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

Peter A. Kreckel, RPh

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

Articles

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.

Welcome to the Apotheke

The COVID-19 pandemic and immunization seems to be winding down for us in the community pharmacy space. As I’ve seen over the past 41 years of pharmacy practice, we will not take time to celebrate victory but will move on to the next crisis. Crisis management is how we seem to operate.

I remember back in the 1980s when the battle was for more than average wholesale price plus $2.55 reimbursement. In the 1990s the battle was with drug utilization review and the HIPAA, and although many independent pharmacies closed during that time, we still survived.

Independent pharmacies are still surviving thanks to those hard-nosed businesspeople/pharmacists who work relentlessly to keep out of the jaws of the major chains; sometimes we feel like guppies in a tank of piranhas. But in spite of those outside influences, we take care of every individual patient who reaches out to us for our expertise and help.

I’m typing this column as I sit in Pittsburgh International Airport. My amazing wife of 41 years planned this trip 3 years ago. Our trip has been canceled twice, but we are now ready to fly to Washington, DC, connect in Frankfurt, Germany, and then jet off to Prague. Denise, my wife, has been vigilant in following all the recommendations. Yesterday we spent the morning at an independent pharmacy, Perry Drug Store in Perryopolis, Pennsylvania – the only place within 100 miles of us that performed immediate PCR tests.

Our results were negative. Our luggage was checked in. We brought our own lunch and arrived 3 hours early…and we just got a text saying our flight from Pittsburgh to Washington has been delayed by an hour. We will miss our flight to Frankfurt. 

 is the vibe I’m getting as I sit here at gate A-4.

Daniel, a young United Airlines employee, has wheeled over a snack cart and is assisting passengers. He gives Denise word that he has everything taken care of. We will still arrive in Washington on the same flight, still 1 hour late, but Daniel has made arrangements for us to take a different flight—this one on a 

—to Germany. Taking care of customers who have spent years preparing for this vacation is his first priority, even if it means steering business to a rival airline.

United Airlines has taken a beating over the years regarding their customer service. In 2009, singer-songwriter Dave Carroll released “United Breaks Guitars,”

 a song that went viral and dropped the value of their stock 10% in a matter of 1 week. In 2017, the airline took another hit when reports emerged of their forcible removal of a passenger from a flight due to overbooking.

Since then, United has responded positively to an outpouring of negative publicity. My personal experience with the company was also a positive one. Daniel didn’t say,“It’s not my problem,” or “I’m not the guy who made the plane an hour late.” He didn’t say, “It isn’t my job;” instead, he took care of the people standing in front of him. We pharmacists do the same thing to serve our patients: We spend hours on the phone with insurance companies who create problems for us to solve.

The big 4 pharmacy chains have also taken a hit, at least on social media, and pharmacists are leaving in droves. Frequently, these posts show signs stating the pharmacy is “closed for business due to lack of staffing.” Will the pharmacists and pharmacy employees be the ones to bring these big 4—who routinely understaff and provide unpleasant working conditions—to their knees?

United Airlines learned a valuable lesson and has trained their employees to take care of the people in front of them. Pharmacists at the big 4 want to do the same. But working conditions in these pharmacies are miserable at best, and pharmacists are quitting in droves. Anytime you see a pharmacist counting pills, answering an unscreened phone call, or ringing a cash register, it is a failure. The big 4, and many others, continue to fail. Pay attention to what United does: Take care of your employees and they will take care of your patients.

1. Carroll D. United breaks guitars. Uploaded July 6, 2009. Accessed June 6, 2022. 

https://www.youtube.com/watch?v=5YGc4zOqozo

2. Neuman S. Officers fired after forcible removal of United airlines passenger. Published October 18, 2017. Accessed June 6, 2022. 

https://www.npr.org/sections/thetwo-way/2017/10/18/558469185/officers-fired-after-forcible-removal-of-united-airlines-passenger

A twice-cancelled trip, a delayed flight, and a United Airlines employee can show retail pharmacies how it’s done.

A Lesson From the Friendly Skies

Have you heard about the college student who ran out of money? They went to the chancellor and said, “Since I’ve been here a while and have paid you—and I know you have lots of money—I’ll continue to sit in class, take exams, and graduate without any more money going to you.”

Have you heard about the guy who walked into a physician’s office, or physical therapy clinic, or nursing home and did the same? Neither have I. It never happens.

No one who provides a service does it for free. Professionals administer these services, and payment is expected.

Have you heard about the uninsured person who walked into the pharmacy to get their second or third or fourth COVID-19 shot? The billing mechanism for these patients—the Health Resources and Services Administration—is now out of money, and yet we, the pharmacists, are expected to take care of these patients.

In the pharmacy where I work, we use 3 different platforms to complete 1 COVID-19 shot. Drawing up the injection and sticking it in a patient’s arm is the easy part. Reporting the required data to federal government programs, billing the administration fee, and reporting to the state immunization information system takes almost 15 minutes if a patient is new to your pharmacy. Our people in Fayette County, the poorest county in Pennsylvania, appreciate the fact that we do not require online registration. Unlike at the “big chains,” our people show up without appointments and are taken care of.

According to the Pennsylvania Pharmacists Association,

pharmacists have administered more than two-thirds of COVID-19 vaccines. I suspect that number is even higher, given the number of pharmacists—like my daughter Gretchen Kreckel Garofoli—who helped head the vaccination effort in West Virginia. Also included in that count would be my wife, Denise Kreckel, who ran clinics for Centre Volunteers in Medicine, where 2400 vaccines were administered on Saturdays.

According to the CDC website,“[The] COVID-19 vaccine is free of charge for everyone. Participating pharmacies will bill private and public insurance for the vaccine administration fee. For uninsured patients, this fee will be reimbursed through the Health Resources and Services Administration’s Provider Relief Fund.”

At least half the patients who come into the pharmacy will ask why we need their insurance card. “These shots are supposed to be free,” they say. I explain to them that it takes at least 15 minutes of our time to administer a shot, and even though the vaccine is “free”—and even the alcohol pads and syringes are “free”—there is still a cost.

Through December 31, 2021, Medicare was paying for the vaccine. After the first of this year, Medicare Advantage plans had to pay, and again, we battle to get claims paid. Some Medicare Advantage plans have different billing parameters than others, and some just outright refuse to pay. Centers for Medicare & Medicaid Services does not require managed care plans to cover out‐of‐network providers unless the Medicare Advantage plan has an out‐of‐network benefit.

And now, the Health Resources and Services Administration plan has run out of money, so there is no longer a mechanism for pharmacies to get paid for services provided to the uninsured. And even though COVID-19 shots are way down, we still see uninsured patients come in expecting to be cared for, even though there is no money available to pay for our time, our liability insurance, and all our fixed costs required to keep the lights on.

The government has said that COVID-19 vaccines are free, and we as pharmacists are obligated to administer them at no charge. We community pharmacists have been—and still are—the heroes of the vaccine administration efforts. My store has taken care of plenty of uninsured patients. We’ve administered vaccines for “free” to the Medicare Advantage plans that refuse to pay us.

Free has become my new dirty little F-word.

 practices community pharmacy in Lemont Furnace, Pennsylvania.

White coat brigade: PA pharmacists rally on capitol steps for legislation. News release. Pennsylvania Pharmacists Association. Published April 25, 2022. Accessed May 5, 2022. 

https://www.papharmacists.com/news/603365/White-Coat-Brigade-Pa-Pharmacists-Rally-On-Capitol-Steps-For-Legislation-.htm

Federal retail pharmacy program. CDC. Reviewed May 6, 2022. Accessed May 9, 2022. 

https://www.cdc.gov/vaccines/covid-19/retail-pharmacy-program/index.html

Government money to pay for COVID-19 vaccines has run out, but pharmacists are still obligated to provide these services without compensation.

Pharmacy’s New "Dirty Little F-Word”

I frequently remind my fellow pharmacists that their license hangs by a nail on the wall. It is not bolted there; if you are not happy, find yourself a new nail.

Given the current climate of community and hospital practice, I know several pharmacists who will not be looking for a new nail but who instead have given up entirely on this profession. The common thread among these colleagues is that they practice community pharmacy, but I am quite confident the same feelings hold true for my brothers and sisters in hospital pharmacy practice. (I would love to hear their stories as well.)

Each of these pharmacists’ names have been changed.

 Bob wanted to run heavy equipment, like his father. His father insisted that he go to pharmacy school, which he did. Bob graduated at the
top of his class and never worked more than a couple of hours of relief. He loved the bulldozer and the backhoe more than the computer and the counting tray. Because pharmacy was never his passion, we cannot count him among the disgruntled.

 Nate was one of my student pharmacists who had a passion for hospital pharmacy. He practiced in the hospital setting for 7 years. Of all the pharmacists who left the profession, he was truly called to a higher duty: Nate enrolled in the seminary and will be ordained as a priest in the next few years. Sometimes salary, staffing, and satisfaction do not really matter when one hears a higher calling. When we attended morning Mass together, I knew there was something special about him.

 Diana practiced pharmacy for at least 30 years at a grocery store chain. She has been less than pleased for some time with her staffing, management, and environment. She left the profession to take up her passion of baking. She opened a bakery and is extremely satisfied now.

 Donna had an excellent position as a clinical pharmacist. She shared her amazing skills with physicians and nurses, but mostly with patients. Donna and her husband moved away to be closer to family. Although there are numerous opportunities available to her, she would do “anything” to not work in commu- nity pharmacy practice; she is happy being a grandma, and I doubt she will reenter community practice.

 I met Jerry when he worked as a representative for a drug company. He knew his products well and was an asset to his company. Jerry left that company and took a job practicing community pharmacy for 20 years. Although he is a few years younger than me, the demands from his grocery store chain have made him leave the profession to pursue his true passions. He is an avid fisherman and hunter and will change his income stream from pharmacist to taxidermist and maple sugar manufacturer.

 Of all my pharmacist friends and acquaintances, this loss troubles me the most. Abe comes from a family of pharmacists: his mother, father, and cousins are all pharmacists. He has been out of school only 8 years. During the 8 years he practiced, Abe took a newly opened grocery store pharmacy to the top in prescription volume and sales. The metrics, demands of management, and lack of staffing have made him give up on the profession and work for his mother-in-law’s health care business. He has never been happier and gets to spend time with his growing family.

Enrollments in pharmacy schools are down and for many schools, wait- ing lists no longer exist. Thanks to the glut of pharmacists produced by academia and the miserable working conditions that the 4 major chains— “Corner,”“Three Letter,”“Spark,” and “Lefty”—have created, many excellent, seasoned pharmacists have left the profession to be priests, bakers, taxider- mists, or maple sugar makers... anything but chain pharmacists.

Feel free to send your management my way. I want to keep those nails covered with satisfied licensed pharmacists.

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

Our columnist shares true stories of pharmacists who have left the practice for their own greener pastures. 

Empty Nails Are the Cure for What Ailed Them

We pharmacists are indeed a meticulous bunch, striving for perfection because we 

be perfect. I gave a presentation once where I shared that, for pharmacists, 99.9% is not good enough. In my 40-year career, I have worked 7680 days.If on average I filled 200 prescriptions per day, that would be a total of 1,536,000 prescriptions in my 4 decades. If I had an accuracy rate of 99.9%, that would be 1536 errors—a number to keep any pharmacist awake at night!

We community pharmacists are loners, usually the only one on the bench for a period of time. So it was with great delight when I got tapped to help my wife Denise with her massive COVID-19 vaccination effort in State College, Pennsylvania. I stood back in amazement watching my “lab partner” take, with minute-to-minute precision, the vaccine from the dry ice, then to the refrigerator with digital data logger, then to the clinic site with prescribed hard-side cooler and digital data logger, where 2400 patients would be immunized. With stopwatch accuracy, she would chart when the vaccine was pulled from the refrigerator, then taken to the drawing room, where syringes were filled to exactly 0.3 ml after dilution with exactly 1.8 ml of saline. The syringes were put into a labeled bag and checked for accuracy and bubbles. The time was then written on the bag, to the exact minute.

At 1 point, the 2 pharmacists in the room were discussing the use of a 3-ml syringe to draw up 0.5-ml doses of the other vaccine. We learned during our first lab in pharmacy school that the minimum measurable quantity of any vessel was 20%: a 100-ml graduate should never be used to measure less than 20 ml; a 25-ml graduate never less than 5 ml, and, therefore a 3-ml syringe should never measure less than 0.6 ml. But the government had sent these 3-ml syringes to do just that: measure 0.5 ml. Beside me in the drawing room were several dentists, physicians, and nurses. One of these brilliant young physicians was Dr Mark Stephens, who works for Penn State Medicine. Stephens has a military background. He’s tall, muscular, and very personable. Hearing our discussion, Stephens replied in a way I won’t soon forget: 

“For crying in the bucket, we’re in the middle of a pandemic.”

At the last clinic, we were busy pulling up booster doses that were 0.25 ml. Lo and behold, we were given U-100 insulin syringes marked in units! Come on, ref…throw the yellow flag! Insulin syringes are never to be used to measure anything but insulin! TB syringes are never to be used to measure insulin; this is a mortal sin in pharmacy practice. But Stephens just smiled again and said, 

After reconstitution, the Pfizer vaccine does produce some bubbles that can coalesce into a visible bubble. Pharmacists are concerned with potential dosing inaccuracies, and again we hear it: 

“For crying in the bucket, we are in the middle of a pandemic.”

I’m not here to tell my fellow pharmacists to aim lower. In fact, in some cases aiming lower could produce tragic results. Over the course of our 8-, 10-, or 12-hour days, we are required to be perfect. Dispensing 119 tablets of hydrocodone in a prescription order that calls for 120 tablets is 

But sometimes in our day-to-day work, we need to lighten up on the rigorous rules we were indoctrinated with. Stephens has also been known to quote Voltaire, reminding us that 

 But my favorite quote of his goes back to his military days: “Sometimes, health care is like throwing hand grenades. Getting close is good enough to get the job done.” Lighten up, fellow pharmacists—we are doing one heck of a great job!

While volunteering at a COVID-19 vaccine clinic, our columnist learned about the benefit of lightening up.