This is Oscar.

Oscar predicts — with 100% accuracy so far — when people are going to die. The following excerpt is from the NEJM essay mentioned in the AP article, for those who don’t have access.

Oscar takes no notice of the woman and leaps up onto the bed. He surveys Mrs. T. She is clearly in the terminal phase of illness, and her breathing is labored. Oscar’s examination is interrupted by a nurse, who walks in to ask the daughter whether Mrs. T. is uncomfortable and needs more morphine. The daughter shakes her head, and the nurse retreats. Oscar returns to his work. He sniffs the air, gives Mrs. T. one final look, then jumps off the bed and quickly leaves the room. Not today.

Making his way back up the hallway, Oscar arrives at Room 313. The door is open, and he proceeds inside. Mrs. K. is resting peacefully in her bed, her breathing steady but shallow. She is surrounded by photographs of her grandchildren and one from her wedding day. Despite these keepsakes, she is alone. Oscar jumps onto her bed and again sniffs the air. He pauses to consider the situation, and then turns around twice before curling up beside Mrs. K.

One hour passes. Oscar waits. A nurse walks into the room to check on her patient. She pauses to note Oscar’s presence. Concerned, she hurriedly leaves the room and returns to her desk. She grabs Mrs. K.’s chart off the medical-records rack and begins to make phone calls.

Within a half hour the family starts to arrive. Chairs are brought into the room, where the relatives begin their vigil. The priest is called to deliver last rites. And still, Oscar has not budged, instead purring and gently nuzzling Mrs. K. A young grandson asks his mother, “What is the cat doing here?” The mother, fighting back tears, tells him, “He is here to help Grandma get to heaven.” Thirty minutes later, Mrs. K. takes her last earthly breath. With this, Oscar sits up, looks around, then departs the room so quietly that the grieving family barely notices.

I think if I were dying, it might be nice to have an animal next to me. Even if I wasn’t aware of it. Oscar has a plaque dedicated to him, as well, “For his compassionate hospice care, this plaque is awarded to Oscar the Cat.”

Note: Since he was adopted by staff members as a kitten, Oscar the Cat has had an uncanny ability to predict when residents are about to die. Thus far, he has presided over the deaths of more than 25 residents on the third floor of Steere House Nursing and Rehabilitation Center in Providence, Rhode Island. His mere presence at the bedside is viewed by physicians and nursing home staff as an almost absolute indicator of impending death, allowing staff members to adequately notify families. Oscar has also provided companionship to those who would otherwise have died alone. For his work, he is highly regarded by the physicians and staff at Steere House and by the families of the residents whom he serves.

That’s pretty amazing.

And it seems that I Can Has Cheezburger? has made a LOLCAT out of him.

“Hello, may I help you?”

“Hello… my boyfriend is a heroin addict.”

Not exactly the sort of greeting one expects after picking up the telephone.

“OK.”

“Yeah, I was wondering if you could sell him like one needle. I’m worried about him and I don’t want him to get AIDS or something like that.”

“Um, well, we can’t sell you just one syringe. They come in packs of 10. I don’t have any way of selling you just one.”

“Oh. Really.”

“Yeah, I’m sorry.”

“Well, how much are they?”

“They’re about $2.50 or so for ten.”

“Oh. He can’t afford that.” At this point I’m thinking WHAT THE HELL? You can buy HEROIN but you can’t afford $2.50 for some freakin’ syringes?!?! Think of it as an investment in the future, FFS!

“Yeah. I’m sorry. I wish I could help you.” Where help doesn’t necessarily mean “Get you a needle so your SO can shoot up.”

“Well… Do you know where I can get him one?”

“Um, you could try a hospital. Maybe they can give you one.”

“Oh!” she says brightly. “I’ll try that. Thanks!”

*click*

It seems that Massachusetts does not have a clean needle program, and I’m fairly certain that NH doesn’t either, since hypodermic needles require a prescription in that state. I guess she really was SOL. I wonder what happened.

Regular readers already know my feelings about selling needles OTC.

While working in an affluent town the other day — not my normal pharmacy stomping grounds — I was in a pretty good mood. When I’m happy, I get talkative, particularly if I’m somewhat caffeinated, which I was.

Anyway, I rang someone out. Their script was for Imitrex. Since I had done the whole thing from start to finish, I looked at her profile like I always do. (Contrary to popular belief, filling a prescription is NOT a passive activity.) 9x50mg tablets about once every two months. Less than your normal Imitrex user.

She was a nice woman, and (what I assume was) her SO seemed pretty cool, so we were chatting at the register. For some reason, I saw fit to tell this woman that if you take enough Imitrex, your blood will turn green, as it is a bisphosphonate. Useless trivia that I thought was pretty cool. (Cyanosis brought on by sulfhemoglobinemia, where a sulfur atom takes the place of a carbon atom in normal hemoglobin. How green? I don’t know, because I’ve never seen it — though I’d really like to find a picture.)

As soon as I told her, I saw fear come in her eyes, and I knew I had made a mistake. I assured her that this would never happen to her, and that you’d have to be taking huge doses for a long time, but I could see it didn’t matter. The damage was done.

Next time I’ll just keep my mouth shut about what I think is awesome, and useless. I wince every time I think about the conversation. Why did I have to mention this? Why? It served no purpose.

Errors in judgment can be just as damaging as a “technical” error like dispensing the wrong drug.

A woman came up to the counter yesterday to ask about Robitussin as fertility aid. I was at the other end of the counter doing God knows what, but got called over when the pharmacist I was working with didn’t know the answer. Her friend had told her that Robitussin could help her conceive, and she had “read on the Internet” — a statement that always makes me cringe — that this was indeed possible. (This is probably the page she read, btw.)

But she couldn’t remember which type of Robitussin her friend told get, and needed our help.

The pharmacist pulled an answer out of his ass and made it sound really good. Turns out it was the right one. Guaifenesin, of course, thins mucus and he suggested that it might also thin the cervical mucus, allowing sperm to more easily penetrate. Seems this is, in fact, the idea behind using it to aid in fertility.

There is a small body of published literature that supports its use. One article (PDF) from Fertility and Sterility, published in 1982 stands out:

Couples with infertility should not use vaginal lubricants, which can impair sperm motility and activity. Twenty-three out of 40 females taking guaifenesin (200 mg orally three times a day) from day 5 to the day of BBT rise demonstrated improved cervical mucus quality, and 15 out of 23 couples conceived.

A second study published in 1991 (PDF). These findings are only relevant in the case where cervical mucus is abnormal, and can’t be applied outside of this context. I’m not a fan of taking OTC or prescription meds willy-nilly, even if it is “only” Robitussin. Especially if the reason is because a friend told you so, or you “read it on the Internet”.

Talk to your doctor, naturally. But I thought it was pretty interesting. But talk about off-label usage!

Everyone has their own preferred method of dealing with forged prescriptions. Ryan at EclecticEsoteric recently asked what I would do. It so happens that Andrew at PharmCountry has a related post, so it seems an opportune time…

When you’ve got a forged or altered prescription, there are two basic things you SHOULD do.

1) Contact the prescriber. Verify that it has been forged or altered.
2) Initiate a PharmAlert, the details of which can be obtained by contacting your state’s board of pharmacy. I believe this is how such an alert is usually initiated anyway — I’d say “always” but I haven’t worked in every state, so that’s impossible for me to know.

PharmAlerts start a cascading reaction. A notice is typically faxed to the pharmacy at the top of the list in your area, and they, in turn, fax to other pharmacies who fax to other pharmacies. You are also supposed to pick up the telephone, and notify the pharmacist at the receiving pharmacy as well, but we rarely do. I should take a picture of the PharmAlert notification map for my area. It’s kind of nifty because one of my stores is #1 on the list. If I had to guess, I would say that the seed pharmacies at the top of the lists are probably chosen that way because they are lower volume, and it’s thought that they have more time to seed the word along? I have nothing to back this up, I’m only guessing. We are responsible for notifying three pharmacies, whereas everyone lower on the list than us is only responsible for one.

Doctors’ offices can also initiate pharmalerts, and often do if a prescription pad is stolen.

There are a couple of things you COULD do beyond these two steps, depending on how crazy you want to be. These include contacting the police, the DEA, and anyone else you might want to contact. It all depends on how zealous you want to be. Me? I don’t bother because I don’t particularly want to be a law enforcement officer. If I did, I’d work for the DEA. Some pharmacists also take the opportunity to lecture the person about altering a prescription. That’s not really my style either. The person already knows they did it, and they know it’s wrong. I don’t need to beat it into their head, or threaten to call the police on them.

All this changes, though, if you’re a habitual offender and/or I suspect there might be organized crime involved. In that case, I verify the script, call the police very quietly, and keep you waiting until the officer arrives, at which point you are arrested. And yes, it always does seem to fall on me to keep the person waiting and so on. I have no idea why. Apparently my poker face is pretty good.

Assuming no drastic measures are taken, I would also say that you shouldn’t give the prescription back to the person, but I have seen it done. (An act which never ceases to boggle my mind!) By doing this, you are giving the person another chance to take the script elsewhere. This is unacceptable!

Regardless, I believe it’s important to keep whatever action you decide to take low-key and professional. You are not this person’s parent. You aren’t the police. You are the medication gatekeeper. Politely deny them, do what you must do, and keep the ball rolling.

[tags]Pharmacy, pharmalerts, pharmacy practice[/tags]

Chantix is pretty popular these days, and with good reason. It works pretty well. In fact, of all of the people I’ve talked to, there’s not one that’s not had success with it. Anecdotal, but nifty. I was dead wrong in my guess that insurers would balk at paying for it. Even medicaid is paying for it in my area, which is truly mind-blowing given how tight they are with their formulary. Even when it’s not covered, it’s still usually cheaper than buying a month’s worth of cigarettes.

What’s not so nifty about Chantix are the horrific prescriptions we see for it. Directions that make no sense. Or make sense within a certain context, but probably not the context the prescriber was thinking of. This will become clear shortly.

This is a short post, but it’s big because of all of the pictures.

Table of Contents:

1. How does Chantix come?
2. Normal Chantix Use: prescribing a course of Chantix
3. Normal Chantix Use: the first month (photos begin)
4. Normal Chantix Use: Month 2 and beyond
5. Abnormal Chantix Use and common missteps

Continue reading The ins and outs of prescribing Chantix (varenicline): an illustrated How-To guide →

The folks in Tulsa, Oklahoma recently dug up a car that was buried as a time capsule in 1957. They put a few things in the car before they buried it:

In the trunk, workers meticulously pulled out some of the objects buried with the two-door hardtop to celebrate Oklahoma’s 50 years of statehood a 5-gallon can of leaded gasoline, which went for 24 cents a gallon in those days, and rusted cans of Schlitz beer.

The contents of a “typical” woman’s handbag, including 14 bobby pins, lipstick and a bottle of tranquilizers, were supposed to be in the glove box, but all that was found looked like a lump of rotted leather.

Tranquilizers: the solution to all women’s ills in the days before men took them seriously. Dysmenorrhea? Have some Valium. Bad day? Valium. Kids acting up? Valium. Dinner didn’t come out right? Sprinkle some Valium on it.

Valium! Valium! Valium!

So let’s see. If I were a bottle of tranquilizers back in 1957, what would I be?

The first benzo approved was Librium, which was discovered in 1954, and re-discovered again in 1957. So it’s probably not Librium. Valium, of course, is newer, having been approved in 1963.

The other possibility might be methaqualone (Quaalude), which was discovered in 1955, but wasn’t popular until the 60’s.

My guess would have to be phenobarbital which was approved back in 1912. What’s your guess?

[tags]History, women’s issues, tranquilizers[/tags]

The pharm can get pretty wild and crazy sometimes, and Twix aren’t always handy. And let’s face it, candy necklaces are for kids. Valium is SO much more stylish:

You, too, can have your very own Valium necklace for the low, low price of $55.62!

No Valium was harmed during the making of this blog post.

[tags]Valium, candy necklace, humor[/tags]

One of my more popular posts has been “Do we need Tekturna (aliskiren)?“. The comments have been varied, but I still stand by my doubts over its usefulness. Other medbloggers have expressed their doubts as well. And I should state right now that I think Tekturna being on the market is a Good Thing™. I am not against the drug’s existence.

In fact, I’m not arguing how efficacious it is. I’m sure it works. If it didn’t, it wouldn’t be approved. I’m merely questioning its place in current treatment paradigms. To explain what I mean, I’m going to use a crude analogy to compare angiotensin II receptor blockers (ARBs) and aliskiren, the only direct renin inhibitor (DRI).

Think of a sink. For whatever reason, you want to keep liquid from going down the drain. Does it make more sense to keep the sink turned off, or to plug the drain directly?

Well obviously if the goal is keeping the drain dry, you’d plug the drain. This is what ARBs do. They prevent specific and non-specific binding at the angiotensin II receptor sites. Tekturna just keeps the sink from turning on and does nothing to block the drain directly. This means there’s still going to be non-specific binding at the angiotensin II receptor site. (Incidentally, this non-specific binding is not merely theoretical; if it were, ACEis would be more effective as a class than the ARBs, but instead they are merely comparable.)

Back to my point: Tekturna is more expensive than the ARBs, and it will be for a long time. I don’t think having aliskiren as an option is a bad thing. I just question how valuable the drug truly is with less expensive ACE inhibitors and ARBs. Sitting here, it doesn’t seem to have a real niche. Would I try Tekturna if nothing else worked? Of course I would. If I were targeting the RAAS, would I reach for it as first-line therapy? Hell no I wouldn’t. I’d go for an ACE inhibitor in most cases.

I’m not going to delve into the heated debates about reactive renin production and other similar topics because I suspect that the reality lies somewhere in the middle ground, as it usually does.

In the meantime, I think don’t think Tekturna has a meaningful place in current drug therapy. If ARBs do not work, it is unlikely that a DRI will, either. The only time I see it perhaps being useful is if a patient cannot tolerate ACEis or ARBs.

[tags]Medicine, pharmacy, Tekturna, aliskiren, hypertension[/tags]

It looks a little something like this: