I spent one year working full-time as a pharmacy technician at a high-volume community pharmacy prior to entering medical school. Besides learning the intricacies of billing and the dispensing process, I was granted personal access into a world nearly all patients, but few providers are aware of. At the time my job was just that: a job. There were fun perks like counting pills in multiples of five and visualizing the different colors and sizes of capsules and tablets I had never come across before. But it wasn’t until medical school that I began to fully appreciate my pharmacy knowledge.
Our school has a free student-run health clinic, and I was asked to manage its dispensary of over-the-counter and prescription medications. The dispensary was in disarray when I took it over: medications were arranged according to what they were generally used for, and students were having difficulty finding specific medications requested by their attendings. After a unanimous vote from the student board, I set to work re-arranging the shelves alphabetically so that when a student went to find atenolol it could easily be found at the top left corner of the shelves before atorvastatin. Locating and dispensing necessary medications at no cost to our special population of uninsured and underinsured patients became much easier.
Everything was running smoothly until physicians who volunteer in the weekly resident-only clinic saw the shelves. There was a minor revolt, in the form of a collaborative hand-written page of notes from residents and an attending requesting the dispensary be returned to its original arrangement. They were unable to locate specific medications since the change, and they didn’t “think like a pharmacist.” Apparently, these physicians had been searching for brand names of medications that were now only found as generics. So I arranged the shelves back into their general sections — anti-depressants, antipsychotics, beta-blockers, and miscellaneous, although many medications have dual purposes or off-label uses that span multiple categories. Now I find that visiting volunteer providers have difficulty finding what they are looking for under these categories, and they continue to search for brand names of medications that have for years only been found as generics.
Brand versus generic is only one reason why a pharmacy elective should be offered to medical students. In a time when healthcare systems and patient compliance are thoroughly being studied, we cannot forget the pharmacy as an integral continuing part of patient care after departure from the hospital or clinic. I have seen from personal experience that a provider who talks to a patient solely about Effexor during a visit will cause future confusion and perhaps distrust of the initial venlafaxine prescription that is handed to him at the pharmacy window.
There are also issues when prescription strengths aren’t accurately prescribed. Our pharmacy had numerous cases of providers writing prescriptions for “Vicodin 5/325,” meaning 5 milligrams of hydrocodone and 325 milligrams of acetaminophen. However, the brand Vicodin comes in a 5/300 combination; the brand name Norco is the 5/325 combination. Likewise, prescriptions came in written for “Norco 5/300.” While this may seem like splitting hairs, both medications are Schedule 2 (II) drugs due to their hydrocodone content; therefore, prescribing and dispensing them is carefully monitored and scrutinized by both the pharmacy and the Drug Enforcement Agency (DEA). Patients would often have to wait while we phoned the prescriber for clarification on which medication they intended to prescribe. If the prescriber could not be immediately reached, then the patient would have to leave without getting the pain medication filled.
There also seems to be some confusion amongst providers on DEA scheduled classes of drugs. Several providers, I have spoken with seem unaware of classifications numerically higher than Schedule 2 (II) drugs, which include oxycodone and amphetamines. While this is certainly an important class to be aware of, addiction and abuse does still happen with benzodiazepines, modafinil, and tramadol, all Schedule 4 (IV) medications.
Familiarity with physical characteristics of medications is also important: Knowing that many types of potassium tablets are available for dispensing, some of tolerable size and others of horse-pill size, could mean the difference between a patient taking (and tolerating) her medication and not taking it. Medication sizes, smells, and textures are all factors involved in patient compliance — and most importantly, so is cost. Understanding how expensive some medications can be for our patients and how much of a burden this puts on them — especially for Medicare Part D patients in the “donut hole” — is essential. Working in the pharmacy introduced me to ways to help patients who cannot afford their medications: brand medication and drug distributor coupons, and prescribing syringes and vials of medication rather than autoinjector pens can all save patients a great deal of money. A 10 mg strength tablet might be on a $4 generic list at a community pharmacy, whereas the 20mg strength is not. The year I worked in the pharmacy, doxycycline hyclate was hundreds of dollars cheaper than the same dosage in doxycycline monohydrate — nearly interchangeable antibiotics that vary so widely in cost that we would often call the prescriber and request a prescription change for the benefit of the patient.
When business got slow, I used to pass the time in our pharmacy by having our pharmacists identify stray pills. I marveled at their quick identification of names and dosage strengths (not an easy feat with several manufacturers per generic drug and hundreds of drugs within the pharmacy). I don’t expect providers to be at this level, as we don’t have four years of pharmacy school under our belts. I do, however, see the value in knowing more than just the mechanism of action and common side effects of the medications we prescribe to our patients on a daily basis. And as our own schooling is intense and long enough, I would rather see pharmacy electives offered during the fourth-year of medical school than additional curriculum required of us. As medical schools continue to teach us to consider the non-physiological aspects of and barriers to our patients’ health and well-being, so too should they consider the major impact that specific medications and pharmacy interactions have as well.
Sarayna Schock is a medical student.
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