The Black Hole of Prescription Refills

My doctor’s office wouldn’t refill my prescription over the phone; instead, they told me to contact my pharmacy. When I stopped in to pick up my refill the pharmacy told me they hadn’t heard back from the doctor yet, despite it being nearly a week since I’d requested it. When I called my doctor’s office to find out why, THEY told me they had already faxed it to the pharmacy 4 days ago, but the pharmacy claims they never heard back. Who’s telling the truth?

Both of them are.  Many doctor’s offices now instruct you to “don’t call us, call your pharmacy instead” for any refills, and it’s very frustrating to get caught in the middle, with both sides claiming that it’s not THEIR fault, it’s the OTHER party that didn’t follow through. Trouble is, when you need your medicines refilled, when you run out it of them it becomes YOUR problem.

It seems that today’s doctor’s offices only want to hear from your pharmacy if you need a refill, not from you. I see three reasons why doctors offices created this policy:

1. A refill request sent to your doctor from your pharmacy has the important information about your requested refill already organized for the doctor, including which pharmacy to send the refill request to, saving your doctor a lot of time.

2. A faxed refill request doesn’t require a nurse or staff member to stop what they are doing, answer the phone, listen to you state your request, then write it down for the doctor to respond to later. It may not seem like very much time, maybe 3-4 minutes, but multiply that times the number of medicines prescribed by just one clinic and it really adds up.

3. The medication, dose and directions you are requesting a refill for may not be exactly the same as what your doctor has on file for you. You might have seen a cardiologist specialist for a heart problem and they changed your medicine, or you may be asking for a refill of medicine that is managed by another doctor, and should be directed at another physician’s office instead. As a pharmacist, I often see medications coming from 2 or 3 doctors on the list of prescriptions we fill for our customers.

What’s supposed to happen when you run out of refills of your medicines? First, you call your pharmacy to request a refill; next, your pharmacy faxes the doctor’s office with the details of what you are requesting; your doctor then reviews that request and responds to it with any changes and additional refill instructions and sends it back to your pharmacy, which refills it in time for you to pick it up or mail it to you so you don’t run out of your medicine.

It doesn’t work like this every time, though. What goes wrong when it doesn’t? Why do your pharmacy and doctor’s office get into this blame game of, “I’ve already sent it, it’s not MY problem?”

These days, the medical community communicates both by manual and electronic faxing. Manual faxing involves walking up to a fax machine, sticking a piece of paper into it, dialing the number of the fax machine you want it to go to, then listening for a confirmation tone which will tell you that your fax was transmitted successfully to the fax at the destination you requested. With a manual fax, you can tell if your fax was received, or not.

Today’s faxing is electronic, and I’ve noticed that it works differently than the old way of “put a piece of paper in, get a piece of paper out”. Using a computer instead of a fax machine, when you click the FAX button on your computer screen your faxed request goes to a central holding area first before being transmitted on to the doctor’s office. What’s good about this is that with electronic faxing you don’t have a stack of paper to deal with.

An electronic fax will show only that IT WAS SENT, not that it was received by its intended recipient. Unfortunately, electronic faxes get lost every day, sucked into some “black hole” somewhere, never arriving at their expected destination. Just because an electronic fax was SENT doesn’t mean it actually ARRIVED!

That’s why you get the “we’ve already sent it” response from both your pharmacy and your doctor’s office when you ask why your refill isn’t ready. It’s SO tempting to bypass all that hassle and just call your refill requests directly to your doctor’s office to avoid dealing with your pharmacy. Instead, why not accept the fact that there is a “black hole” out there that sucks up unsuspecting and innocent electronically faxed refill requests, and expect that sometimes refill requests will go missing on their to or back from the doctor’s office despite everyone doing everything right. I believe that this “black hole” of electronically faxed refills really exists, and recommend that you always call ahead for refills early enough to allow for the possibility that your requested refill won’t get through the first time. Call your pharmacy back a day or two later to verify that your requested refill is ready in case it needs to be re-sent to avoid the hassle and stress of the blame game and of going without your medicine. Good luck!

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Drugs and The Sun

The bright midsummer blue sky of that July afternoon was waiting just for us. Finishing our lunch of grilled cheese sandwiches and tomato soup, my 7 year-old niece Crystal and I decided to go feed the ducks. First we put our lunch dishes away, and then put on sunscreen, because blue-eyed, blonde Crystal burned easily.
The ducks were on the other side of the pond as we walked up to the landing. One duck saw us tossing pieces of our bread into the water and paddled over to one to check it out. The floating treats attracted other ducks and soon there was lively competition for each one. Laughing, we pitched our bread chunks into the quacking crowd until we ran out, and then headed for the swing sets, pumping our legs to carry us higher and higher into the cloudless sky.
Then Crystal called out, “Aunt Louise, I feel hot. ”
“Okay, head for that big tree over there; I’ll get us some water.”
Opening my pack, I grabbed a water bottle and twisted the cap off. Turning around to offer it to Crystal, I nearly dropped the bottle when I saw her. Her face had turned a bright tomato red, and her arms were only a couple of shades lighter. As we headed back home, I kept thinking, “How did she get burned so quickly?”
Helping her lie down on the sofa, I raced into the kitchen for more water and noticed Crystal’s prescription bottle sitting next to the sink. She was supposed to take one teaspoonful of the antibiotic twice a day and I’d given her the morning dose right after breakfast, leaving it out on the counter to remind me to give her the next dose at dinnertime. Could her medicine be the cause of her sunburn-like rash? Sure enough, there WAS a small yellow sticker on the side of the label warning about exposure to sunlight. Luckily, her burn faded quickly, but I’ve never forgotten how scared I was.
Exposure of unprotected skin to sunshine causes our skin to react by either “tanning” or “burning”. Sunlight contains radiation; particularly the wavelengths of ultraviolet radiation called UVA and UVB and can trigger symptoms like rash, itching and exaggerated sunburn, called photosensitivity.
Sunburn, skin cancer and accelerated skin changes such as wrinkles and spots called photo aging are caused mostly from exposure to UVB radiation. UVB rays are most intense between 10 in the morning and 4 pm, and helps our skin produce Vitamin D. UVA radiation can trigger photosensitivity reactions in people taking certain medicines. Normal sunlight has approximately 20 times as much UVA radiation as UVB, and tanning beds have even more: 96% UVA to 4% UVB wavelengths, to decrease the risk of burning.
Crystal’s antibiotic increased the sensitivity of her skin to the UVA wavelengths in the sunshine we played in that July afternoon. The sunscreen I used back then only protected her against UVB rays, not the UVA wavelengths, which trigger photosensitity or phototoxic skin reactions. Today’s sunscreen products must be formulated to protect against both UVA and UVB. The measure of how much protection a sunscreen product gives is called SPF (Sun Protection Factor). The bigger the SPF number, the better the protection. For example, if you properly apply a sunscreen with an SPF of 15, you could stay out in the sun 15 times as long without burning as you could without it.
Sunscreens come in two main types: chemical and physical. Chemical sunscreens absorb specific wavelengths of UV radiation before they penetrate your skin, while physical sunscreens reflect and scatter UVA and UVB radiation. The lighter your skin, the more quickly it can burn and the more protection you need.
If You Take a Medicine That May Cause Sun Sensitivity:
1.     AVOID using tanning beds or direct sunlight if possible. If you do go outside during the day, cover up with long sleeves and a hat with a brim at least 4 inches wide, or apply sunscreen.
2.     Apply sunscreen at least 15 minutes before you expect to be outside in the sun. To be most effective, sunscreens need time to bind to your skin.
3.     Use enough sunscreen. The FDA estimates an adult in a swimsuit should use about 4 and 1/2 teaspoonfuls when applying sunscreen to their whole body.
4.     Reapply sunscreen frequently, including after swimming or playing in the water, sweating heavily AND especially after drying yourself off with a towel.

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A Safer Way to Take NSAIDs for Pain

Q: I’ve taken Aleve® for years for a bad knee, but now my stomach burns whenever I take it. Ibuprofen doesn’t work as well. My doctor gave me a prescription for Celebrex® which didn’t cause burning but only helped a little bit. Icy-Hot® didn’t help and capsaicin cream burns like fire. Are there any other creams out there to help joint pain?

In other countries, gel or creams containing medicines like ibuprofen have been available for years. Ibuprofen, also called Motrin®, is related to Aleve® (naproxen), and Celebrex® (celecoxib). These medicines are called NSAIDs, which stands for Non-Steroidal Anti-inflammatory Agents.
NSAIDs treat the swelling and pain of muscles or joints from either sudden injuries like a muscle sprain or strain, or chronic inflammation such as the joint swelling of arthritis. In the United States most people take NSAIDs as tablets, but both tablet and topical (gel, cream, ointment or spray) versions have been used for decades in the UK and Europe.
The advantage to using an NSAID cream or gel over a tablet is that relief goes directly to your painful areas without the side effects that NSAIDs can often cause, like stomach pain, kidney or heart problems. For people who take a blood thinner, using a topical form of NSAID avoids the risk of bleeding.
You’re not the only one who has side effects from an NSAID medicine. Americans with ulcers, kidney or heart problems would benefit from having safer forms of NSAIDs, but the only topical NSAID currently available is diclofenac, and it requires a prescription.
I believe pharmaceutical companies haven’t marketed any topical versions of their NSAIDs in the U.S. because there’s not enough patent protection to make it profitable. Ibuprofen and naproxen became available as non-prescription (OTC) tablets only after the U.S. patents for their prescription forms expired.
Another roadblock to making topical forms of NSAIDs available is whether it can penetrate the skin. Grinding up a medicine into powder and adding it to a cream or ointment doesn’t guarantee that it’s going to work; a drug company may decide that   the topical version of their NSAID isn’t effective enough to justify the investment needed to pursue approval from the FDA.
Topical NSAIDs are used to ease the acute pain of sprains and strains as well as the chronic pain of osteoarthritis. A study called Topical NSAIDs for acute pain: a meta-analysis published in 2004 looked at many different studies of various NSAIDS, with successful treatment being able to decrease pain at least 50% within 1 week. This analysis found ketoprofen gel best at relieving acute pain with ibuprofen gel a distant second. Full details are available at http://www.biomedcentral.com/1471-2296/5/10.
In September 2012 the Cochran Institute published the meta-analysis Topical NSAIDs for chronic musculoskeletal pain in adults. It collected various studies; many of them unpublished work from the files of drug companies. Two NSAIDs stood out as effective in chronic musculoskeletal pain: diclofenac and ibuprofen, with diclofenac being just as effective topically as in a pill form, yet with minimal side effects. Both ibuprofen and diclofenac gel are available without a prescription in the UK and Europe.
Last week while visiting my daughter Maureen in Germany, I saw Voltaren® gel advertised in the window of several German pharmacies. The day before we left to go home I walked into a German pharmacy, called an Apothek to buy some. Pointing at the boxes of gel displayed in their window, I rubbed my arm, saying, “Voltaren®, bitte?” With Maureen translating, I discovered that ibuprofen gel had been available for over 10 years and was now generic, Voltaren® gel was the more popular of the two gels, and both were for sale without a prescription. I walked out of the Apothek triumphantly clutching a tube of each, even though all the directions were in German!

German Gels for Pain

Topical diclofenac is available in the U.S., by prescription only, as: Voltaren® 1% gel applied 4 times daily; Pennsaid® 1.5% solution applied 3-4 times daily; Pennsaid® 2% solution in a pump applied twice daily; and Flector® 1.3% patch applied twice daily. Diclofenac is also available as Solaraze® 3% gel for rosacea.
Check with your doctor to see if one of these would be helpful for you; because they are brand name products, there should be samples you can try.

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Pharmacist Recommendations for Osteoarthritis Pain

Q: Which products do pharmacists recommend most for osteoarthritis pain?

Because of collaboration between the publications Pharmacy Times and US News and World Report the general public can find out which products are recommended most by pharmacists by category.

For the past 19 years, Pharmacy Times has invited its pharmacist readers to share their expertise in recommending their favorite brand-name non-prescription products. Over 168,000 pharmacists are asked to submit the over-the-counter or non-prescription products (abbreviated as OTC) in 160 categories.

Together Pharmacy Times and US News and World Report have made the results of this survey available online for viewing at www.otcguide.net. There is even a mobile app for it as well, called “OTC Guide.”

Looking over the category of Oral Arthritis Pain Relievers for the 2013-14 study results I saw there were 5 pain relievers recommended. The top pick in this category is Aleve®, with 33% of the pharmacists’ vote. The next two recommendations were pretty close together which didn’t surprise me because they are the same medication: Advil® was second place with 26% and Motrin®-IB third place at 20% of the vote. My personal favorite for arthritis pain, Tylenol Arthritis® was recommended with 17% of the survey responders and Osteo Bi-flex®(glucosamine/chondroitin) rounded out the group with 4%.

The top 3 products recommended by pharmacists belong to a family of compounds called non-steroidal anti-inflammatory drugs, often abbreviated as NSAIDs.  Aleve®, the generic name of naproxen is also the number 1 prescription NSAID as well. Naproxen 500mg twice daily is considered the gold standard of pain and inflammation relief among prescription NSAIDS like nabumetone, meloxicam, and Celebrex®.

Since they are very similar, why did naproxen get first place? Pain relief from naproxen lasts for 6-8 hours, while ibuprofen often wears of in 4-6 hours. I have a personal preference for naproxen over ibuprofen as well because of my own experience. I took prescription strength ibuprofen while recuperating from ripping a ligament in my right wrist 20 years ago, injured by chopping wood in 15 degrees below zero weather. My ibuprofen wore off at every night exactly at 3:15 am and it took nearly an hour for the next dose to kick in and allow me to go back to sleep. After 2 weeks of this I tried in desperation 2 tablets of OTC naproxen for a total of 440mg and blessedly slept through the night.

Naproxen gets my vote for best relief of muscle pain, but for osteoarthritis pain, #4 in the survey, Tylenol Arthritis® is MY #1 pick. I recommend this medication for anyone taking blood thinners such as aspirin, warfarin (Coumadin®) or clopidogrel (Plavix®) because it doesn’t have the tendency to cause stomach bleeding. It also works all through the night, lasting 8-10 hours. I recommend taking two tablets twice daily, once every morning and again at bedtime.

The tricky thing about Tylenol Arthritis® is it’s popularity. That’s right, it’s TOO popular. Acetaminophen, abbreviated as APAP on prescription labels, is used as an ingredient in over 200 of OTC products and if that were not enough, it’s one of the ingredients in prescription analgesics like Vicodin®, Lortab®, and Percocet®.

Although the product mentioned in the 2013-14 survey is Tylenol Arthritis®, its manufacturer has long-acting acetaminophen product called Tylenol® 8-Hour.  Tylenol® 8-Hour is a brightly colored capsule that contains an extended release formulation of acetaminophen with a similar long acting pattern of pain relief.

Osteo Bi-Flex® are #5 in the current survey. Osteo Bi-Flex® has two ingredients, glucosamine and chondroitin.  I like glucosamine because if you respond to it, it is the most safe of all these options for long term pain relief of arthritis. I have not seen any side effects nor any interactions with other drugs in the 15 years I have used it in my patients taking warfarin as a blood thinner.

Glucosamine may take up to 6-8 weeks for a full effect, and while you are trying it can be expensive. Osteo-Bi-Flex retails for around $30-60 for a month’s supply. If cost is an issue, I have recommended getting it as a powder from a company called Bio-Alternative based in Klamath Falls, Oregon. Their glucosamine powder is a bargain at only $20 per a pound jar, a 6-month’s supply, plenty to see whether you will respond to it.

Curious what other products were recommended in other categories? Check it out at www.otcguide.net or get the free OTC Guide app.

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