Some patients think that pharmacies want a patient to only use one pharmacy out of greed. While this is not actually the case, convincing them otherwise can take some effort. Sometimes they just don't understand or feel they have no choice, or sometimes they are deliberately attempting to mislead pharmacy staff. With $4 drug lists, there are an increasing number of elderly who use large chain pharmacies to get the medications that are eligible for the $4 list and will go to a locally-owned pharmacy for everything else for the "human touch" or just because they know the pharmacist. Many aren't aware that most locally-owned pharmacies are willing and able to match the $4 prescription list. Sometimes all you have to do is ask.
There is an inherent danger to both the patient and the pharmacy when a patient chooses to use multiple pharmacies. While the danger to the patient may seem obvious, and the danger to the pharmacy trivial, both will be discussed here.
A Danger to the Pharmacy
In today's interconnected world, many patients assume that records from one pharmacy are instantaneously available to most, if not all, pharmacies. The truth is, HIPPA laws prevent one pharmacy from sharing information with another without the consent of the patient, sometimes even within a chain.
Even if they are aware that information is not readily available like that, sometimes the patient forgets which pharmacy has already been given which information and which pharmacy has filled which prescription. More often than not in this case, they assume they've told you everything to avoid looking like they don't know what they're talking about or because they don't want you to know they're also seeing the competition.
With medical malpractice suits on the rise, patients are quick to blame doctors and pharmacies for interactions between medications that they "knew all about". And just about anything can leave a pharmacy legally culpable for the consequences: failure to offer counseling, failure to notice the few notes an insurance company MIGHT provide about existing interactions, or even failing to ask the right questions during a counseling session.
Some patients are even intentionally defrauding the system in an attempt to obtain controlled substances in high quantities for either sale or abuse. I've heard cases of families of overdose victims attempting to hold multiple pharmacies liable for their loved one's overdose. And while it's rare the charges stick in the event of intentional misuse of the system, it can still cost time and resources to fight the charges if anything comes of it.
Dangers to the Patient
The dangers to the patient may seem pretty obvious; there are dangers of overdosage of medications, therapeutic duplications, drug-drug interactions and drug-disease interactions that may have been caught if the patient had been using one pharmacy.
In 2009, the FDA Advisory Committee recommended that the daily intake of acetaminophen be reduced to 4000mg per day and that single-dose intake not exceed 650mg. These recommendations have not been officially adopted yet, many healthcare professionals agree with these guidelines. With so many prescription and non-prescription products containing acetaminophen, acetaminophen toxicity is a real concern in medicine today. Acetaminophen is available in combination with tramadol, hydrocodone, oxycodone, butalbital and codeine, just to name a few popular ones. And over the counter it is available in almost every cold medicine, guaifenesin, chlorpheniramine, diphenhydramine, dextromethorphan, pseudoephedrine, and phenylephrine. Black-box warnings can only do so much to inform patients of the danger. But how many patients know that "APAP" on their prescription label means acetaminophen? A patient taking Fioricet (acetaminophen/caffeine/butalbital) from one pharmacy for migraines and Ultracet (tramadol/acetaminophen) from another for chronic pain can easily take more than the recommended amount of acetaminophen. If the two prescriptions were filled at one pharmacy, this potential overdosage would likely be caught.
Likewise, therapeutic duplications can have potentially deadly consequences. Taking multiple classes of NSAIDs can increase the risk of ulceration and bleeding. And taking multiple members of the same class of medication usually causes a large increase in the risk of side effects without a substantial increase in the therapeutic effect. Multiple -statins or -statins in combination with fibrates increases the risk of rhabdomyolysis. Multiple opiates increases the risk of dependence and through synergistic effects, increases the risk of CNS and respiratory depression, sedation, coma and death.
Many drug to drug interactions will be flagged by an insurance company, but not all. Some have been discovered recently enough that they haven't been incorporated into software algorithms at the pharmacy or the insurance company. For example, diabetics or pre-diabetics taking Paxil (paroxetine) and Pravachol (pravastatin) may have an increased risk for hyperglycemia. SSRIs and tramadol concomitantly may decrease the seizure threshold. Both of these are serious and have just been brought to the attention of the medical world. I know for a fact that neither interaction is flagged by the algorithms in the software we use at the pharmacy I work at. It takes a human scanning through the patient's profile to catch these interactions. And pharmacy staff cannot do that without complete and accurate records of medications that a patient is getting. Even the ones that insurance companies might flag cannot be properly evaluated without an accurate record of a patient's medical history.
Drug to disease interactions get a little tricky, even if a patient is not using multiple pharmacies. A lot of the interactions are caught through assumption. For example, there is no direct interaction between oxycodone and Advair (fluticasone/salmeterol), but a patient using Advair may be assumed to have COPD and oxycodone use with COPD may depress the respiratory system too much and result in difficulty breathing. Similarly, a patient getting Clarinex-D who has been taking Prinivil (lisinopril) will not experience a drug to drug interaction, but the pseudoephedrine will likely irritate his hypertension. These types of interactions are already difficult enough to catch, having to extrapolate diagnoses from a listing of medications, but the issue is made more difficult by patients using multiple pharmacies.
Intentional Misuse of the Pharmacy System
Then, to make the pharmacy staff's lives even more difficult, some patients even intentionally misuse the system to get high quantities of controlled substances for sale or abuse (or both). This is the responsibility of the entire pharmacy staff to put a stop to, and fraud will be covered more thoroughly in a future post.
Cheers,
C.Samuels
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