Jay Sochoka, RPh, BSPharm, CIP

Before I started my pharmacy rotations, the last job I held was bartending at a golf course. Believe it or not, it really helped prepare me for my career as a pharmacist.

Being a bartender is so similar to being a pharmacist that I am often tempted to put out a tip jar at work. Think about it for a second: both jobs require standing behind a counter for the whole shift, compounding concoctions while paying attention to ratios, dispensing sometimes mind-altering substances, and most important of all, just listening to somebody and perhaps offering a bit of advice.

While this is a tongue-in-cheek look at my employment history, it addresses a very important point. Listening to patients talk can benefit them more than anything I can dispense them.

I have had patients break down and sob in my arms on more than one occasion about a cancer diagnosis, the horrid loss of a child, or the stress of being a long-term caregiver, just to name a few. When this happens, I usually wipe a tear or 2 out of my own eyes.

I am sick of independent pharmacies advertising how personal their care is compared with the “you are a number and a dollar sign” view of chain retail pharmacy. Speaking for myself, I can say that this is a huge pile of rubbish. There are many patients who I consider extended family, and when bad things happen to them, I get upset.

A patient I had been taking care of since I started at my store 15 years ago had been diagnosed with cancer, and the outlook was not good. He was a fantastic patient and friend. He always gave us a day to fill his maintenance medications, and at least once a month, he would bring the pharmacy staff a dozen donuts.

When family members started to pick up his prescriptions, we started to get worried. I was working one Thursday, and someone wanted to see me in the drive-thru. It was my patient and he didn’t look good. The cancer was winning.

He waved to me, and I waved back. I thought he was waving hello, but when I read his obituary the following Monday, I realized he was saying goodbye.

Whether you are bartending or playing pharmacist, you make friends on the other side of the counter. Sometimes, all you can offer are your ears, arms, and sympathies. That may just be the best medicine there is.

Jay Sochoka, RPh, is going to mix a drink.

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Before I started my pharmacy rotations, the last job I held was bartending at a golf course. Believe it or not, it really helped prepare me for my career as a pharmacist.


Making Friends Across the Counter

My first professional pharmacy rotation was high-volume community pharmacy at the Thomas Jefferson University Hospital Apothecary. They were filling 500 scripts a day on a God-awful software program by today’s standards, getting patients out in 30 minutes or less, and not getting anybody killed. Moreover, they only filled scripts for Jefferson doctors, patients, students, and employees. If they had taken outside scripts, the workload would have been totally unmanageable.

The operation ran like a Rolex meeting for the Steelers’ dynasty teams, and quarterbacking the operation was Scott Kuhn, RPh. He showed me exactly what the little old bachelor of pharmacy degree could do in a boiler room setting, and he taught me the equation of efficiency + accuracy = quality—a mantra that is now 21 years old.

Although I only spent 4 weeks with Dr. Kuhn, I learned a lot. When I misfilled an alprazolam script with clonazepam, he let me know in no uncertain terms that I had just killed a patient. While it probably was not a fatal mistake for toxicity reasons, the patient could have gotten dizzy, mismanaged a flight of stairs, and suffered a fatal conclusion. From that moment on, I have had a healthy fear of my profession.

Thanks to Dr. Kuhn, I also developed a healthy fear of microscopic life and sub-life forms, namely bacteria and viruses. One morning, he ran by the profile of a patient who was one course fail of antibiotics away from going to the hospital for an IV. In his disgust, he said, “People who say that humans have no natural enemies are forgetting about bacteria and viruses. One day, they will be the only things left.”

To this day, I believe him. Bacteria and viruses evolve faster than we can keep up. Eventually, every antibiotic we have will be as powerful as oral penicillin 50 mg. In the big picture, our antiviral therapy is sketchy at best. In 25 years, nothing has even come close to resembling an HIV vaccine. If there was, I would be dispensing it already, and now—get this&mdash;Ebola has made it onto American soil. Why someone has not blamed President Obama for this yet is beyond me.

It actually is not his fault this time. Instead, I would say the hospital that let Patient Zero go home with a course of antibiotics after he said he had been in Liberia might have a glove in it. I’m surprised that, at the words “in Liberia,” plastic sheeting did not automatically canvas the examination room, sirens did not wail and buzz, and red lights did not start spinning as 2 men in black and a team in hazmat suits showed up.

If you have children, consider guiding them into a career in immunology or biotech, because they will always have a job. The United States’ involvement in Ebola’s eradication has escalated exponentially. We will soon have a wartime economy against an enemy that we can’t even see. I expect to be administering your Ebola vaccine as soon as it clears the FDA.

We will soon have a wartime economy against an enemy that we can't even see.

Healthy Fear of Ebola in America

It all went to the dogs on the first day that a physician and chemist accepted profit for their services. When quality of wallet took precedence over quality of life, the healing arts suffered for it.

Today, corporations own huge chunks of the health care system. Hospitals, pharmacies, and third-party insurance companies abound with corporate logos and a singular focus: more profit.

In corporate pharmacy, it’s all about how many prescriptions a pharmacist can fill with as little help as possible. When a pharmacist is distracted by other jobs aside from drug utilization review and quality control and assurance, patient care is compromised. It takes a individual with extreme concentration skills, a great staff, and a touch of obsessive compulsive disorder to do 450 prescriptions a day while squeezing in 20 flu shots without making a grievous error.

There are 2 kinds of pharmacies: the quick and the dead. If you are not running at full throttle from open to close—squeezing as much profit as you can into that day&mdash;then you are doing it wrong and will probably get yourself a conference call. The pressure to fill every legitimate prescription in corporate pharmacy is what keeps the oxycodone addicts coming back. If I had my own pharmacy, I swear that I would not stock narcotics and amphetamines. While there are patients who absolutely require the medication for legitimate purposes, there is a certain portion of the clientele that absolutely do not.

Considering the profession, pharmacists have a part in the rate of opioid addiction, but they do not play as big of a role as certain physicians. In medicine, there are bigger candy men than Willy Wonka. For just a few minutes of work, they make $150 cash and give patients ridiculous doses of pharmaceutical joy that keep them coming back every month. If you get hooked on those drugs, they have a maintenance narcotic license to keep you on buprenorphine/naloxone sublingual products for eternity.

Narcotic prescribing and dispensing is an egregious mess and, as I said in my last column, 

reclassifying hydrocodone won’t change things

. A colleague of mine noted that if access to hydrocodone is restricted and the drug becomes more expensive than legitimate therapies, then the reclassification could actually make heroin abuse more prevalent.

Health care is a hot mess, and I don’t see it getting better anytime soon. We made our bed, and now we have to sleep in it. If we are going to keep score with the quantity of services, then we need to increase their quality. It might cut into the profit structure somewhat, but it needs to be done. Lives depend on it.

When quality of wallet takes precedence over quality of life, the healing arts suffer for it.

Corporate Pharmacy Distracts Opioid Dispensing

Twenty years ago, at the Philadelphia College of Pharmacy, I was taught to trust no one when it came to dispensing controlled substance prescriptions, especially for opiates like oxycodone and soon-to-be-reclassified hydrocodone. I was told to be suspicious of every patient, make sure all of my ducks were in a row on the hard copy, and never let a forgery go by.

As hard as you try, you get burned in this business. When I think of all the pharmaceutical garbage that has made it onto the street, due to a really good forgery passing me by, I literally want to cry.

A few days ago, it hit a new low for me. An individual brought in a prescription for 120 oxycodone 15 mg that was completely legitimate, but the person seemed way too polite. If you are trying to act like we are fraternity brothers when I have never met you before, then I don’t trust you. I could just smell the shadiness on this person.

The prescription was dated to be filled the next day. I was offered assurance that someone in the pharmacy knew this individual was going away the next day and said we would accommodate the situation by filling it. Strike two. A first-day cashier would know enough to never say that, or to punt the call to the pharmacist. The individual then left the pharmacy, taking back the script.

Lo and behold, the next afternoon, the same individual returned with a smile—and the script. Strike three. What was that about going away the next day?

So, this person stood in front of me with a big smile and a script so legitimate that if it were fake, they almost deserved to get it for the work put into perfecting the handwritten signature. I put it through the insurance, and no overuse warnings were returned from the insurance company. I felt a little more comfortable about filling the script, since cash is such a dead giveaway. After I filled it, the person—who still seemed shady to me&mdash;went away happily.

A few hours later, a hysterical mother called to tell me that the same shady person supposedly sold her child some of the tablets. I instantly felt queasy. I would have preferred a non-fatal misfill call over that, so I called the police and filed a report.

The next day, the mother called back saying her child had made up the whole thing and actually bought them from a friend who stole them from the kid’s mother. I did not believe her in the least, but I didn’t have a leg to stand on. How did that kid provide a name and know the pharmacy? Without a leg to stand on, I had to let it go.

I hate the thought of having this happen again, yet it will. Reclassifying hydrocodone will not stop the drug from being filled legitimately and sold illegally. As the late O.J. Simpson defender Johnny Cochrane would have said, “If the script’s legit, you must fill it.”

Jay Sochoka, RPh, is feeling sick over this.  

Reclassifying hydrocodone will not stop the drug from being filled legitimately and sold illegally.

Reclassifying Hydrocodone Won't Stop Shady Scripts

The community pharmacist’s life is about to get a lot more difficult.

On October 6, 2014, the admittedly powerful narcotic hydrocodone 

will be moved from Schedule III to Schedule II

 of the Controlled Substances Act. In layman’s terms, this means the drug will be reclassified from having a medical benefit, but being really addictive, to having a medical benefit, but being super addictive.

This move will add a few more minutes of processing per script, which is extra time that a high-volume pharmacist doesn’t exactly have. I already run from 9 a.m. to 9 p.m. with very few minutes to take anything resembling a break.

Reclassifying hydrocodone means that every time we fill a prescription, it is required to be on a hand-signed, hardcopy prescription without any refills.

Refills usually take about 1 minute to do from start to finish. You scan the stock drug bottle, get a label, count it, label it, and check it. A narcotic prescription, however, takes 3 times as long. It needs to be entered into the computer, procured from a safe by only the pharmacist, counted twice by a tech and once by me, and labeled. Then, I have to enter the quantity dispensed into a logbook and check the prescription ever so meticulously.

Now, we will have to complete this process every time a hydrocodone script shows up. We’re good for at least 12 of these a day. Sometimes, it’s double that.

The safe in which we are going to keep thousands of tablets is what perplexes me. We have a double-door safe where real estate is already at a premium. Are we going to get a walk-in model next? If so, where are we going to put it?

We could also use a full-time pharmacist whose main job is to process the narcotic ordering, receiving, logging, and dispensing. I might as well catheterize myself before work, because I am not going to be able to get away from the counter.

In addition, hydrocodone’s reclassification is going to vastly increase the number of patients staying and waiting for their prescriptions. Rarely does a patient with a narcotic prescription not wait for it or come back in 15 minutes. All I can envision is an angry mob with pitchforks and torches in withdrawal because they, once again, used up their medication 2 days too early. No problem there, though.

In my opinion, hydrocodone should have been classified in Schedule II from its release. I have seen it become a silverback gorilla for patients that just absolutely ruins them. I don’t think that will change, though, because our society is far too drug happy.

The streetiest of street drugs are available by prescription. Yet, somehow, medical cannabis is not federally legal.

Jay Sochoka, RPh, is going for a pack of Reds.

The community pharmacist's life is about to get a lot more difficult.

Reclassified Hydrocodone Means More Headaches for Community Pharmacists

“Those ‘lithium psychos’ look at me with those eyes! Those eyes!” This is a quote from a former partner of mine regarding patients with bipolar disorder who take lithium.

The sad thing was I shook my head in agreement, even though my dad was a lithium patient at the time. I was no fan of psychiatric patients, either.

Due to cosmic irony, I was diagnosed with bipolar disorder in 2005. When my dad got sick a few years before, I was diagnosed with depression and anxiety, so I had a new perspective on patients with mental illness. The patients were now peers of mine; we had common ground in that our brains were sick. It was that simple.

Once again, my illness gave me some insight into those under my care. I am now a lot more empathetic toward patients with mental illness. When a patient comes in for a psychiatric medication for the first time, he or she is usually apprehensive or shy about it. If patients have questions—and they usually do&mdash;one of the first things I do is share my story to help them feel at ease. When they discover they are not alone, it is a tremendous icebreaker.

Sometimes, my practice goes beyond dispensing. I have used my testimony to help patients realize that they can get out of the hole and become productive members of society once again. I never offer advice, because that is a counselor’s job; I just share what has worked for me.

I believe that the stigma of mental illness in society has decreased, but it has far from vanished. I don’t know a lot of pharmacists who say so, but I would be willing to bet that some still see the “lithium psychos” as a nuisance. Supposedly, there are mental health parity laws, but I don’t believe they are always are enforced.

While private insurance cannot legally limit the amount of psychological services you can receive in a lifetime, they are one of the first things to be cut from a government budget. Patients in dire need of treatment are falling through the cracks. For every psychiatric patient who makes the news, there are thousands who suffer in silence.

Silence, however, is not my style. I will do everything I can to make mental illness a kitchen table topic. Informing those who surround you is important, because if something is a little off in you, then they can spot it and douse a highly flammable situation.

You cannot feel truly healed unless you acknowledge what is wrong and get comfortable with it. From there, it gets much easier to cope and recuperate. After all, we’re only human.

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