Peter A. Kreckel practices pharmacy in Lemont Furnace, Pennsylvania.

Peter A. Kreckel, RPh

In a previous issue, I introduced you to my 10-year-old Nissan Frontier pickup truck. I described its rusted bed and the big dent in the front from hitting a deer on my way home from work. Recently, the brakes on my truck needed attention. We are all too familiar with what that grinding sound means when applying the brakes: the sound of $500 or more in repairs, meaning we need new brake pads and possibly new rotors. So I took my truck to the garage we usually use for inspection. They pulled it into the service bay, yanked o! the wheels, and did a visual inspection. “Hey buddy, the brakes look great,” the mechanic said. “You have another 20,000 miles left on them.”

The next day, I took the truck out and heard that familiar sound: 

. The brakes continued to make a grinding noise. We reached out to the neighbors for advice, but they all drive new cars; my truck is the oldest vehicle in our development. One neighbor recommended we check out Eldon’s Auto Service, a repair shop on the other side of town. My wife called Eldon and set up a service appointment.

I dropped o! my truck and met Eldon in his spotless garage. He took the keys and told me he would get back to me the next day. The next morning, he called and said he took the truck for a long test-drive up and down the hills of West Virginia. He said that the brake pads and rotors were indeed fine. The issue? A faulty antilock braking system sensor. Eldon replaced the sensor, and now the truck is running—and stopping—just fine.

If only the chain pharmacies could encourage their executives and district managers to develop the commonsense knowledge that Eldon has. What the district managers, regional managers, and everyone else at the top of the food chain need to do is spend an entire day in each of their stores. When they see the massive volume, short staffing, inadequate computer systems, angry patients, and incessant ringing phones, they will get a better sense of the problems their stores face.

But like the first garage that looked at my truck, upper-level management looks only at the figures. They might stop by the pharmacies in their district for a quick surface-level look at the operation or to make a ridiculous comment: “Other pharmacists handle more volume with this level of help.” They don’t stay in the pharmacy long enough to see their excellent pharmacist explain how to use an autoinjector, measure a dose of children’s antibiotic, or counsel a woman whose 65-year-old husband has just received a diagnosis of Alzheimer disease.

Our profession, especially the community pharmacy specialty, is having significant problems. These problems require a deep dive not only by operations managers but also by national associations and academic institutions to solve. When I see major chains closing pharmacies on weekends because of lack of staffing, I have no trouble understanding why fewer and fewer pharmacists are interested in this aspect of the profession.

If the movers and shakers in this profession need guidance to solve the problems of community pharmacy, I know a guy. I suggest they take a page from Eldon. Test-drive a pharmacy for a whole day, and you will come away with a renewed respect for the community pharmacist. But you might want to get there before the front door is locked because of another excellent pharmacist leaving his amazing health care profession

Articles

A local West Virginia mechanic exemplifies the kind of problem-solving that pharmacy executives from major chains should apply to their stores.

To Improve Retail Pharmacy, Look Beyond Figures and Dig Into Facts

Academia just loves titles, initials, and degrees after names, but I contend that real-world experiences are what truly matter. I don’t care if you have 30 letters after your name. What practical knowledge do you have in patient care? It doesn’t matter to me whether you can draw the structure of naloxone if you don’t provide it to a patient at risk for overdose.

Robert H. Jackson is a stellar example of how on-the-job training is far more important than the degrees attained or the letters after your name. Jackson was born in Warren, Pennsylvania, a small town in rural northeastern Pennsylvania, approximately 1 hour from the small town I grew up in. Jackson was a lawyer who worked his way up to solicitor general, attorney general, and associate justice of the Supreme Court.

Although these titles are all impressive, Jackson is most renowned for being the chief prosecutor for the United States in the Nuremberg trials in 1945 and 1946. Although the other 3 Allied powers—the British, the French, and the Russians—thought a trial of the Nazi regime was not necessary, Jackson pushed for a trial that would eventually become the basis for international law.

It’s fair to assume that an attorney of such caliber would have been trained at Yale University, Princeton University, or Harvard University—but he was not. Jackson did not possess a degree from an Ivy League school; rather, he attended the University at Albany and enrolled in law school for 1 year. He went on to practice law and quickly rose to the top of his profession. With only 1 year of study at a university, this brilliant man went on to leave his fingerprints all over international law. I encourage you to watch his opening statement at Nuremburg on YouTube.

In the late 1990s, all schools of pharmacy switched from the 5-year BSPharm degree to the PharmD degree. We thought adding more letters to our profession’s degree would be of great benefit, but I believe that this has not worked out as planned. Students pay for another whole year of tuition for “exposure” to different elements of the profession. When I graduated in 1981, we had three 5-week rotations: hospital pharmacy, community pharmacy, and clinical pharmacy. After those 3 rotations were done, I was well satisfied with my choice to practice community pharmacy.

A few days ago, a young woman came to the pharmacy with a prescription for doxylamine/pyridoxine (Diclegis), which wasn’t covered by her insurance. Her husband piped up: “We’ll pay cash.” I explained that the brand name of this medication cost over $500, and the generic cost over $200. “Let’s take a walk out front,” I said. We walked to the sleep aids aisle and grabbed a box of doxylamine (Unisom SleepTabs), then went to the vitamin section and grabbed a bottle of vitamin B6 (pyridoxine). I explained to the couple how this combination of OTC medications would work—and for less than 10% of the generic prescription price.

A funny thing happened during our walk and discussion: They never looked at my credentials. This young couple just saw an experienced pharmacist, who didn’t need a phone or computer to help them. All this seasoned pharmacist needed was the desire to help this struggling woman who had been vomiting for 2 weeks.

Since graduating over 40 years ago, I have not added a single letter to my professional title. I will admit it has held me back from consideration for some academic opportunities. But watching the way an experienced pharmacist practices, it’s not clear that anything is missing. Like so many of my fellow bench pharmacists, individuals like Jackson exemplify the way that hard work and practical experience trump letters after your name, or the prestigious institution you graduated from.

When it comes to practicing pharmacy, do titles and degrees actually matter?

What’s in a Title?

Back in 1981, my new bride and I went to the car dealer in search of our first big purchase. We bought the cheapest car on the market: a beige Datsun 210 for the sum of $4400. Since that monumental occasion, I’ve bought a new vehicle approximately every 10 years—mostly minivans when we had a full-size family.

The last vehicle I purchased was a 2012 Nissan Frontier pickup truck. It has plenty of rust in the bed and a sizable dent in the front where I hit a deer on my way home from work last year. I look at my vehicles with the same affection as I do a wheelbarrow—as a tool to get a job done. My car gets me to work and brings me home, and that’s all I need. But I am meticulous about caring for the operational parts of the vehicle; I get the oil changed on schedule to keep my vehicles performing well.

The money I spend on preventive maintenance is well worth it. I’m a cheapskate, but I gladly lay out the money for inspections, tires, and oil changes. Spending $100 every few months keeps me from spending thousands on major repairs or, even worse, replacing the vehicle.

I wish our chain pharmacies would apply this wisdom to the operations of their stores. The chains have pinched pennies on staffing for so many years that major breakdowns have occurred. Some of the Big 4’s stores can’t open on weekends because of staffing problems. University towns with pharmacy schools were once the holy grail of places for community pharmacists to work. At my first job, one of the pharmacists was putting in his time in rural Pennsylvania to get enough seniority for a job in Pittsburgh. Today, even the university towns are seeing staffing shortages and reduced hours.

My brothers and sisters in community pharmacy have been pushed to their limits. Ridiculous metrics, administering vaccinations, and COVID-19, along with reduced staffing and lower pay, have led to community pharmacists looking for a new nail on which to hang their license. For some pharmacists, the “Great Resignation” would be better described as the “Great Reshuffle.” So many pharmacists have been given the opportunity to work from home, for pharmacy benefit managers or insurance companies, that they have chosen to move off the bench and away from the stress and commotion of the retail environment. I doubt we will ever see them come back.

With a little preventive maintenance, district and regional managers could have averted this crisis. Providing adequate technology, ensuring staffing breaks, eliminating metrics, and—most of all—increasing the number of pharmacy technicians on hand to assist with the workload would have prevented this catastrophe. Because the Big 4 chains neglected preventive maintenance, they are experiencing a major breakdown—much like not changing the oil or rotating the tires on my beloved pickup truck.

The bad news even gets worse: Pharmacy school enrollment is down—way down. Because of the switch to virtual classrooms, current graduates are struggling to pass the North American Pharmacist Licensure Examination. Even new graduates who were easily plucked with big salary offers are declining retail opportunities. Younger pharmacists with families are leaving the long hours on the bench. The very chain pharmacies that were giddy with the “pharmacist glut” 5 years ago are now crying the blues.

One of these retail giants is offering a $75,000 signing bonus at some locations. I’ve surveyed some of my pharmacist colleagues as to whether they would prefer the bonus money or have a guarantee of 2 pharmacy technicians at $18 per hour. All but one said they would prefer the technicians and having a fulfilling job in patient care. This response is a result of the chains’ neglect of the “preventive maintenance” that would have avoided this dire situation.

The chains have no one to blame other than themselves. They had great pharmacists who worked through the COVID-19 crisis with minimal (if any) staffing increases. Chain executives need to increase salaries, significantly increase technician hours, incentivize pharmacists’ efforts, reduce store hours, and develop a caring attitude—much like the one on display in their TV commercials.

It’s too late for retail chain pharmacies to engage in the preventive maintenance that would have spared them the worst of the Great Resignation.

Crisis (Not) Averted

Simply put, one of the biggest challenges of moving from one house to another is what to do with all the stuff. We decided to move from central Pennsylvania to Morgantown, West Virginia, to live closer to our daughter, her husband, and our adorable 6-year-old grandchild. This move also put us 1 hour closer to Pittsburgh, Pennsylvania, where my son, his wife, and our 2 beautiful granddaughters live.

We had lived in our home for 36 years, and we raised 3 children there. When raising 3 active kids, you accumulate a lot of 

: 4 canoes, a canoe trailer, yard decorations, and numerous bicycles all filled the extra garage I rented downtown. Knowing we could not possibly bring all this stuff to Morgantown, we had to sell it. What was all this stuff worth? Whatever the next person would pay for it!

At our yard sale, my canoe trailer brought me $250—more than I’d paid for it 20 years ago—and the canoes did equally well. However, small kitchen appliances were hauled away for pennies on the dollars. We were just glad for the major downsize. We had priced items reasonably, but to keep in the game, we discounted everything when the buyers asked for a deal.

This process reminds me of what I do every day in the pharmacy. When I look at the 5 biosimilars of insulin glargine, ranging from $144.28 to $405.41 for the brand name, I am amazed that not a single patient has the least expensive biosimilar on their formulary. Instead, the most expensive brand is preferred. Could you imagine going to the grocery store and seeing cans of pineapple priced from $1.44 to $4.05, and everyone buying the most expensive can?

Unfortunately, this happens in the pharmacy every day. We are acutely aware that brand-name therapies have grossly inflated prices to help cover the offered rebates. We know full well that there is not a pharmacy benefit manager (PBM) or insurance company paying the full $405.41 for brand-name insulin glargine. PBMs blame drug companies, drug companies blame PBMs, and patients blame pharmacists, as we are the only ones that they can complain to. Yet 3 PBMs process 79% of the prescriptions filled on a daily basis.

According to the National Community Pharmacists Association, “PBMs raise drug costs by almost 30% due to the rebates they charge manufacturers to be on their formularies. PBM rebates, at $143 billion in 2019, add nearly 30 cents per dollar to the price consumers pay for prescriptions.”

 I find it interesting that the government is not interested in looking for a 30% discount, 30 cents on the dollar, for the prescriptions processed by the PBMs. One of the PBM administrators made $36 million in 2019. Think of the insulin that could have been discounted to our older population, some of whom are paying outrageous co-pays on Medicare plans.

Over the years, I have learned that when something doesn’t make sense, follow the money. My yard sale netted us some nice money; fortunately, we didn’t have to contribute to a political action committee or give anything to a middleman. I wish the government could operate health care with such a simplistic game plan. Drugs are worth what the next patient will pay for them, just like my canoes, stepladder, and ice fishing equipment. And as long as someone else is picking up the tab, drug prices will continue to escalate, while the PBMs continue to take advantage of pharmacies, the government, drug companies, and—of course—patients.

1. The truth about pharmacy benefit managers: they increase costs and restrict patient choice and access. National Community Pharmacists Association. Accessed September 12, 2022. 

https://ncpa.org/sites/default/files/2020-09/ncpa-response-to-pcma-ads.pdf

As he prepared to move house, our columnist was struck by the similarities between a yard sale and the prescription drug pricing infrastructure.


Follow the Money

As a young pharmacist in 1982, I dispensed conjugated estrogens (Premarin) by the thousands. We bought Premarin 0.625 mg and 1.25 mg in bottles of 1000 and moved them over the course of 3 or 4 weeks. Every woman was on this medication. We sold 100 tablets for approximately $15, and my customers seemed happy. Today, a bottle of 100 conjugated estrogens tablets, at any strength, is over $600 direct cost.

The pendulum has swung the other direction for use of estrogen, as my fellow seasoned pharmacists can attest to: two trials— HERS

 (NCT00000611)—essentially pushed the pendulum to where it is today. Even I have shouted from the lecture halls of St Francis University that “estrogens should be only used for relief of vasomotor symptoms, at the lowest dose for the shortest duration.”

Another pendulum that has shifted is the prescribing of opioids. Back in my younger days, it was rare to see an oxycodone/acetaminophen (Percocet) prescription for 60 tablets. Thanks to the explosion of oxycodone (Oxycontin) in the mid-1990s, providers became too comfortable prescribing opioids, and the opioid pendulum swung wildly. However, approximately 10 years ago, the pendulum slowly moved back toward the center, as the opioid dispensing rate declined from 81.3 to 43.3 per 100 persons today.

The subsequent crisis of heroin addiction was addressed by the Drug Addiction Treatment Act of 2000,

 with waivers that allowed physicians to write buprenorphine (Suboxone) prescriptions following an 8-hour training, then dispensed in community pharmacies. This change was made to avoid the stigma of standing in line at a methadone clinic and was intended to help our citizens living with opioid addiction. We’re told buprenorphine is a partial agonist, with less potential for euphoria, and that naloxone helps decrease the abuse potential. Buprenorphine has a morphine milligram equivalent (MME) factor of (x30). The buprenorphine/naloxone combo (8 mg/2 mg) dosed twice daily is equivalent to 480 mg of morphine, or oxycodone 80 mg dosed 4 times daily. I know opioid experts who would disagree on some of these points.

Every day, we community pharmacists see the benefits of prescribing buprenorphine. Patients come in for their 2- or 4-week supply after a day spent working as mechanics, plumbers, roofers, or mothers. I also know of many pharmacists who will not dispense buprenorphine because they don’t want “those people” in their stores. However, these pharma- cists dispense oxycodone, hydrocodone, oxymorphone, and fentanyl— likely not realizing “those people” are already in their stores.

When I check the prescription drug monitoring program,

 the MMEs for buprenorphine are no longer there. At one time, the 480 MME was listed, but I’ve been told this was removed to avoid stigma. When a new patient comes to the pharmacy, I outfit them with a naloxone rescue kit and a pamphlet describing the MMEs of buprenorphine. In response, many patients tell me it’s the first time they have been treated with respect. I’ve studied this disease enough to understand it truly is a mental health disorder, usually stemming from childhood trauma. It has been postulated that 75% of women abusing alcohol and drugs were victims of sexual abuse

; it’s not in my wheelhouse to determine who deserves compassionate care—all my patients do.

Pharmacies frequently get calls from their warehouses, questioning their buprenorphine purchases. Wholesalers do this at the behest of the Drug Enforcement Administration, as the big 3 wholesalers have been slapped around for opioid sales in the past. Pharmacists are cognizant of the microscopic analysis of their buprenorphine purchases, whereas the Department of Health and Human Services wants to see more buprenorphine prescribers.

I, for one, do not want to see my brethren in the profession stigmatized for providing such lifesaving medications, including buprenorphine, to people with substance use disorder. Pharmacists are not riding a pendulum; we are more like a Ping Pong ball getting slapped back and forth between government agencies.

1. Hulley S, Grady D, Bush T, et al. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. Heart and Estrogen/progestin Replacement Study (HERS) Research Group. 

. 1998;280(7):605-613. doi:10.1001/jama.280.7.605

2. Henderson VW, Lobo RA. Hormone therapy and the risk of stroke: perspectives 10 years after the Women’s Health Initiative trials. 

. 2012;15(3):229-234. doi:10/3109/13697137.2012.656254

3. US opioid dispensing rate map. CDC. Reviewed November 10, 2021. Accessed July 13, 2022. 

https://www.cdc.gov/drugoverdose/rxrate-maps/index.html

4. Become a buprenorphine waivered practitioner. Substance Abuse and Mental Health Services Administration. Updated April 21, 2022. Accessed July 12, 2022. 

https://www.samhsa.gov/medication-assisted-treatment/become-buprenorphine-waivered-practitioner

5. Statues, regulations, and guidelines. Substance Abuse and Mental Health Services Administration. Updated July 1, 2022. Accessed July 12, 2022. 

https://www.samhsa.gov/medication-assisted-treatment/statutes-regulations-guidelines#DATA-2000

6. Prescription drug monitoring programs (PDMPs). CDC. Reviewed February 12, 2021. Accessed July 12, 2022. 

https://www.cdc.gov/opioids/providers/pdmps.html

7. Liebschutz J, Savetsky JB, Saitz R, Horton NJ, Lloyd-Travaglini C, Samet JH. The relationship between sexual and physical abuse and substance abuse consequences. 

 Treat.2022;22(3):121-128. doi:10.1016/s0740-5472(02)00220-9

8. HHS releases new buprenorphine practice guidelines, expanding access to treatment for opioid use disorder. News release. Department of Health and Human Services; April 27, 2021. Accessed July 12, 2022. 

https://www.hhs.gov/about/news/2021/04/27/hhs-releases-new-buprenorphine-practice-guidelines-expanding-access-to-treatment-for-opioid-use-disorder.html

A pharmacist reflects on how prescribing behaviors have changed over the years and the potential for stigma linked to providing buprenorphine to patients who need it.

Pendulum Ping Pong

Three years ago, my wife, Denise, planned another vacation of a lifetime.

 In 2001 and 2013, we had traveled, with our parish priest and our kids, to Italy on a pilgrimage to various religious sites. We had a marvelous time. This trip, though, would be different: We were going to Germany, where all of my grandparents are from. My dream to see the Passion Play in Oberammergau would become a reality in May 2020.

The Passion Play was performed there first in 1634 and every 10 years thereafter as a thanksgiving offering for the village being spared from the plague. The Passion Play deviated from every 10-year schedule only twice: in 1940, during World War II, and again in 2020 for the COVID-19 plague. The Germans seemed to know that COVID-19 would last longer than 1 year and rescheduled the performance for 2022. We were excited to get tickets to the second performance on May 15.

Whenever I travel to a different locale, I like to stop by the pharmacy for a quick visit. In Germany, it is easy to find a pharmacy. Each store is designated by a big, red A for apotheke.

Pharmacies, by German law, are owned and operated by a pharmacist who has graduated from an accredited school of pharmacy. It is a strange experience when you walk in. The employees, technicians, and pharmacists are sharply dressed in white lab coats with name tags. Throughout the country, pharmacies had the same vibe: calm, quiet, and professional—unlike the chaos in some American pharmacies. Each pharmacist we talked to happened to be a woman and spoke English with proficiency.

Prescription products were available only in unit-of-use blister packs. I asked one pharmacist if they ever split the boxes and received a firm no in response. These boxes were dispensed as a single unit, QR-coded with the lot and expiration date entered on the patient’s profile. There are absolutely no stock bottles and no prescription vials.

German pharmacists do not frequently receive electronic prescriptions. Instead, patients carry a pink and white prescription blank from their physician. There are no directions or drug names on the blank; there is a serial number that, when entered, populates the drug name, quantity, and directions for use. This information is contained in a central database and it is virtually impossible for a pharmacist to enter data incorrectly. There is no chance the pharmacist will enter amitriptyline 100 mg for an order written for amitriptyline 10 mg.

All pharmacies in Germany utilize the same formulary. Patients pays 10% of the cost of the prescription: between €5 and €10, maximum. Can you imagine a prescription in your pharmacy having a maximum co-pay of $10? Best of all, there are no prior authorizations in the pharmacy; everything is approved.

Of all the wonderful experiences Denise and I had interacting with our fellow pharmacists, our encounter in Oberammergau stands out. It was Sunday afternoon and I went to the apotheke to buy a box of ibuprofen 400 mg. When she rang up the sale, she warned me that there would be a €2.5 inconvenience fee because it was a Sunday purchase. I told her I would be honored to pay a surcharge; I’ve always been annoyed with Sunday shoppers. Of the prescriptions we fill on a Sunday, seldom are there more than a few true emergencies.

The German population is covered by a national insurance, which seems satisfactory to most of the citizens there. They have had national health insurance since 1883 thanks to Otto Von Bismarck’s social legislation. Today, the German government spends $685 for health care for the average citizen. Compare that with the United States, which spends over $1000. When it comes to providing drugs to our patients, we could learn a lot from the Germans about safety, cost containment, and satisfaction of its pharmacists.

Kreckel PA. A lesson from the friendly skies. 

https://www.drugtopics.com/view/a-lesson-from-the-friendly-skies

American pharmacies can learn a lot from the Germans about safety, cost containment, and pharmacist satisfaction.