Is the medication indicated?

As Pharmacists we operate on three core principles while assessing prescription-drug related needs of our patients. (1) Is the medication indicated (2) Is the medication effective (3) Is the medication safe (4) Is the patient compliant. Each of these aspects are critical to the practice of pharmacy and as the gate keepers of drug therapy, it is quintessential that pharmacists conduct this work-up for every patient.

 

First, I will explore the principle of indication. In the practice of medicine 'indication' refers to the reason why a particular medication is prescribed or procedure is conducted. For instance if a doctor prescribes an antacid (e.g. Tums), the indication could be heart burn. If a patient has a prescription for an antibiotic, the indication could be a bacterial infection. While working in the pharmacy, we fill hundreds of prescriptions a day and each of these prescription must be indicated to treat the right condition. Indication does not only emphasize the type of medication but also the dosage and route of administration.

 

While reviewing a prescription a pharmacist will analyze the medication prescribed, the dosage and the route of administration. The patient specific factors that play a major role include the patient's age, weight and gender in certain cases. Hospital and clinical pharmacist have the advantage of having more information available (such as a patients chart) to conduct their assessment and review compared to a retail pharmacist who typically has only the medication history. In the retail setting the pharmacist can take advantage of the patients' medication history and consultations to conduct a thorough work-up. It is not the most ideal setting but with time, a retail pharmacist could in fact develop a stronger and closer patient-provider relationship which could yield the desired information needed to implement interventions.

 

As health care providers we hope that technology and online data bases will make it easier to harness all the patient's information in a universal online database in future practice. This is particularly beneficial for the practice of pharmacy which strives to solve drug therapy problems. A universal database would for instance be instrumental in minimizing duplicate therapy, drug interactions as well as providing a more detailed patient health history. Once the patient reports are accessible, pharmacists will be more equipped to make sure that the prescribed medications are indicated, effective, safe and convenient for our patients.

 

As a health-care community, we still have a long way to go-- to fully address the issue of indication. I receive numerous phone calls from patients some of whom have just left the Doctor's office with no clue why a particular medication was prescribed. This is a very dangerous precedent and it makes me wonder what goes on during these Doctor's visits. I value my role as a pharmacist in the community --to provide my patients with up to date knowledge about their drugs. However, it is very critical to have a strong foundation established at the clinics and hospitals. Often times a patient will ask you what a medication is used for—and those familiar with drugs understand that there could be more than one indication and in some cases unlabeled and investigational indications. If a patient calls the pharmacy and asks why their doctor prescribed Prozac, the pharmacist is faced with a situation where they have limited information about the patient's medical history and the intentions of their prescriber. It is simplistic to say that this medication is used to treat depression because it is the major indication. That answer is inaccurate. I cautiously inform my patients in these cases that there are other possible indications. Prozac for instance can be indicated for major depressive disorder, treatment of binge-eating and vomiting in patients with moderate to severe bulimia nervosa, obsessive compulsive disorder, premenstrual dysphoric disorder, panic disorder with or without agoraphobia-- and some unlabeled indications include mutism, mild dementia and post-traumatic stress disorder. This example emphasizes the need for physicians to take time and explain to their patients why they are prescribing certain medication to prevent confusion.

 

Finally, with increased access to online information and direct consumer advertising for drug products, there is an increasing number of patients demanding particular medications from their health-care providers. Access to medical information has its benefits and it is always encouraging to see patients involved in making health-care decisions. However, it is critical that patients don't influence or coarse their providers to prescribe particular drugs. The gist of this discussion is to encourage patients to play an active role in making health care decisions. This includes asking their health-care providers to explain each and every intervention and why certain medications are prescribed. As Pharmacists we have to conduct a thorough work-up and patient assessment—particularly paying attention to the indication of every prescription we fill.

© Kawuma

The Dog ate my pills!

Life as a Pharmacist can be challenging especially as a rookie! Many of these problems are inherent in the way the health-care system currently operates and were not a surprise. However, there some which caught me by surprise—and these usually vary depending on the location of the pharmacy. One of the main challenges I have faced is prescription drug abuse and high costs of prescriptions for patients in my pharmacy. Prescription drug abuse normally hits you as a pharmacist in two dimensions.

First, we have patients who consistently finish all their medications and call in earlier than they should for refills. These are usually the most interesting ones since you get to hear all sorts of explanations for early refills. They range from vacation trips abroad, to my dog ate my pills, I accidentally threw away my bottle, I received less than the amount allocated on the bottle, my doctor told me to double up on the dose, am leaving town tomorrow and I don’t have enough pills to last me while am away and all sorts of other reasons. The challenge is figuring out who is telling the truth and those who simply try to get around the system and fill their prescriptions early. It usually gets easy as you get more familiar with patients and figuring out those who make it a habit. Sometimes patients will also try to call more than once to see if they get a different answer and therefore it helps to have staff that operates under similar guidelines. It is also important to understand that while insurance companies do a great job of alerting Pharmacies in case of early refills through claim rejects, it is worth taking the time to take note of prescription fill patterns (jumping from one Pharmacy to another) and patients who explicitly state that they want their prescriptions cashed out or billed to a different insurance.

Secondly, you have a category of forged or adulterated prescriptions. This is usually easy to identify as an experienced pharmacist and when in doubt it is always worth picking up the phone and calling a prescriber to verify the validity of a prescription. Sometimes you will also find patients traveling from different states and regions to fill narcotic prescriptions from un-authorized providers. As Pharmacists we are the last line of defense of the health-care hierarchy and it imperative that we do the best we can and use all the tools we have available to minimize prescription drug abuse. It is alarming how prescription drug abuse is continuing to spread with little or no publicity.

Prescription drug cost is the most frustrating aspect of life as a pharmacist. It is disheartening to look in the eyes of a patient and tell them it’s a $3 co-pay on their blood pressure medicine but they cannot afford it--- and walk away from the pharmacy knowing they are going to remain un-treated and non-adherent. Next in line you dispense prescriptions to another customer who is willing to pay $300 for their Viagra. This is where I believe we need to do more as pharmacists to advocate for affordable alternatives where possible. Sometimes patients will not share their financial struggles and continue paying for expensive brand name prescription drugs. There is a perception among many patients that brand-name products work better than generics. It is mostly the outcome of the overwhelming direct consumer advertising of prescription drugs which is often more misleading than informative.

It is frustrating when some patients shut their ears to any explanation a pharmacist can give, but I always make the effort and those who are struggling financially will often listen. We can’t solve every financial problem, but we have more knowledge and exposure to prescription drugs than most patients and therefore can make a big difference at a time where health-care costs are drowning many families.

© Kawuma