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XL, ER, and SR (Oh My!)

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How many of those at home have gotten an Rx that looks something like this:

Wellbutrin 150 QD


Depakote 250 QD


Effexor 75 BID

Now how many of those at home after getting these prescriptions felt the urge to slam their face into the counter.  For those not in pharmacy (or for those douche-canoe asshat prescribers out there who are stuck in 1990) all of these drugs come in different formulations BUT in the same mg strength.  The regular-release is the SAME strength as the extended-release.  Its not like Coreg or Paxil which the extended-release dosage form has a different strength than the non-XR form. Hell, in that case its easy.  Dr writes for Coreg 20, and we know that he wants the once-daily CR caps (unless he wants the patient to start shaving the IR tablets, which would be rather funny).

Does the MD want Wellbutrin 150 SR given once daily? Or did he/she mean to write the once-daily XL?  Depakote comes in a 250 DR and a once-daily 250 ER, but depending on the patient they may want the DR given once daily.  I’ve seen Effexor plain given BID as well as the XR given BID.  Should I just guess?

Its shitty at best and outright dangerous at worse, and there is absolutely nothing that we can do to prevent this.  The only thing that we can do is to call the Dr, be left on hold while the patient gives us the “Why cant you fill it? It says the drug on the prescription!!” face, and be at the mercy of the *sigh* wonderful doctors staff to give us a call back saying “Doctor wants the extended release Wellbutrin” *headdesk* “IT COMES IN 2 WAYS!”.  What makes matters worse, is that ALL of these drugs are relatively new (compared to like Theophylline, Cardizem, or Verapamil) thereby removing all shred of hope that we could “guess” what the doctor wanted (since some doctors are stuck in 1990).  It requires a phone call/fax, which is just balls for everyone involved because 2 little letters could have solved this.  This isn’t something that the insurance doesn’t cover, this is just sloppy Rx writing!

Is there a good solution to this problem?  The one time we guess as to the release-mechanism it’ll be wrong, so there is no point doing that.  Of all of the examples regarding sloppy Rx writing, this has to be the most annoying for pharmacists.  I can deal with not having a quantity.  In some cases I can deal with not having a sig if I can tell from the quantity (I mean how many ways can a dentist give 28 amoxicillin caps?).  I can deal if you didn’t sign the damn prescription.  No IR/ER/XL/WTF designation? Boned-every-time.  Saving 2 seconds on your end just cost me (and the patient) 15 to 45 mins.

Just go give us one more kick in the balls, the patient wont understand what the problem is.  They see a drug, a strength, and some T’s with dots over them with some letters.  They don’t care about the IR/ER/XL/OMFG  dosage form, they want the drug on the prescription and they wanted it filled before they handed you the Rx.  Short of yelling at the doctor for omitting probably the second-most important piece of information on the Rx (yeah, that’ll teach him! *sigh*), all we can do is just bend over and accept the 30 min phone-call and hateful glares from ungrateful patients.

Comments #

Comment by PAS on 2010-09-24 01:20:23 -0700 #

Oh, I hear you. Believe me I hear you. Even here on the dark side.

We have a bunch of small business insurance plans. Things like car dealerships, real estate firms. Mostly local things with less than 100 employees. These of course, absolutely have to have their formularies customized in inane, utterly trivial detail down to the most obnoxious point of all: some use NDC level edits. One of their big things is that they never want to cover smoking cessation medications. Wellbutrin, under whatever given brand-name it’s being sold under this week, can be used for that, and that kicks it into Prior Auth land – covered for depression, not covered for smoking cessation.

Let’s see. The number of names Wellbutrin can be sold under? Wellbutrin, Wellbutrin SR, Wellbutrin XL, Budeprion SR, Budeprion XL, Bupropion XR 24, Bupropion XR 12, Aplenzin, Zyban. With the exception of the Budeprions, which are just Teva’s BS trade name for their generic, these can, or cannot be interchangeable.

So they file for an authorization. By fax? You’re -never- even getting a SIG, dosage strength, let alone a dosage form. By phone? The physician’s receptionist has no idea. The patient has no idea, the pharmacy is in the same spot we are and has no idea what the physician wants. Then, on top of it, the physician has absolutely no idea that different forms of the drug are available. So then of course, some hapless PA Tech runs it through on whatever name the physician’s office throws out (which turns out to be wrong), and I get to spend 20 minutes fighting with overrides in software more complex than the space shuttle. Because magically, we can’t read minds either.

And then of course there’s the MDs who intentionally prescribe something like Bupropion immediate release once daily. Hello nonlinear pharmacokinetics.

Another one we have to deal with but you probably don’t see so often in retail: Ciclosporin. Available in two main forms, modified, and the classic SandImmune. This one once devolved into a 45 minute argument with an MD from a transplant program who categorically refused to answer the question as to which one he wanted. Turns out, that despite managing a transplant patient, he didn’t know anything about the drug. Never mind the big warning on the PI sheets that says “These drugs are not bioequivalent and cannot be used interchangeably,”.

Basically, I’d like to apologize for every botched override and Prior Authorization on these guys. They do the exact same thing to us over here in the other side of things. Plus big thanks to the prescribers who do write it out, and do recognize that these are different drugs – you make life easier for retail, insurance, and make sure your patients get sane medication doses.

Oh, any comments on prescribers who tell their patients to split controlled release drugs? We’re getting a lot of that lately.

Comment by DevinC on 2010-09-24 01:24:19 -0700 #

Same deal with Toprol & Lopressor…. ><

Comment by Me on 2010-09-24 01:30:48 -0700 #

Okay, I’ll admit that I have no idea how this pharmacy thing works (outside of reading your blog of course!).

But, can’t you just ask the patient?

I’m guessing you can’t look up what the patient has had in the past?

Does anyone know how the Australian system works?

Comment by Dr. Grumpy on 2010-09-24 04:51:58 -0700 #

Believe me, this drives us nuts too. Because the patient will take, say, REGULAR Keppra qD, (when it can only be BID) and then have seizures, becasue they don’t quite grasp that the XR has a different dosing and release mechanism.

Then you get to Depakote, where Depakote-ER 500mg = regular Depakote 400mg, and things get even more screwed up.

Comment by theblondintern on 2010-09-24 05:01:46 -0700 #

Amen! C’mon, docs…you’re supposed to be familiar with the drugs you write for. It’s almost scary. Then it’s OUR fault because you didn’t take 3 seconds to double check. If you hate us bothering you, write right the first time!!

Comment by xviben on 2010-09-24 05:36:38 -0700 #

I thought that SR CR XR etc, means to sustained revenue, continued revenue or extended revenue?
With computerised prescribing the doctor has to actively choose the IR or SR preparation. Surely most of your doctors use computer generated prescriptions don’t they?

Oh sorry they live in the 1990s.

Comment by GoGatorsTech on 2010-09-24 06:37:49 -0700 #

Well gee, the solution is OBVIOUSLY E-Rx!!! They never have any problems or typos, do they? hahahahaha 🙂 I hate the stupid E-Rx as much as bad doctor handwriting. Rock on TAP!!!

Comment by midwest woman on 2010-09-24 09:02:29 -0700 #

haha…the docs in the hospital usuallly have their butt boys and girls aka nurses straighten these messes out. recently noted an order for a prn statin…it was dosed in the PM so I guess we were half way there.

Comment by cardsfanbj on 2010-09-24 09:43:06 -0700 #

What’s worse? Forgetting to put ER/IR on Oxycodone/Morphine prescriptions.
For the most part, you can tell based on the strength (Oxy 5 & 15 comes in IR only, and ER covers 20 and up, but 10mg is both; not the biggest problem, since the crack prescribers in our town rarely write for 10s. Morphine is worse, it comes in variable 10, 20, and 30 mg strengths…)
Adderall is even worse, which just about every strength has a ER/IR form. The only difference is ER comes in caps and IR in tabs. Even worse, the doctor writes “Adderall XR X mg tabs” or “Adderall Y mg caps” and mean they end up meaning “Adderall X mg tabs” and “Adderall XR Y mg caps”

Less severe, Zofran comes in the same 2 strenghts in both regular and ODT (orally dissolving, for the non-medical here). I don’t think that really even matters, though.

I live in a college town. Lots of our student customers (including myself) see our doctors in our home towns and bring the CIIs with us to fill while we’re at school. (although, this effectively becomes a non-problem during the summer)

Comment by Sarah G on 2010-09-24 10:26:52 -0700 #

You’re lucky sometimes if the patient even knows what it is FOR. You can ask the patient if he/she knows which formulation the doc meant, but don’t count on their knowing.

Comment by PAS on 2010-09-24 10:53:25 -0700 #

While some of the medications released in these forms are little more than ‘evergreening’ a patent, that can’t be said for all of them.

Wellbutrin’s a good example – the immediate release version is basically useless. I’ve never seen a script for it that was written intentionally. The drug’s kinetics are far from ideal. Controlled release can allow a drug to side-step undesirable or problematic properties.

Dr. Grumpy mentioned seizure meds. In epilepsy, failure to maintain proper drug levels can result in therapeutic failure – which leads to a good deal of nastiness. Breakthrough seizures, hospitalization, injuries.

There are plenty of examples of ‘extended revenue’ though. Doryx, Solodyn, and Oracea are little more than $4 antibiotics repackaged in controlled release forms at a cost of hundreds and hundreds of dollars that offer exactly nothing in terms of therapeutic benefit for the patient.

Comment by Mike on 2010-09-24 15:03:07 -0700 #

Just a minor correction:

“Oxy 5 & 15 comes in IR only”
Oxycontin comes in 15mg. (BTW, not that it matters, but I think that there is even a 5mg Oxycontin only available in Europe)

“ER covers 20 and up”
There is a 30mg IR tablet of oxycodone.

I completely agree w/ the content of your post. The Adderall thing, in particular, drives me nuts. Especially when you ask the patient “What have you had in the past? Capsules or tablets?” and you get that nice blank stare back at you. And I feel your pain on the college town thing.

Comment by :) on 2010-09-24 16:41:56 -0700 #

I’m not sure how it works in other states, but here in Iowa we’d have to have a doctor’s approval anyways. We can’t just take the patient’s word for it. And for the most part, the patient has no clue anyways.

Comment by :) on 2010-09-24 16:44:52 -0700 #

ugh, that frustrates me too! “Toprol Xmg”….. soooooo, is that Toprol XL Xmg or do you just not realize that Metoprolol IR is generic for Lopressor? GRRRRR.

Don’t even get me started on the Hydrocodone/APAPs…
Vicodin 10mg?

Comment by Ann on 2010-09-24 18:44:33 -0700 #

How many times do people call or come in to refill “the little white pill, I don’t know what it’s for but I take it at bedtime”. If they take it for months on end and still don’t know what it’s for, why should we expect them to know the details on a brand new rx that they just got and didn’t listen to the doctor when he said why they were getting it!

Comment by WrongAid on 2010-09-24 19:45:04 -0700 #

Most of the time I just fill it as it says. Let the patient and high school dropout at the MD’s office fight it out later. Is it wrong? Yes.

Comment by Mark on 2010-09-24 20:21:29 -0700 #

My response to the angry/impatient customer is to ask “Is your life worth the time to get this right?” I used to tell people that there were 2 ways I could fill their script; correctly or quickly. Which one do you want?

Comment by rxstudent on 2010-09-25 10:05:41 -0700 #

are you serious? ask the patient? most patients dont even know what their medications are for let alone the name.

Comment by Aussie Pharm Assistant on 2010-09-26 00:43:18 -0700 #

In the exact same way buddy.

You can look up what the person has had in the past, but what you’ll usually find is that (real example) they’ve been taking Metformin 500mg XR tid for years and yours is the first pharmacy to pick up on it.

Comment by Barry Solomon on 2010-09-26 15:47:27 -0700 #

This is really great.
Some time ago I called the FDA
I asked if they had a definition for Long Acting, Delayed Release,
Timed Release and all of the other \names\ we see on
Rx Bottles.

They said they did not.
Why doen’t the A.Ph.A. or ASHP talk to these folks and come up with
some universal definition?

Barry Solomon, R.Ph M.Ed

Comment by AndIThoughtIWasAngry on 2010-09-26 16:03:58 -0700 #

Why can’t you just tell the pt that the doctor didn’t give all the info he/she should have on the script and to have the doctor’s office call/fax you with the correct script and write down for the pt: “I need to know if it’s XL or SR?” ie, put the onus back on the pt where it belongs and save yourself the 15-45 min phone call. Yes, the pt may go elsewhere for the script, but for $1.50 do you really care?

Comment by Zach on 2010-09-27 09:07:17 -0700 #

The worse of it is that I’d you call the md office and to ask which dosage form is wanted, the nurse/receptionist/man servant who you talk to will just make up an answer without asking the doctor. The doctor turns a blind eye to this kind of behavior because he knows it saves him time and frankly doesn’t care. The pharmacist doesn’t care for the same reasons.
So what ends up happening is that somebody with a drug knowledge less than the MD or RPh makes the decision.

Comment by lovinmyjob on 2010-09-27 10:53:56 -0700 #

My personal fave is when you do get someone at the doc’s office on the phone and ask “Did Dr. X want immediate-release or extended-release?” and the response that comes back is “What’s the difference?” Seriously? How do I answer that question? Long, detailed explanations of AUC? Really, I thought that what I asked was pretty straight forward so they MUST want something else, right? Do I baffle them with bull-shit or just repeat the question in mono-syllables? Personally, my first step is to view previous rxs on the profile to see if this is habitual with the patient’s doc. If so do I have documentation of calling on past rxs. (My other fave is when the staff member that answers said phone stalls by saying “Can you fax that to us?” How does that help?”)

Comment by PhCrunner on 2010-09-27 18:06:26 -0700 #

I work in hospital now, but spent 10 years in retail. I often told customers they had a choice: Right or right now.

Comment by Shalom (R.Ph.) on 2010-09-27 19:59:10 -0700 #

Funny you should mention this just now. Today I saw a prescription for Wellbutrin 100mg – tab i QD. Well, the XL doesn’t come in 100mg, and neither of the other two are once-a-day formulations… so both are wrong, but which wrong one did the doctor want?

(The tech said “Well, he got the IR last time.” Yeah, but how do I know that wasn’t also wrong?)

Comment by stargirl65 on 2010-09-28 05:34:08 -0700 #

Patients are useless for drugs. Often they bring in their list which includes something like lisinopril BUT they were really on lisinopril hct. I had a patient seeing derm for a rash and the derm couldn’t figure it out. Finally biopsy said drug rash and they thought lisinopril was possible. I called and explained patient on combo with hctz which did make sense. Stopped the hctz and rash gone. Copying meds, unless done right, can be dangerous. They always forget the xl or cr or whatever.

Comment by :) on 2010-09-28 16:40:49 -0700 #

haha, I know right?!?! “I don’t know, the round white one that I take every morning for my heart!” UHHHH, you just describe about 297 different medications! hehe. Even if they said they knew, I’d have a hard time trusting them anyways!

Comment by :) on 2010-09-28 16:47:31 -0700 #

I don’t blame you.. sometimes it’s more hassle than it’s worth!! ugh! The doctor will eventually learn to take a couple extra seconds to make sure they right/enter the prescription right, once they realize how many of their prescriptions are getting filled as written instead of how they intended it. Sometimes they need a lil tough love instead of us constantly saving their butts all the time b/c they’re too lazy.

Comment by kdog909 on 2010-09-28 16:56:31 -0700 #

I do the same thing. As long as it won’t harm the patient, I fill for what the doctor writes. If the drug doesn’t work, the doctor will get bitched at, not me.

Comment by RxDawg on 2010-09-28 17:07:37 -0700 #

Interesting this keeps you up at night. If an MD is prescribing these meds, they should be more than familiar with the dosage forms and unless there is a glaring problem, such as conflicting strengths like you mentioned, the patient will get what the MD writes.

Effexor 75mg BID, is just that.

Seroquel 100mg qhs, you got it.

Just the other day I saw Cardizem 120mg BID. I found it unique, but it was what was intended. I know MD’s can make prescribing mistakes. I see them everyday. But this is an area I’ve always trusted them in because it just doesn’t seem like an error would be easy to make here. If they are prescribing the ER version of a med, there is probably a specific reason.

Comment by RxDawg on 2010-09-28 20:08:19 -0700 #

Oxycontin comes in 15mg? Are you thinking of MS Contin?

I did know about the 30mg IR tab though.

Comment by phirexman1 on 2010-09-29 09:21:13 -0700 #

docs have no idea what their staff is doing with the e-rx thing. most staffers transmit for the doc. and when WE as rph have to call the doc and the patient is drumming the counter or jingling 29 keys on a ring, waiting \patiently, remind them that even heaven has a line!

Comment by rph3664 on 2010-09-29 20:29:24 -0700 #

Try to get away with that at CVS, the way they’re running things now.

Comment by niterph-pacingmyselfsargeant on 2010-09-30 16:52:54 -0700 #

Yep, just another reason why our profession blows to the nth degree. We bend over and take it, when we should hand the script back to the patient and tell them to go back to their doctor and have them write an unambiguous script.
I personally love the tid wellbutrin sr scripts, and the bid cardizem cd scripts …they are fun for me… I’ve even seen a bid claritin rx (earth-shaking, I know.)
Don’t even get me started on the Ambien 10mg 2 qhs scripts.
I’d LOVE to start billing the MD or the patient for ALL work we do that isn’t OUR fault or OUR problem. “You want me to resolve YOUR insurance problem? You don’t know which of these 3 different insurances is current? OK, just put $20 on the counter and I’ll do it for you!” And for the MD’s that need to be contacted for clarifying rx’s, a single fax to the MD stating: “Patient waiting: need answer STAT”. If the patient wants to get involved (hell has just frozen over), have THEM call the MD and tell the office to FAX back the answer! NO PHONES! Phone calls should’ve ended 10 years ago! Leave a message on the phone or fax . . . DON’T BOTHER ME, I’m with other patients!

Comment by Jenna-na-na on 2010-09-30 17:32:01 -0700 #

I just want to say (& this has nothing to do w/ this entry) that I have complete & utter respect for my pharmacist. Yep, I’m a chronic pain patient. I never fill early, I never ask. I always say please & thank you, & I treat those pharmacists behind the counter with the utmost respect. I take my medications as they should be taken, I don’t mess around man. I think people that try to bilk the frigin system are scum bags & are taking credibility away from the true pain patients that really need the damn meds.
I was behind one of these people a couple months ago, & the way that pharmacist handled that crackhead was amazing. I was so impressed. The pharmacy I go to is great. They all know me, treat me very kind, & know me by name. That right there, is true customer service. Thank you for a funny & insightful site. I think you’re great. I told my pharmacists about it. They probably come here & unload too, & I wouldn’t blame them, but it helps to know it wouldn’t be about me. 🙂

Comment by Jube on 2010-10-01 17:05:40 -0700 #

Had this exact situation last week. On the weekend, discharge med. Dr. wrote wellbutrin Sr 150. Had xl in hospital. Oh yes, take @ hs none the less. We called. In the end he had intended the change to sr but it was the mom picking up so she had no clue. very frustrating. What the hell are these drug companies thinking of making the strengths the same… make it different for crying out loud. Make it 149mg instead, would it really make that much of a diffence vs. 150? It certainly would prevent much of the confusion on these things.

Comment by riotgreen on 2010-10-02 19:30:39 -0700 #

Walgreens and the damn call center have the corner on the market here! Try to talk to a hs drop out and not have a migraine!

Comment by riotgreen on 2010-10-02 19:33:53 -0700 #

and thats what they ask at the office, “What did they have last time?” I am spending my time to check, could you do the same!

Comment by PharmASSistant on 2010-10-04 17:23:33 -0700 #

I got to wake up a doc at midnight because he wrote a roxanol ex like this: 1-2 gtts q 4 h prn pain/sob disp 1 month supply. It was for a hospice patient. He just laughed when I said I can’t dispense a c ii w/o a real amount saying, “they don’t teach us how to write rxs in medical school”. I laughed back and said you’re gonna have to get your pen & pad out and give me a quantity and be thankful I can take a fax instead of an original. There was silence on the other end until he said well how much do the other docs write for? C’mon guys the fucking law has been on the books since 1978–Obama and his FDA only started enforcing it now!

Comment by :) on 2010-10-05 16:49:26 -0700 #

HA! nice. That’s a pretty good idea. I wonder how well that would go over at the Dr’s office (you know those uppity-doctor-attitude DO’s we have to deal with all the time.. hehe). Might tick em off (both the patient and the doctor), but like you said, for $1.50 do we really care?? It’s sure hard to care at that price…

Comment by AndIThoughtIWasAngry on 2010-10-05 19:00:20 -0700 #

I AM a doctor, and I think it’s perfectly reasonable. My mistake, my time to fix it. Again, really: what do you care if you tick them off? The worst that can happen is a doc who costs you extra time by writing stupid scripts will tell his pts not to come to your pharmacy. Boo hoo.

Comment by ONU RPh on 2010-10-07 12:04:54 -0700 #

Jenna-na-na, We love patient’s like you!! Anymore it is rare to get through a day without being called a 4-letter word, much less having someone actually say please or thank you!!

Comment by Irish Pharmacist in UK on 2010-10-07 16:26:29 -0700 #

You really need to chill out Lad. I too am a Pharmacist, and from time to time I feel like exploding, however it’s not good for your health. Some customers absolutely infuriate me, but it’s best to just laugh it off. If your personality is such that you can’t, I would suggest changing profession, as you are storing up problems for later in life ie (cardiovascular disease and other stress related illnesses.)

Comment by Hatecareerchoice on 2010-10-07 21:28:11 -0700 #

Why do these DO/MD jackholes get the right to prescribe anyway?? I am on rotations (last yr of pharm school) in pediatrics with 5 medical students who do NOT know shyt!! And neither does their resident?! They had 1 class of pharmacy? How do they feel comfortable prescribing? Guess who doesnt know what Linezolid is?? Or Keppra?? Or Toradol? I cannot believe these people learn to prescribe based on what they see done in practice over the next few years to patients without really understanding or knowing how to direct an individualized therapy! afterall lets give a generalized CCB for all HTN’s!…kinda like monkey see monkey do!

Comment by Hatecareerchoice on 2010-10-07 21:30:35 -0700 #

Or why dont prescribers take it upon themselves to actually learn how to presribe medication correctly, afterall all they should be held accountable…Pharms are not Psychics!

Comment by AngieA on 2010-10-09 04:13:18 -0700 #

Doryx, Solodyn, and Oracea -these drugs infuriate me! Dont even get me started on INTUNIV. Every mental health medicaid kid in my county is on it!

Comment by AngieA on 2010-10-09 04:17:30 -0700 #

No there is a 15mg Oxycontin. I am sitting on a partially open bottle because soem idiot prescribed 10 tablets of it. ugh.

Comment by angrytech2010 on 2010-10-10 13:48:01 -0700 #

This has nothing to do with today’s entry, just wanted to pop in and say a few words. THANK YOU SO MUCH FOR DOING WHAT YOU DO! The entire pharmacy staff that I work with, myself included, love you. While others may think you website is negative, insensitive blah blah blah, we view it as a safe haven. All of your posts express what we secretly want to say to patient’s faces on a daily basis, but are not able to because we would definitely lose our jobs. Reading your posts prove to us that we are not crazy, because obviously there are other people out there that think just like we do.

Comment by Mike on 2010-10-10 17:36:22 -0700 #

No, they most definitely do come in a 15mg (OxyContin, that is). NDC is 59011-0415-10. It’s a round grey tablet, one side says “15” and the other, “OP”.

Comment by bcmigal on 2010-10-12 10:08:27 -0700 #

Got another personal fave yesterday: Testim 1%, #30, take one tablet daily. And it wasn’t even an e-script!

Comment by sumotoad on 2010-10-12 22:19:08 -0700 #

you are the patient we all want. I love you. Please come visit me. You will stand in line behind a dozen or so non-English speaking, “entitled” scumban shoplifters, but I will see to it that you are taken care of first, every time… I swear

Comment by Ike M on 2010-10-13 08:45:03 -0700 #

Here at our clinic (with the pharmacy in the basement – as usual), IT instituted a test of internet e-prescribing. And do you know what the verdict was? They fucking hated it because they were faced with the shit we pharmacists have to go through every single day: “All i’s have to be dotted and t’s have to be crossed. NO EXCEPTIONS!” Then half of them didn’t give a shit and started choosing drugs from the picklist that had the right drug and would type the strength in the comment section. Once again, we have to cover their asses in the course of professional practice. They finally decided it was a huge time-waster and discontinued using it. Welcome to my world.

Comment by Surgeon on 2010-10-16 21:14:09 -0700 #

Wow…I just happened on this site, and what a lot of anger I see. Right down to naming yourself “hatecareerchoice”. It is true that pharmacists will receive prescriptions that are not properly filled out (or are illegible or what-have-you), but we are all on the same team of providing the best care that we can to our patients. I view pharmacists as equal partners in patient care (as well as their pharmacy techs and interns), but mistakes do occur. Sometimes, it is the doctor, sometimes it is the nurse or assistant that helps providing the prescription, but mistakes happen. I am always thankful when pharmacists or their assistants call me with problems that they have discovered. But it works both ways. I have had patients who are reluctant to take medicines I have prescribed, only to have the pharmacist say something to them which results in the patient refusing to take the prescription. And I have never gone on a forum and crabbed about it.

If you hate what you do, get into another career path. Health care professionals who hate what they do are an equal danger to patients as those terrible doctors who don’t call you back when you want them too because they are explaining to a patient their problem and what their alternatives are.

Comment by sad surgeon on 2010-10-16 21:46:01 -0700 #

Ok, I’ll make you a deal. You stop calling me to check on what dose of “Maxzide” I want then.

Although there ain’t no such thing, I have taken to writing for Maxzide “50” . Well, that isn’t in the PDR, but I still get pharmacists calling to hound about what a moron I am for not writing the strength.

I am usually kind enough to ask them to point out the page in the PDR that lists Maxzide “50”, you know, just for my education. Let me tell you, it’s a LONG phone call


Comment by sad surgeon on 2010-10-16 21:54:42 -0700 #

No sweat for you then….Med School apps are cheap….why don’t you go ahead and get the degree and really school those big ol’ dumb doctors!

It’s always fun to watch pharmacists/nurses/ med students in their last years….they are all balls and no forehead. Won’t take long for reality to sink in I imagine…

Comment by seriously on 2010-10-16 22:34:21 -0700 #

Why don’t YOU decide? (to be fair, this may not apply to this blog’s writer) We now have our pharmacists hiring nurses to “counsel” patients on (high margin) hormone replacement then finding a Dr. who knows nothing about hormones to sign ‘authorizations’ to allow the pharmacist to Rx as required – based on Their ‘experience’ and the nurse’s!!! We diagnose and treat a pt. once and then the pharmacist tells them they don’t have to spend all that money for exams when for just the price of the Rx, ‘our’ nurse can do the ‘same thing’! Or how about the pharmacist that tells a patient “I ‘work with’ a lot of [x kind of Drs.] and I’ve never filled an Rx for y with z… Clearly, you guys know exactly what you’re doing so why bother to even ask? Maybe it’s just the pharmacists around us? But after calling in a Rx, faxing it and then speaking with the staff, our pt. says the pharmacist says “well, we’re still waiting on your Dr.” Looks pretty pathetic when we have to show the pt. the fax time stamp was 2 days ago. AND, OUR handwriting is NOT a wiggle but is clearly legible even to the pt. (I know many are not). Hell, survey says people trust their pharmacist far more than they do their doctor so go ahead – just pick what you gd want!

Comment by Deserat on 2010-10-17 01:12:33 -0700 #

Interesting blog – what you are pointing out is that capitalism where one has to pay for services ends up having more informed customers and providers. That is a big issue with healthcare in the US right now – I personally abhor the use of of the word insurance for what is a firm fixed price contract for contracted services – with a catastrophic insurance policy on top of that. You are apot on – if someone has to pay for something, they usually must use self-discipline to manage their consumption versus an external mechanism for discipline. There is a built in damper at the point of consumption of “if you don’t have the money, you don’t get the material good.” We need to migrate back towards that model.

As for the computer pharmacists – that was a classic. Yes, technology should enable not disable healthcare – you should see the EMRs – eyes of the clinician are glazed over from the packed screen and requirements to fill out said database block——they hardly ever look at the patient.

Comment by Canadian Pharmacist in UK on 2010-10-17 14:36:21 -0700 #

Are you kidding me? You are blatantly one of the “bend over and take it” types. A bit condescending as well. This shit is funny and let’s face it, most/all community pharmacists are thinking it on the daily. Luckily in England most GPs use computer prescribing programs that filter out potential errors such as those above (I think? not completely sure- usually work in hospital….). I’ve worked in Canadian retail pharmacies so I can appreciate what the lad is trying to get it. Rage on!

Comment by mk on 2010-10-19 13:37:23 -0700 #

as a mental health case manager, it is a night mare to try and understand which dosage and type the meds are prescribed as. and i can’t depend on the client’s to know. and in my own health care this has been an issue as the lovely insurance company says effexor and wellbutrin do the same thing!? and then trying to get the med becomes worse when the pt is trying to stay educated but doesn’t have all the information. like, there are 3 kinds, not 2.

Comment by Linda on 2010-10-22 12:38:06 -0700 #

If it makes you feel any better….I love you Pharmacists! I am a Nurse who has an occasional question about a medication. What works better, what will be cheaper; is there an guys know everything!
You help me help my patients, THANK YOU!
Even the chain pharmacists are well informed and helpful. I always apologize because I know that they are slammed!

Couldn’t do it without you!

Comment by rph3664 on 2010-10-23 09:49:44 -0700 #

I just saw an ad for blackberry scented Metformin. Has anyone seen an RX for that?

Comment by darksider on 2010-10-27 09:30:54 -0700 #

Vicodin HP…hydrocodone 10mg/APAP 660mg

Comment by Jube on 2010-10-27 20:29:54 -0700 #

That makes me laugh.

Comment by Marianne DeGreen on 2010-10-29 17:09:26 -0700 #

How about the doctor who prescribed Ambien CR 6.25 mg, 1 tab at bedtime as needed. I told him that Ambien CR is not covered by insurance, but needs a prior authorization. He hand-writes a “new” Rx for “Ambien CR plain 6.25 mg generic!” WTF! Jeez, Doc, just writing it doesn’t make it exist!

Comment by Kenpharm on 2010-10-31 17:57:39 -0700 #

Yes it’s generic metformin from mylan… Walgreens switched to it as the preferred generic, but at my store we have 20+ patients that have had documented decreased effectiveness and much higher go effects from that generic, so now we special order other generic metformins

Comment by Summer on 2010-11-05 08:04:41 -0700 #

Lol,in the area where I live Doctors love to write for Norco 10/500 and their patients love to bring these scripts in about 2 or 3 hours after the Dr’s office has closed.

Comment by Mark on 2010-11-08 20:42:26 -0800 #

Not directly related to XR/ER/SR topic but shows how bad doctors can be: I’m a coumpounder who generally makes HRT topicals and capsules. Last week had a lady bring in a script from her CARDIOLOGIST for ‘Testosterone 1/4 gm’ ointment! When I called the office and asked if this person was attempting a gender reassignment, I was told ‘oh, 1/4 mg.’ WTF, that’s a factor of 1000 mistake! (250mg vs 0.25mg) Doctors should not be allowed to prescribe outside their speciality.

Comment by Ben on 2010-11-09 17:44:30 -0800 #

I was wondering, would a pharmacist dispense if the patient is obviously high on something? I’m curious.

Comment by newbill123 on 2010-11-14 06:30:20 -0800 #

Just curious, but would this be a fair analogy?

\Your boss has left you a post-it ‘Urgent! Get Diet Coke, 2 liter size, For serving 10 visitors.’ Your boss might mean 10 two-liter bottles (which sounds a little funny), or just one 2-liter bottle shared among 10 servings (which also sounds a little funny). Even though it’s a simple guess, guessing wrong would be very wrong. This is similar mixup to what’s happened with your prescription, but we aren’t going to guess with your health. Sorry, for the delay, but we need to get through to your doctor and tell us what was meant.\

Comment by Disgusted Pharmacist on 2010-11-19 19:57:15 -0800 #

Just curious–why is a doctor reading an angry pharmacist site?

Comment by Disgusted Pharmacist on 2010-11-19 20:04:42 -0800 #

Perhaps being a pharmacist in the UK is substantially less stressful than being one in the continental United States. I’m sorry I’ve been called everything in the book including a F—ing A–. If you don’t find that infuriating perhaps there’s something wrong with you! You can laugh off so much –I think we should all demand more respect –perhaps then we’d get it!

Comment by Disgusted Pharmacist on 2010-11-19 20:11:26 -0800 #

WTF? Don’t the MD’s/Surgeons have their own website to blow off steam?

Comment by VancouverCanadapharmacist on 2010-11-21 02:09:57 -0800 #

In Canada, we do have blackberry flavored Metformin made by a generic company

Comment by Iowapharmd on 2010-11-22 19:40:39 -0800 #

I’m a manager of a small independent pharmacy. When my patient comes in with a prescription for wellbutrin 150qd, and the rx doesn’t specify xl, sr, ir, I first look at their history…if they’ve had it before I ask them if they talked with their doc about a change in therapy…if they say no, they get what they had the previous month. I’m not going to waste my time, the patient’s time and the physician’s time. I’ve never once been wrong…and quite honestly, I’m sure the physician and their staff are thankful that I saved a phone call and used some common sense.

Comment by ihatepharmacy on 2010-11-22 19:46:10 -0800 #

I’d send that script away…I’m not wasting $500 bucks on a bottle to make $10 on the script, and waste the rest…

Comment by Rivalry on 2010-11-24 08:04:03 -0800 #

Good news – there’s now a Zolpidem Tartrate ER 6.25MG 😀

Comment by Jeansbeans on 2010-12-16 20:35:54 -0800 #

In reality, I took a pharmacy class for the Physician Assistant students at a good University (shall leave it anonymous), which mind you was only a semester long, and I feel like we only covered the very basics of the drugs and the drug classes. Learned that Warfarin “has many drug interactions so be careful in prescribing it.” Granted I am not going to school to be a PA, I am not sure if they learn more in clinicals, but in reality coming out of the class I am for sure not ready to prescribe. I have been a tech for 5 years, and for all those pharmacists out there, really watch those drug interactions because they do not really teach them at all in Medical Pharmacy class, nor did they teach anything on dosing.

Comment by rph3664 on 2010-12-23 20:48:13 -0800 #

Pharmacists don’t use the PDR, except as a door stop.

Comment by Erin Smith on 2011-01-01 18:04:21 -0800 #

Dear Seriously,

I would love to pick. Really. It would save me a lot of time and annoyance if I could pick. Unfortunately, that is out of the scope of pharmacy practice. I don’t know where you work or why your doctors haven’t confronted pharmacists they believe are exceeding their authority, but the blogging pharmacist is right on the money as far as I am concerned. I spent two days trying to untangle a Wellbutrin prescription for a child, talking multiple times with the “staff”, never being able to talk to the doctor, FINALLY got the correct extended release dosage form documented, dispensed the prescription, and the next month I got a prescription for the same child from the same doctor for Wellbutrin, and ONCE AGAIN HE DIDN’T SPECIFY THE DOSAGE FORM!!!!!!!!!!

Comment by Erin Smith on 2011-01-01 18:18:46 -0800 #

We can look up what the patient had in the past, and if it makes sense we can go with it. Not too much help if they have never had the drug before. But that is poor pharmacy practice. Also, there are lots of slips when multiple doctors get involved. For example, the cardiologist puts the patient on a drug, the family doc continues it, and somewhere in the transcribing the dosage form or salt gets lost. Then to make matters worse, we get a call from the doctors office to “add 6 refills to all the patient’s maintenance meds”. I just won’t do that. I make the office go through the list one by one and compare notes, and I always catch at least one drug, dosage form, dose, or direction for use that doesn’t match what the doctor has. ALWAYS.

Comment by Erin Smith on 2011-01-01 18:32:06 -0800 #

In my area, we are seeing more and more computer generated prescriptions, which creates a whole new set of problems when docs can’t manage their software, but STILL we get the computer generated script with a dosage form that doesn’t match the directions for use, i.e., 24 hour sustained release prescribed bid, or immediate release prescribed once a day. Just because a computer generated it, everything still has to come to a standstill while we call and clarify the prescription. We aren’t complaining about rare problems, this disconnect between dosage forms and directions might apply to between 5 to 10 percent of the prescriptions we fill in a day, which is a major problem, with plenty of room for real harm for the consumer.

Comment by Erin Smith on 2011-01-01 18:47:51 -0800 #

Well Doc, it may be reasonable for me to hand it back to the patient and let him fight it out, but I have always imagined myself to be a patient advocate. Also, since I practice in a rural area with few doctors, I can not afford to get into a pissing match with an MD. I’ve been on the receiving end of one of those blistering ” you’ve interfered in the doctor patient relationship” phone calls, and that was when a patient ASKED me for a printout on the prescribed drug.

Comment by Erin Smith on 2011-01-01 19:01:32 -0800 #

Dispense what, Ben? An antibiotic? A blood pressure med? Oxycontin? You asked WOULD a pharmacist dispense to a patient who is obviously high. Some would, all could, but most should not. It is only illegal for me to dispense a narcotic to a patient if I know for a fact that he has no medical need for the drug apart from his addiction. That means that you could be high as a kite, shoot yourself in the foot, to to the ER, get a prescription for pain meds, limp into my drugstore with your bandaged foot, present your prescription, and I could fill it.

Unfortunately, I will have just dispensed my last one of those pain pills to the customer that cut off his thumb with his chainsaw, so you will have to go somewhere else.

Comment by Jenny on 2011-01-13 23:48:56 -0800 #


Comment by Sarah on 2011-01-26 02:07:01 -0800 #

University… lol! They teach u the basics and the rest is ‘fill in the blanks’… it’s impossible to teach everything in uni
I’m wondering why the heck i’m putting in all the effort for patients that would spit at my face as soon as they walk in the pharmacy department… can’t really help it can we… we’re the last station, so it’s their last chance to blow.

MDs? oh they’re a whole new level.

Comment by Fialchar on 2011-02-11 08:59:48 -0800 #

uhhhhhhhh not everyone coming in will have a history with your store or have taken the medication before…d’oh!