Sunday, October 26, 2008

Customers Who Like to Show Off

Do you ever get customers that try to show off what they know about the drugs they are taking? It's always an interesting experience. Most of these customers only think they know what they're talking about. They read two sentences about the drug on, completely misinterpret the information, then spit that jumbled mess back out at you in an attempt to show you how smart they are. Most of the time, I have to stop for a second to try to figure out just what the person is talking about before proceeding with some form of an answer to whatever question they might have. Sometimes, the person doesn't even really have a question. They just tell you something about the drug as if they're giving an answer on a game show.

We have one woman who comes to our pharmacy who's especially annoying in this regard. I guess her boyfriend is a medical resident, so she apparently feels that his knowledge somehow transfers over to her. No matter what she's picking up or how many times she's picked up that medication in the past, she always has to speak to a pharmacist. It's not that I mind talking to customers or answering questions. Quite the opposite actually. However, her questions have no real point, or they start with a point but soon end up as just an opportunity for her to tell you how much she knows.

Take my last encounter with her: She picked up a new prescription for carbamezapine (it was being used as a mood stabilizer in her case). She asked me if the carbamezapine would affect any of her other medications.

I immediately thought to myself, "Great! This is a question that actually has some kind of clinical significance." However, before I could even get a word out of my mouth she starts reciting carbamezapine plasma concentration levels, how she knows it can make her drowsy, and that it might decrease the effectiveness of oral contraceptives.... Of course, she added, "but I'm not taking oral contraceptives, so I guess I don't have to worry about that."

What was the point of all that? She asked me a specific question relating to her other medications, but then she cut me off and started telling me random drug facts as well as how it interacts with a medication that she doesn't even take. Thank you very much for telling me stuff I already know. Who's the pharmacist here?

I've decided that any time she does this to me, I will respond by telling her everything I know about the drug and using as much medical terminology as possible. Therefore, after her little spiel, I told her about how carbamezapine is an inducer of the cytochrome P450 enzyme system responsible for metabolizing many drugs. I told her that it, over the course of several days to weeks, will cause the plasma concentrations of her Geodon to drop, and it might be necessary for her doctor to increase her dose to keep it therapeutic. I also told her that carbamezapine is the only drug (at least that I know of) that is capable of inducing its own metabolism. Therefore, what may start out as an effective dose for her may gradually need to be titrated up to make up for the self induced increase in elimination. I could have gone into the myriad of side effects it can potentially cause, but I figured that will undoubtedly come up the next time she comes in.

Listen... I think it's very good for all people to try to read up on the drugs they are taking. I also encourage everyone to ask questions about their medications to help them understand how they work, what kind of effects can be expected, and in order to ensure the medication is taken correctly. Just don't come to the pharmacy counter reciting a bunch of drug facts that really don't have anything to do with your situation. It's just annoying and serves no purpose.

As a sort of related aside.... If you ask a pharmacist a question about your medication and it seems like he's having a hard time answering you, it most likely isn't because he doesn't know about the drug. It's probably more that he's having a hard time explaining it without using fancy medical terminology.

For example, a woman recently asked me if I could recommend any supplement that might help ward off frequent urinary tract infections. I told her that Cranberry supplements might help help. She wanted to know how Cranberry worked, and I tried to explain that it's thought that an ingredient in cranberries actually works to prevent bacteria from attaching themselves to the lining of the urinary tract. I was trying to use as much simple language as possible, but couldn't quite grasp the concept of bacteria sticking to the lining of the urinary tract and why it would be beneficial to prevent this. I immediately thought of bacteria colonies growing on agar plates in biology labs, so I asked her if she ever took a biology class, and of course, she hadn't. I ended up relating it to mildew growing on shower walls, and explained that if the bacteria have nothing to attach themselves to, they just get flushed out of the system. That seemed to click with her. (Of course... Just how effective cranberry actually is for preventing UTIs is another story completely)

That's a simple example too. Sometimes it's just really hard to put things in non-medical terminology, especially when you start dealing with drugs with complicated mechanisms of actions that involve very specific receptors located at specific sites of the body. Therefore, if it seems like we're stammering when trying to answer a question, it's probably because we're just searching for the right words that the average person would understand.


Anonymous said...

I think Phenobarb induces its own metabolism via CYP450 - FYI

Pharmacy Mike said...

Not to the same extent as carbamazepine. Phenobarb is a major substrate of 2C19, but it is not an inducer of 2C19. Therefore, it doesn't induce its own major metabolic pathway. Carbamazepine is a major substrate of 3A4, and it is a major inducer of 3A4. Therefore, it is a much more potent inducer of its own metabolism than phenobarb.

I really can't think of another drug that induces its own metabolism to anywhere near the same extent as carbamazepine.

dm said...

water is also a great inducer of metabolism. i know when i drink it, i have to pee. that's metabolism right? ;)

Anonymous said...

'Zactly so! I have to chuckle at your dilemma--it happens all the time. I was talking with my HF group about constipation and one of my patients (on warfarin, ACE-I, diuretic, CCB, etc.) told me she had occasional problems with irritable bowel and that her elderly brother-in-law who's into natural herbs and plants gave her remedy for gas. I had just finished mentioning that constipation is one of the most common OTC issues and to be expected with changes in diet, medications, exercise, travel, etc., and it would be a good idea to consult with the doctor or pharmacist ahead of time, especially if taking drugs, I asked if she mentioned the problem to her doctor, no, she said, she would ask her 85-year old brother-in-law who knew about herbs and plants before she would buy something in a drugstore. So...

Speaking of receptors, I had fun talking about chemical receptors with a group of school children once--we played a mock game of musical chairs. For oldsters, it might be more difficult to conceptualize without some fundamental knowledge of biology.

Cathy Lane RPh

Intern2ndyr said...

This summer I had a lady come into the pharmacy with a list of every medication her husband along with a notebook. She demanded to know exactly how every medication he was taking worked and why he had to take multiple medications to control some of his conditions. She wrote every word of my explanation down, which took forever and she was very rude about the whole thing. I was happy to help and did my best to explain everything so she could understand.

The reason she wanted to know all this was because she believed the doctor/pharmacists/drug companies are all in cahoots, shoving extra meds down everyone's throats.

Intern2ndyr said...

Hey Mike,

I am P2 and I am considering doing an internship with IHS this coming summer. I was wondering what your opinion of IHS is and if you know anyone working in Public Health Service or Military as a pharmacist?

So have you decided anything about being a preceptor yet? Faculty may mean well, but the instruction I receive from preceptors is the instruction I value most.

I hope all is going well in your life.

Frantic Pharmacist said...

I feel like I'm very seldom asked a question where the customer actually listens to my answer. They have usually already made up their minds, or just want you to verify what they think they already know! There's just too much information out there, and a lot of it is junk.

Anonymous said...

Maybe it's not so much that they are showing off, but they want to show that they have done some research on their own.

The Welsh Pharmacist said...

Or we're trying to understand how to make sense of a question that doesn't make sense.

Anonymous said...

definitely more obscure...but i'm pretty sure some HIV meds are a substrate for and induce 3A4also..nevirapine comes to mind. Definitely not seen as often as tegretol though...and I don't think it's significant enough to see a dosage change like tegretol...just thought i'd throw that out there anyway..