Friday, 31 January 2014

Bachelor of 'give a damn'

I have a new subject  to add to the standard Pharmacy degree. It's called 'Defending the Profession' and it is something every budding Pharmacist needs to master.

I am always surprised by the surveys (like this one) that name Pharmacists as one of the most trusted professions. In practice it feels very different, with patients/customers becoming defensive and even aggressive when we ask them basic duty-of-care questions. I gotta tell you, it's pretty tough to deal with when I am just looking out for them. When I reveal to an acquaintance that I have a Pharmacy degree their response is usually along the lines of: "Is that really boring?" and "Do you have to go to uni to be a Pharmacist?" followed closely by "Why do I have to show my license to buy pain-killers?". I guess these aren't the people surveyed. For the record, the answers to those questions are: No, not boring, stressful and busy usually but not boring; Yes, it is a four year degree plus an additional year of supervision and well, I'm going to talk about question 3.

Recently I had coffee with two friends, one of whom is a Pharmacist. During the conversation the non-Pharmacist friend mentioned that she hates having to answer questions when she wants to buy something. She gave the example of her local Pharmacist questioning her as to why she was buying two bottles of Nurofen for her baby. I think she was a little surprised that instead of nodding sympathetically and muttering about bad Pharmacists we both leapt in to defend him. Our response was that the Pharmacist was doing his job properly by clarifying why she needed two bottles and as long as he was respectful of her answer and maybe asked a few questions to make sure she knew the correct dose for her baby, that he was a shining example of the profession.

I know there are bad Pharmacists out there that use their position to be difficult and enjoy their moment of power but honestly these guys are in the minority. The Pharmacists that ask no questions at all, that blithely nod away requests are the bad guys. You see, drugs are not safe. You may be able to buy as much paracetamol as you like from the supermarket without questioning but unless you read the label and follow the directions you can also give yourself permanent liver damage. Pharmacists are required to oversee all medication requests, which is virtually impossible. To get around this, staff members are supposed to be trained to ask specific questions and refer to the Pharmacist if there are any queries that arise from the person's response.Yet in the current environment, owners are cutting costs and using young, minimally trained staff. Should a pharmacy assistant sell a medication without appropriate screening and referral to the Pharmacist, and something terrible happens to the customer, it is very likely the Pharmacist will end up in the midst of a malpractice investigation. Pharmacists are required to have professional indemnity insurance as a condition of registration because the things we do, or don't do, can kill people. Similarly, we are responsible for the stuff that happens on our watch. In 2009 a Pharmacist  (in the USA) was jailed for an error made by a Pharmacy Technician - I don't know if the same could happen here but this story illustrates how easily mistakes can occur.

When you request a Schedule 3 (Pharmacist Only) medication in a Pharmacy (also considered an over-the-counter medication) the guidelines from the Pharmacy Board of Australia state that "The Pharmacist must be satisfied that there is a therapeutic need." This means we need to ask you questions. We have a responsibility to ensure you know the appropriate way to use the medication and to give you guidelines regarding appropriate duration of use and what to do should your condition not resolve. The vast majority of people, even the polite ones, usually announce over the first few questions in a loud and discussion-ending voice "I've had it before". Here's the thing- we know that. Usually if you ask for something by name it means you know the product. That is not enough.

Quite a few people say "my doctor knows I take it" and imply 'end of conversation'. What this means to me is that at some stage you have gone to the doctor with a sore back/neck/arm and he or she has suggested an over the counter product for you to use for a specified period of time based on your current overall medical status. This same product might not be suitable for you 5 years down the track when you are taking different medications or have developed a new condition or if you have just continued taking the product because the pain has not resolved. That is why Pharmacists ask questions.

Whilst the law varies from state to state, most responsible Pharmacists will now ask to see a driver's licence and record sales of codeine products. Generally people seem to have the attitude that if you can buy a medication without a prescription, that it is safe, and that recording the purchase of codeine-containing medications is yet another way that Pharmacists are being difficult. A member of the opiate family (yep, the younger cousin of heroin), codeine is a prodrug that is metabolised into morphine by the liver in order to exert an analgesic effect. Codeine is highly addictive and is becoming a major problem, especially when you consider how easy it is to obtain. Whilst I am not suggesting for a moment that codeine and heroin are similar (other than the receptors they work on), codeine (or any medication for that matter) is not something to get blasé about using. The reason we record codeine purchases is to help you, to monitor usage and speak to you about it if you are using the medication regularly.

There is a stigma attached to people who are on methadone or Suboxone (pharmacotherapy) programs. In some areas I have worked, the local shops have rallied against the Pharmacy's participation in the program because it is believed that by dosing pharmacotherapy patients the Pharmacy is attracting 'junkies' to the area. If only the storeholders knew that a good chunk of these patients are withdrawing from prescription and over-the-counter pain killers; the same (often upper- and middle-class) people that are supporting the local businesses are being treated for addiction. Addiction is a scary thing and it can happy to anyone- read this great article.

If you have been taking codeine regularly for, say, headache or migraine and you keep getting those headaches there is a good chance that the pain is a withdrawal effect. The other side of the coin is even more terrifying. If you are getting pain regularly and it is not resolving you need to go to your doctor and find out what is causing the pain. A few years ago a conversation I had with a regular codeine buyer led to an investigation and eventual diagnosis of lymphoma.

Even non-addictive over-the-counter medications are dangerous if not used correctly and without monitoring by a health professional. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) like Nurofen (ibuprofen) and Voltaren (diclofenac) are often self-initiated for relief of arthritis and muscular pain. They are only ever intended for short-term use unless you are being monitored by a doctor. They can cause stomach irritation, ulcers, renal damage and there is evidence that long-term use increases cardiovascular risk.

So there you go, there is a reason those snoopy pharmacists ask you all those questions and the reason is that they care. I know it can be annoying, but if by asking those questions, a Pharmacist can prevent even one person per year from developing a serious side effect or masking a more severe condition, then it is worth it.

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