and function as a team player. Keeping these attributes in mind, we must think beyond time spent on education and training; quality not just the credit hours of our courses, should be evaluated. A teacher should demonstrate an enthusiasm and excitement for the subject, genuine concern for the student, and a process of learning the material. The students should learn how to raise and answer important questions. An intellectually stimulating session can produce larger payoffs than simple one-way transfer of facts. It is my experience that once students become enthusiastic about the subject matter, they work hard to learn both within and outside the classroom."

- Milap C. Nahata

Issues Facing Clinical Pharmacy Education for Undergraduate Students. DICP - The Annals of Pharmacotherapy Vol. 23 No. 3 (March 1989): 250 - 251.

Try mnemonics

To istine:

Try MNEMONICS - a technique of improving the efficiency of the memory.

For example, if you were asked what is the major intracellular/extracellular cation, just think of PISO -- Potassium In, Sodium Out!

A friend and colleague of mine once told me not to assign new interns in her area during weekdays. Before I misinterpret her request, she was quick to explain that she has a deadline to meet and that she may not be able to give a thorough orientation to them. So, we agreed to assign new interns on Saturdays when her workload is lighter.

For more than a decade now that I work with her, she is known for not giving "half-cooked" orientation to interns and new employees and feels guilty when she does.

QUOTE OF THE DAY

"Under the Generics Act of 1988, the pharmacist is not only a dispenser of drugs. He is also a teacher; he has been given the responsibility of informing the consumer what are the available generically-equivalent drug products and their prices. To discharge this responsibility properly the pharmacist himself must be professionally competent and must also be well-informed on the provisions of the Generics Act and the current developments in the pharmaceutical field."

- Quintin L. Kintanar, M.D. Ph.D.

former Assistant Secretary for Standards and Regulation

and Director of the Bureau of Food and Drugs

Here's my feedback to the article "PHAP answers PCIJ's questions" (Malaya, Sept. 29, 2006)* sent to malayanews@yahoo.com:

Dear Sir,
I agree with the statement of the PHAP that "to reduce medicine prices, the government has to strictly implement the generics law."
We often point to the pharmaceutical companies and doctors as to why the law has failed to bring down the prices of medicines.
I think that the success or failure of such law is also right at the counter of every drugstore or pharmacy where pharmacists are required NOT to fill prescriptions that are not in accordance with the said law [DOH A.O. 63 s. 1989 Section 4 (4.1)].
That pharmacists, aside from being required to "inform every buyer on available products that meet the prescription" [Section 5 (5.4)], are also required "to report to the nearest DOH office cases of violative, erroneous, and/or impossible prescriptions within three months after receipt of such prescriptions." [Section 5 (5.7)]

___________________________

* http://www.malaya.com.ph/sep29/edreader.htm

Last Wednesday was our Continuing Education (CE) Lecture and the topic was about "Counterfeit Drugs." We had as our lecturer the Chief of the Regulation I Division of the Bureau of Food and Drugs, Mrs. Nazarita T. Lanuza. She was very accommodating in answering our questions after the lecture that she encouraged us to ask more questions even if these were not related to the topic anymore.

I was given the chance to ask several questions and because we were already going over time, I finally asked if we can report or complain to her e-mail address that was on the last slide of her lecture. She smiled and told us that it was purposely included in the lecture to encourage us to report or complain directly to her office. She even gave us her mobile phone number.

_________________________________

pinoypharmacist's note: To anyone who would like to report drug establishments and outlets selling counterfeit drugs or are violating existing pharmacy laws, you can e-mail Mrs. Lanuza at ntlanuza@bfad.gov.ph or you can call or text her at (0918) 6980842.

It's nice to see previous interns especially when you discover that they are doing good in their chosen field. There are some, however, who seem to be losing their professional values despite their school, talent and intelligence.

For example, I've talked to a brilliant young doctor who happens to be a former intern of ours. During our conversation, I have mentioned that I've been keeping myself away from sponsorship of pharmaceutical companies in attending conventions, symposiums, seminars and other related activities. It's because these company expenses are eventually added to the prices of their drug products.

He replied by saying,"If we will not take it, others will. So, we might as well take it."

So, the next time I met with our interns I wrote on the white board one of my most favorite statement from R. David Anderson just before they came in because I find it relevant in our time:

"...Pharmacy's practice component is losing its control over the breeding of pharmacists; unfortunately, hospital pharmacy has never exerted any effective control at the undergraduate level. Entry into the profession is largely regulated by the colleges of pharmacy, though they frequently plead for assistance from alumni and practitioners. Students are selected primarily on the basis of grades and the ability to meet demanding curriculum requirements. Little, if any, attention is given to identifying and rejecting those who would violate professional ideals and morality."

I told the incident to the interns without explaining what was written on the board. I just hope that they got the message and do something about it in their time.

_________________

pinoypharmacist's note:R.David Anderson's Harvey A. K. Whitney Award Lecture can be read in the American Journal of Health-System Pharmacy vol. 61, Nov. 15, 2004 issue (p 2373-2379).

Our interns from Isabela (there are 8 of them) left me a personalized mug as a token of appreciation shortly before they went back to their province. Unfortunately, I didn't have the chance to thank them personally since it was my day off.

Anyway, GOOD LUCK TO ALL OF YOU, GUYS! I hope that we were able to meet your expectations.

I am a Pharmacist

<> I am a specialist in medications

I supply medicines and pharmaceuticals to those who need them.

I prepare and compound special dosage forms.

I control the storage and preservation of all medications in my care.

<> I am a custodian of medical information

My library is a ready source of drug knowledge.

My files contain thousands of specific drug names and tens of thousands of facts about them.

My records include the medication and health history of entire families.

My journals and meetings report advances in pharmacy from around the world.

<> I am a companion of the physician

I am a partner in the case of every patient who takes any kind of medication.

I am a consultant on the merits of different therapeutic agents.

I am the connecting link between physician and patient and the final check on the safety of medicines.

<> I am a counselor to the patient

I help the patient understand the proper use of prescription medication.

I assist in the patient's choice of nonprescription drugs or in the decision to consult a physician.

I advice the patient on matters of prescription storage and potency.

<> I am a guardian of the public health

My pharmacy is a center for health-care information.

I encourage and promote sound personal health practices.

My services are available to all at all times.

<> This is my calling <>This is my pride

_________________

Source: Pharmaceutical Dosage Forms and Drug Delivery Systems, 6th ed.

Recently, I was lucky to be chosen as one of the participants in a Post Graduate Course in Occupational Health and Safety. On our last day, one of the topics discussed to us was about drug and substance abuse. Our course coordinator and lecturer is a softspoken and kind doctor of medicine who told us that the subject was part of a commitment she made years ago in campaigning against illegal drugs.

During the lecture (and much to my embarassment), she commented on the laxity of pharmacists in our country in dispensing regulated drugs as compared with other countries where pharmacy laws are strictly implemented.

I learned later that 2 of my classmates in that course are pharmacists who are now doctors of medicine. So, I wonder if they are as embarrassed as I am with that comment.

It is unfortunate that while I have just included in the orientation of interns the BFAD Advisory No. 00-04 "Warning against dispensing expired drugs," an intern reported to me an incident that happened in one of our dispensing outlets whereby a donated drug that was already expired was dispensed to a doctor who said "pwede pa yan" to the pharmacist.

I was able to talk to the senior pharmacist of the area who confirmed the incident and told her I will send a copy of the advisory and news report of similar incident from another hospital* and requested that she retrieve the drug as soon as possible.

I also reported the incident to the supervisor who made follow up for the retrieval of the drug. Luckily, the drug was retrieved and not administered to a patient.

This incident happened despite existing procedure on monitoring expiring drugs in our dispensing outlets.

______________________

* http://news.inq7.net/nation/index.php?index=1&story_id=16683

Today I read in The Manila Times (October 26, 2006 issue) an article entitled "Public told to report doctors insisting branded drugs."* After reading the article, I decided to write to the editor. This is what I wrote:

Dear Editor,

... I agree that "the skyrocketing cost of medicines in the country may be partly blamed on the continuing practice of some doctors of disregarding the generic drugs in favor of the branded ones that are usually endorsed to them by sales representatives of various pharmaceutical companies."

It should be noted, however, that PHARMACISTS ARE REQUIRED NOT TO FILL VIOLATIVE PRESCRIPTIONS (i.e., those written in brand names only) and that these "shall be kept and reported by the pharmacist or other interested parties to the nearest DOH office for appropriate action." (DOH Administrative Order No. 63 series of 1989). Failure of the dispensers and drug outlets to report violative prescriptions within three months after receipt of such prescriptions" is a violation of the said Administrative Order that may be sanctioned by "suspension, or revocation of the license to operate the drug outlet by the Secretary of Health" and that "professionals directly involved in the violations shall be recommended by the Secretary of Health for appropriate administrative sanctions by the PRC."

________________________

* http://www.manilatimes.net/national/2006/oct/26/yehey/prov/20061026pro5.html