Utah Pharmacy Digest

The Utah Pharmacy Digest: Official Publication of the Utah Pharmaceutical Association. Published since 1948, the Utah Pharmacy Digest is dedicated to assisting the profession of pharmacy in better serving and protecting the public health and welfare. This involves educating pharmacists and pharmacies for public service and professional strength, and encouraging scientific and professional research ethics.

UTAH PHARMACY DIGESTft Craig and Gretchen Jackson Are Pleased to Invite Each of You to Join Them at the Annual UPhA Convention Four Seasons Convention Center April 23-25, 1987 St. George, Utah Complete Removable Convention Program Enclosed Use Registration Forms in Digest to Register *u VOLUME 97 APRIL 1987 NUMBER 4 OFFICIAL PUBLICATION OF THE UTAH PHARMACEUTICAL ASSOCIATION McKesson introduces a cure for two of your biggest medical problems. and Demand. A T MCKESSON WE UNDERSTAND an essential medical fact of life for every hospital pharmacist. When a physician or nurse orders a product, you have to deliver. And it doesn't matter whether the order is for a life-saving pharmaceutical or for baby shampoo. That's why so many hospital pharmacists rely on McKesson Hospital Services. They know we deliver . . . on schedule. You can count on McKesson to supply the widest range of Pharmaceuticals including injectables, unit dosages, as well as devices for I-V admixtures. And, McKesson's fast growing subsidiary, Gentec Health Care Company, offers a full line of medical-surgical items. At the same time, we also provide efficient purchasing controls and c 1984 McKesson Drug Company ECONOMOST" is a trademark of McKesson Drug Company 50 supply centers nationwide. Another McKesson advantage. comprehensive management reports, because with PPOs, DRGs, and TEFRA your need for cost containment is vital. McKesson has the tools you need to reduce your hospital's investment in inventory and your working costs. We'll also provide McKesson advanced computer technology to help ease the burden of pharmacy management, Economost to help with inventory management and reduce out-ofstock problems, and electronic order entry or computer to computer ordering to simplify product procurement. At McKesson we offer more than just the supplies you need. We provide the service you demand. Contact your McKesson Hospital Services representative, or McKesson's Director of Hospital Services: [phone]. Another Value Added Service from McKesson. ItMesson McKesson Drug Company Opinions that may be expressed in any article in this publication are those of the individual author, or the editor as an individual and do not necessarily reflect the views or policies of the Utah Pharmaceutical Association. Subscription rate, $11.00 per year, $1.00 per copy. MANAGING EDITOR C. Neil Jensen BUSINESS MANAGER Stacee Nolton UTAH PHARMACEUTICAL ASSOCIATION EXECUTIVE COMMITTEE Roger D. Clements Immediate Past Pres. J. Craig Jackson President Gordon Peterson President Elect Lynn E. Jensen Vice President Garold E. Jensen Treasurer C. Neil Jensen Executive Director Del B. Rowe Legal Counsel TERMS EXPIRE 1987 Lamar Hansen, Martin D. Higbee, Gordon Peterson, Marian Roper. TERMS EXPIRE 1988 Todd Ebert, Garold L. Jensen, Frank H. Robles, Ron Turner TERMS EXPIRE 1989 Reid H. Acord, Lynn E. Jensen, Lesley D. Esklund, Dennis R. White ASSOCIATE TRUSTEES Dean Bishop, Robert Holbeck, Bill Stilling, Myrle Willmore UTAH STATE BOARD OF PHARMACY Frank B. Morris, Chairman; LeNila Homer, Secretary; Mark L. Johnson, Miriam Zabriske, Delbert Park. STUDENT APhA John Downs UTAH SOCIETY OF HOSPITAL PHARMACISTS Tom Sudds, President UTAH VETERANS PHARMACISTS' ASSOCIATION Eldon Frost, R.Ph., Kaysville, Utah UPhA AUXILIARY Delia Van Orden PUBLICATION INFORMATION The UTAH PHARMACY DIGEST, formerly, until January 1963, the U.Ph.A. BULLETIN NEWS, is published monthly by the Utah Pharmaceutical Association, 1062 East 2100 South, Salt Lake City, Utah 84106. Secondclass postage paid at Salt Lake City, Utah. Advertising rate card furnished on request. The UTAH PHARMACY DIGEST is dedicated to assist the profession of pharmacy to better serve and protect the public health and welfare by: (1) Educating all pharmacists and pharmacies in the state for public service and professional strength; (2) Encouraging scientific and professional research talent and ethics; (3) Supporting all Federal and State laws relating to the profession; and all rules, regulations, and memorandums of the Utah State Board of Pharmacy restricting the practice of pharmacy to qualified and licensed pharmacists and pharmacies. The DIGEST urges every pharmacist in Utah to join his State Association first and then join one or both of his National Pharmacy Associations. Postmaster: Send address changes (under Form 3579) to the Utah Pharm. Assn., 1062 E. 2100 So., Suite 212, SLC, UT 84106. UTAH PHARMACY (USPS 654-220) OFFICIAL PUBLICATION OF THE UTAH PHARMACEUTICAL ASSOCIATION HNICS omnium smici UCf CE President's Message 1 2 Auxiliary Message UAflVj <• 4 Cocaine & Crack S/VLT • !f .UTAH- ^ Single Source Pricing !.. fV.v; .CTf.y.... 7 Dickinson's Pharmacy 10 Annual Convention Speakers 14 Alzheimer's Disease 17 Continuing Education for Pharmacists 19 UPhA Executive Board Minutes 24 UPhA Board Minutes .. .. 24 OUR ADVERTISERS McKesson Parke-Davis Marion Foundation-Systems Inc Lilly Upjohn Marion Brunswig Grant Hatch . SUPPORT OUR ADVERTISERS-THEY APhA + HARD UTAH PHARMACY DIGEST / APRIL 1987 Inside Front Cover 3 5 9 16 18 23 Inside Back Cover .. Outside Back Cover SUPPORT US. President's Message by Craig Jackson The Utah State Legislature has now completed the 1987-88 session. There were several Bills introduced that impact pharmacy. Senate Bill 20: ammended the Pharmacy Practice Act to include a definition of "Rural Pharmacy". The language added to the pharmacy law is "Rural Pharmacy means a branch pharmacy that is established in certain rural communities to receive and store medications packaged in advance by a registered pharmacist who is affiliated with a parent pharmacy." At the time we revised the Pharmacy Practice Act several years ago, we took out all reference to the rural pharmacy (Branch Pharmacy) issue and placed all this information in the pharmacy Rules and Regulations. The rural health providers wanted reference to this in the Pharmacy Practice Act. We helped draft this legislation and supported it. This bill passed. Senate Bill 85: In our attempt to discourage the Utah State Department of Health from going to a "closed formulary" for medicaid prescriptions, we promoted S.B. 85-the open formulary bill. Because of the bill, we were able to provide the Legislators with much information regarding how pharmacists, physicians, and patients are affected by formulary restrictions. This bill did not pass but a Legislative Letter of Intent was passed that prevents a closed formulary until a study is completed by the State that addresses the costs/savings that would result from a closed formulary. Senate Bill 157: This bill provides for the establishment of programs to rehabilitate professionals who become involved in controlled substance infractions. This program is only for first time offenders. This bill passed. Senate Bill 43: This was a Sunset Reauthorization Bill for many government agencies and related laws. This included the "Controlled Substances Act." This bill passed. Senate Bill 112: This bill amended the Controlled Substances Act and Imitation Controlled Substances Act. This bill provides specific changes to clarify the nature of offenses especially for imitation controlled substances. This bill will be especially helpful to law enforcement agencies in controlling "street drugs". Senate Bill 184: This law would have authorized a "Registered Physician Assistant" to prescribe drugs under the supervision of a physician. This bill did not pass. The Division of Occupational and Professional Licensing raised the issue regarding registering vs. licensing of Physicians Assistants and also the issue of J. CRAIG JACKSON - UPhA PRESIDENT where this issue should be addressed. Instead of the Pharmacy Practice Act, maybe it should be addressed in the Medical Practice Act. This is the extent of legislation this year that impacts our profession. We had significant input and impact on each of these pieces of legislation. It reminds me of the National Guard Slogan that says something to the effect, "You can sleep well tonight, your National Guard is on duty." In the same vein, the UPhA is on duty watching over your interests at the State Capitol. Of interest this past month was an editorial in American Medical Association "Medical News" that discussed the practice of physician dispensing. Included in this editorial was the following, "Physicians are urged to avoid regular dispensing and retailing of drugs, devices, or other products when the needs of patients can be met adequately by local ethical pharmacies or suppliers". We agree wholeheartedly with this stand and know that it is in everyone's best interest. At a recent conference in Colorado dealing with health care, the statement was made that medical care in the U.S. is in a state of "white water." You river runners will recognize that white water refers to going through rapids with a combination of high adventure and excitement but also with a corresponding potential for danger and tragedy. The speaker at this conference concluded that we are approaching calm water so "hang on". The white water issues in pharmacy are not the number of prescriptions that are written, but is the question of who will fill them and the impact of third party payment systems. As I mull over these issues in my mind, the statement made by Tiny Tim in Dickens Christmas Carol comes to mind when he said, "God Bless Everyone". UTAH PHARMACY DIGEST / APRIL 1987 PARKE-DAVIS GENERICS... the finest quality Pharmaceuticals available, with in-house manufacturing of uncompromising standards... timely market introductions of off-patent products... competitive pricing programs... When you fill a prescription with PARKE-DAVIS GENERICS, you fulfill the trust your customer places in you, and us. PARKE-DAVIS GENERICS PARKE-DAVIS Auxiliary Message DEAR AUXILIARY It's cold outside, windy and raining but hey! my thoughts are turned to St. George and the warm lazy days ahead. The cool evenings, friends, fun and play and all that good food. I believe its called "CONVENTION "87". Make your reservations now and join the gang at the Four Seasons and find out what's happening in Pharmacy. "Earn Your Image", is the theme. Ross and I look forward to this time each year. He gets in his usual golf game and I get a shopping spree. He has had so much fun in years past that he carries around the scars to prove it. (ha ha) Our committee for convention has been busy planning a good time for you ladies. Carol Sevy is chairman and her committee is Faith Stapley, Jerri Everett, and Colleen Davies. We have some beautiful gifts for the auction and plan on using the money to decorate and spruce up the UPhA offices. We are selling T-shirts and have a quilt to raffle. This is one convention you won't want to miss, gals. Lois Foster, Chairman, Carrie Jolley, and Jeri Everett have been busy getting a new slate of officers for next year. You'll find out who they are at convention. We have a special lady that will be given the Dawn Bain Memorial Award at the President's Night Banquet. It's a secret and is exciting. The Ladies in Central region held a luncheon and get-together. Alice Esklund and Francis Beasley are the delegates and Nancy Mottishaw and Jan Christensen are also on the committee. It was at the Apple Butter DELLA VAN ORDEN - UPhA AUXILIARY PRESIDENT Farms Restaurant on March 24th. It was fun to meet and visit with our friends from Central. We extend to Brent Olson our heart felt sympathy in the loss of his dear wife Mary Ann, who was a member of the Auxiliary. She did the Capsulette last year and made many friends in the auxiliary. She was a sweet and talented person. We will miss her. Congratulations to Grace Tassone who has the, honor of being the "Woman of the Year" receiving this award from the Ogden business and professional women. We think you're great, Grace! I know of a terrific way to spend $15.00, Ladies. Join the Auxiliary. You couldn't buy more for your money. Make Easter a special day, spend it with those you love, your family. Love, Delia UTAH PHARMACY DIGEST / APRIL 1987 * YOU WANT YOUR "USUAL AND CUSTOMARY" DISPENSINGFEE. Marion thinks you deserve it. Pharmacists deserve a dispensing fee that reflects the degree of professional service required when filling a prescription. That's why Marion reimburses pharmacists for their "usual and customary" dispensing fee, no matter what it is, when filling prescriptions for Marion associates. To us, it's simply a matter of principle: pharmacists perform a valuable service, so they should be reimbursed accordingly. We believe that an arbitrarily fixed fee is inconsistent with the reality of costs, associated with filling prescriptions, varying from one pharmacy to the next. The positive response to our reimbursement program indicates that our philosophy is shared by most pharmacists. As a result, Marion is currently working with state and national pharmacy organizations to provide information about the success of our reimbursement program so that they may benefit from our experience when negotiating with third-party insurers. Reimbursing for the "usual and customary" dispensing fee-just one more way that Marion demonstrates its commitment to pharmacy through action, not words. PHARMACEUTICAL DIVISION Service to Pharmacy J 11/1 LABORATORIES. MARION IATXI LABORATORIES. INC K A N S A S CITY. MO 64137 COCAINE AND 'CRACK' Pharmacists can be the secret weapon in this war against drug abuse. by Joseph Scarlata, R. Ph. Like millions of others during the past few months, I have become increasingly aware of-and concerned about-the rapidly spreading use within our nation's "drug abuse subculture" of cocaine and its deadly derivative, crack. The more I have learned about crack, the more I have found myself pondering what we, as pharmacists, should-or can-do about the situation. Crack, as everyone knows by now, is the "free base" derivative of cocaine. But, unlike cocaine, crack is smoked rather than snorted. The problems associated with addition to heroin and other drugs seem too pale in comparison with the problems of those who fall prey to the enticements of crack. With crack, addiction can be instantaneous. Most users are hooked after their first try. Crack users do not experience a "break in" period during which addiction develops gradually. Unlike the other illicit drugs that plague our society, crack-or "rock" or "base" as it is also known-is relatively inexpensive. A single fix sells on the streets for about $10 or $15-putting it within financial reach of the very young. Crack is also plentiful and easily obtainable. Law enforcement officials estimate that each day some 2,000 Americans try cocaine or crack for the first time. Most of them are teenagers. Crack is more addictive than heroin-and it produces a greater high than heroin does. Addicts say that their cravings for crack far exceed their desires for food or oxygen. As the most addictive drug now known to man, crack has the capacity to transform the occasional cocaine user into a desperate, fanatical addict. ATOM BOMB One narcotic officer has declared that crack is to cocaine what an atomic bomb is to an ordinary bomb. Cocaine and crack constitute the fastest-growing drug abuse problem in our nation today. And it is a problem among adults and schoolchildren. To those of us who have been educated in the actions and effects of drugs, it is particularly horrifying to see cocaine use glorified as trendy and fashionable among show business personalities and the rich. It is appalling to see atheletes, who should be role models, use cocaine with what seems to be almost unimpeded regularity. As pharmacists, we are well aware of the hazards cocaine poses to mind and body. It accelerates heart rate, increases blood pressure, interferes with performance and produces sudden-and fatal-seizures. This is a time for us to consider what we pharmacists, as society's most visible and readily accessible authorities on drugs, can do about the burgeoning epidemic of cocaine use. For years, we have heard that we have a responsibility to become active in our communities, to speak out against the ravages of drug abuse and to try to educate young people about the hazards of illicit drugs. But even though a number of our professional colleagues have taken part in such efforts, most of us have not. The pressures of business and family, we have no doubt rationalized, leave us no time to participate in programs of drug abuse education. "Someday," we have all promised ourselves, we w///have the time. And then we'll become active. TOLL RISES Meanwhile, as we await the arrival of that "someday" when our time will be freed up, the clock goes on ticking. The toll of people falling victim to drugs like crack and cocaine continues to rise. Government and law-enforcement agencies can only do so much. Reducing the supply of the drugs is only part of the solution. As long as there is a demand for the drugs, ways will be found to supply them. It is up to us to help reduce the demand through education. I think we can do it. As pharmacists-the health professionals who possess the greatest expertise in drugs-we must not i shirk our responsibilities to help counteract the continuing onslaught of illicit drug use. We have a thorough knowledge of the effects of drugs. We are accessible. We have respect and credibility in our communities. All of us in the profession of pharmacy-practitioners, educators, industry personnel, students, scientists-have a role to play in trying to rid society of drug abuse problems. As professionals who have gained much from society, don't we have an obligation to "put something back" that will help improve that society? Of course we do! OBLIGATIONS Perhaps each of us has an obligation to tithe a portion of time to fight drug abuse. Even if this tithing amounts to only a few hours per year per pharmacist, just think of how much could be accomplished through our collective efforts! We pharmacists can be especially effective by visiting elementary schools and speaking to the children about the hazards of using drugs. For pharmacists who want to get involved in drug abuse education, there are many sources to turn to for information and instructional materials. One of the (continued on page II) *• UTAH PHARMACY DIGEST / APRIL 1987 PPSI 5th Annual George S. Magglo Memorial Breakfast NARD Annual Meeting Tuesday, September 30, 1986 "Single Source Pricing- A Manufacturer's View" by Donald R. Lee Editor's Note: This is an excellent article to help us combat the multi-tiered pricing that complicates pharmacy today. It's a pleasure to finally address an audience where I can actually talk about pricing. As you heard in that marvelous introduction, I'm currently Chairman of the Marketing Section of the Pharmaceutical Manufacturer's Association, and I'm a Director of the National Pharmaceutical Council. In those meetings - among all of our astute competitors - we cannot, will not, do not talk about prices of anything... and a lawyer is always present to see that we do not mention -^ a price - especially the Lawyer's fee. So I jumped at the opportunity to come here to Louisville to talk about those elements of pharmaceutical pricing that are issues in a changing health care delivery environment - and all those things I can't talk about or complain about when I'm at PMA or NPC meetings. I also want to tell you about the business reasons why some of us in the industry price and distribute things the way we do - and why we don't understand some of the things you do with your prices to the customer. Then I'd like to wrap up with some ideas about how we could all serve the customer better, because, after all, quality care for the customer - the patient - is what's going to make everyone better off in the Health Care Delivery System in this country. Let me start with a little history on Norwich Eaton Pharmaceuticals, which is now a Proctor & Gamble Company. The background is important because it provides the clear business reasons for our pricing policy. When I joined the company 11 years ago, it was Eaton Laboratories, Division of Morton-Norwich, and we had products ranging from Furacin Urethral Inserts to Chloraseptic Lozenges. And in those days - the mid-70's and earlier - we were really good friends with pharmacists. Chloraseptic built our relationship. WE got physicians to recommend it, and their * patients - your customers - bought it from you. We sold UTAH PHARMACY DIGEST / APRIL 1987 you direct at a 10% discount off list price; and with trade deals at appropriate times, you could stock up and make an appropriate profit on a good move that had a professional reputation. Not unlike other companies, every year we expected to sell more Chloraseptic - and our sales reps' quotas would go up. Also, the food trade saw this product and wanted it on their H & BA racks. Somehow it got there. It wasn't part of the Company's plan; but a good mover finds its consumer, and the food store business began to grow - and you began to grow angry with us for letting the product get outside the traditional pharmacy distribution channel. I began to get pretty upset as well, because our sales people were getting the short end of the stick, and the rest of our prescription pharmaceutical business was starting to suffer. Why? Because our professional sales representatives - who were ostensibly being paid to generate prescription specifications in the doctor's office, were spending the last week of every month (that's 25% of their time that should be devoted to creating demand) calling on every pharmacy in their territory. They were trying to generate an end-of-themonth order for Chloraseptic so they could make sales quota. On top of that, the underground food store buyers were complaining because we didn't have consumer advertising for our product. Hell, we didn't want them to have it in the first place! The net of all this was a real dilemma. Pharmacists were unhappy because the product was being sold to the food store. The food trade was unhappy because we didn't have consumer advertising to increase their turnover. And I was really disturbed because our reps weren't creating enough demand in the physician's office. SoT solved our problem in one fell swoop... by turning the product over to our sister division at the time, Norwich Products. This Consumer Products Division was already doing very well with Pepto Bismol, Unguentine, Norwich Aspirin, and other products. They had tremendous experience and expertise in consumer advertising, primarily TV, and they developed a consumer advertising campaign for Chloraseptic and legitimatized the food store channel. Our Professional Division continued to promote the product to physicians to maintain its professional franchise. Just to complete the story on Chloraseptic, that excellent brand was transferred to P & G's Health & Personal Care Division when we were purchased - and then it went to Richardson-Vicks when they were purchased, where it resides and grows today. As a result of all this activity, an interesting thing has "Single Source Pricing (continued) happened. Consumer advertising helped to grow Chloraseptic dramatically - and the food store H & BA business increased. But your pharmacy business has increased too. You still account for the lion's share of Chloraseptic sales, compared to the food trade, and Chloraseptic volume has grown to a much larger share of the total sore throat market. Now this all speaks a lot for entrepreneurism - and passing the buck - but what does it have to do with pricing? Just this - with Chloraseptic out of our line, we no longer had a strong, commercial rationale for selling direct to pharmacies. And pharmacy was rapidly learning it was more cost effective to buy from wholesalers. So we became a wholesale only house for our Professional Products business to pharmacies, with some 10% of our sales going to hospitals direct. (That percent decreases yearly as hospitals also learn the cost effectiveness of dealing with wholesalers.) With the bulk of our business at wholesale, we removed all other discounts and established a single, uniform price for all customers - regardless of quantity purchased. Let me repeat... we have a single, uniform price for Macrodantin, Entex and all other Professional Products, whether the customer buys one bottle of 100 or a gross of 100"s. I think that's what you've been asking for from all manufacturers, right? We've done this because it is the right thing, the fair thing to do. Pharmacy must be allowed to compete on a level ground. Differential pricing, in light of current evolving situations where nonprofit institutions are entering the retail market, does not provide a fair, competitive marketplace. Even if we lose business to HMOs and other institutions in the short-term, our basic phiosophy is that the fair thing to do is the best and only possible business decision, in the long run. Here's an interesting sidelight to the Chloraseptic story. When our sales reps no longer had to sell you deals every month or quarter, their doctor call average doubled! And they generated considerably more Macrodantin and Entex prescription business for you - and us. Not selling direct to pharmacies had the same effect as doubling the size of our sales force, in terms of prescription generation. And it dramatically reduced our distribution costs and your inventory costs. Now that's entrepreneurism! I hope you can see that there were valid business reasons for making thsi pricing and distribution policy change. I can't communicate these reasons to my competitors, but you can. And I'd suggest you contact the CEO of any manufacturer directly if there's a change he could make to improve business for both of you. Frankly, it does youno good to try to deal with our trade associations on this issue, because we just can't discuss it. An interesting fallout from our uniform pricing policy is that it certainly has made us feel a lot more comfortble when Congressman John Dingell's subcommittee began their drug diversion hearings. I knew we were not caught in the 8 diversionary, differential pricing triangle - that Bermuda triangle that swallows up manufacturers, pharmacies and hospitals alike. Now, I'd like to say we've lived happily ever after. But that would only be sharing the good news. . . So let me tell you what has bothered me about all of this. I guess the main thing is that no one in pharmacy seemed to notice taht we had taken this important action regarding uniform pricing. It was done way before the idea was fashionable - before Merrell-Dow sent out its press releases on the need to raise some of their bid prices; or Marion changed their institutional bidding policies. We didn't get any thank'yous (except from wholesalers) and we never received any positive press. Maybe our timing was wrong. But even more discouraging is the fact that we didn't seem to win any strong friends with pharmacy with these actions. Our representatives still make regular calls on pharmacies to keep you informed about our product line and our activities in your area; but since we're not in selling deals every month, we're almost persona non grata We seem to be constantly fighting battles over pharmacists substituting nitrofurantoin microcrystals for Macrodantin - which is illegal - or a generic decongestant for Entex LA, which is - in my biased opinion - immoral A nd that brings me to your pricing practices - which I have never quite been able to understand, although I've been in this business for 28 years. For example, when you choose to substitute, how do you select what company's product to substitute? - and then how do you price that prescription versus the price you would place on the brand name product? It's your business and I have no right legally, professionally, or intellectually to tell you how to price the product you select. But if I were you, I'd go through this four-step thought process: Pharmacist Thought #1: I'm in this business for the long term. My pharmacy is productive and profitable today because of the Tagamets, Aldomets, Macrodantis, and the Inderals from the laboratories of the research-based companies. I want more of those innovations for the future, so it's in my best interests to support the companies that have helped me build my pharmacy practice over the years. Pharmacist Thought #2: My customers deserve the best. If I want to keep them coming back, I should dispense the product I have the most confidence in. Sure generics are mostly okay. But what would I use for my own family? Which antibiotic do I use when my child is sick? What products do my physician friends demand for their family's use? Pharmacist Thought #3: Now, what about this specific company? Does it have multiple pricing policies so that I'll be undercut by the hospital OPD - or the HMO - or the big chain store? 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The combination of the FOUNDATION SYSTEMS PHARMACY MANAGEMENT SYSTEM hardware and software will give you an unmatched combination of pharmacy systems found anywhere in the computer industry! NSYS1 381 East 500 North American Fork, Utah 84003 801-756-7715 Dickinson's Pharmacy Lawyers v. Writers in Pharmacy. For an alternative title to this column, I thought about "Hesitancy Revisited," because this is a sequel to a previous column, "The Hesitant Profession?", that drew quite a bit of fire from pharmacists. None, however, was more boisterous than lawyer Jesse C. Vivian, in the March 1987 issue of Michigan Pharmacist -- hence the title you see above. Mr. Vivian, who also has a pharmacy degree, found it "amazing" that I would make "reckless and misleading statements" in citing a legal case to support the argument that pharmacists have a duty "to be, to a limited extent, their brother's keeper" (Riffv. Morgan Pharmacy). Worse, I did not confine myself to the narrowest, most lawerly and strict interpretation of law that I could find! It is I who should be amazed. As a lawyer, Mr. Vivian gets fees for his opinions, but on the basis of this example, he renders them without full understanding. He writes: "The thrust of the journalist's (he means Dickinson's) point seems to be (he isn't sure) that caution should be thrown to the wind as pharmacy faces the emerging trends... etc." Surely readers will know I said or implied no such thing. What could be more "reckless and misleading" than this public misinterpretation of my published words? Far from espousing the course he alleges ("fullspeed ahead, damn the torpedoes"), I had merely agreed, in my "Hesitancy" column, with another pharmacist-lawyer, USP's Joseph D. Valentino, who cautioned the graduating class of Rutgers not to let pharmacy be the "hesitant profession." I observed, as many before me have, that the world is full of opportunities (which should be seized), but that opportunities have risks (which should not be a reason for avoiding said opportunities). Now, suppose you are a young and relatively inexperienced pharmacist, and you are listening to Mr. Vivian, as well as to me. Who would you believe? He might remind you of all the pitfalls and roadbacks. He might urge a "look before you leap" philosophy. He might even have some judicious case law examples that you could find instructive. And, after he has given you something to chew on about this, he might suggest that you go away and think about it, and consult him again. "Past experience," Mr. Vivian writes, "not only suggests the value of hesitation before engaging in these new activities, but it demands it." But would he suggest that merely hesitating is all that's demanded, or would he like us to use the pause created by that hesitation to consult qualified experience? You would leave Mr. Vivian's office freshly aware that there are many pitfalls for the unwary. And that 10 by Jim Dickinson only a fool rushes in without due regard for the experience of others. And indeed, you would be sure that we should think very carefully about such serious matters. And that we should at least avail ourselves of the expertise that is available. Tick-tick-tick. Time is money, and Mr. Vivian probably charges for his. The more questions and doubts he can raise, the more need there is to consult, if not him, then another of his colleagues. And if they practice fairly, some of their doubt-sowing may come his way in the form of other consultations. On the other hand, if you come to me, I won't charge you a penny (I'll hope our discussion gives me something I can write about for my "fee"!). What I try to give is a can-do philosophy-hopefully a new dimension, a different slant, a reason to think. Journalists and lawyers work at cross-purposes. We try to magnify and enlarge ("sensationalism"), they try to shrink and diminish. Riffv. Morgan, Mr. Vivian says, doesn't mean all the big things I think it means; to lawyers it maybe means some of these little things, possibly, taken in the proper context which only a lawyer can explain, but then again it maybe means nothing, because of other things. On the other hand, we will have to wait and see if another court takes up this interesting point, and ... I sometimes get exasperated with lawyers. I think the law of the land belongs to the people, but the lawyers have made it comprehensible only to lawyers. Tick-tick-tick. And when mere journalists try to discuss it, some lawyers blow a gasket. How dare a non-lawyer discuss law-in public, yet! Truly, lawyers and journalists are together, down at the bottom of the ladder of public esteem, as revealed in public opinion polls. The only traders below us are used-car salesmen. Way up there at the top is pharmacy. What's the public trying to tell us, do you think? UTAH PHARMACY DIGEST / APRIL 1987 ' Have You Registered for the 1987 UPhA Annual Convention in St. George? Make your plans and reservations today. Bring your family and enjoy Utah's Dixie. Review of Diseases and Their Therapy April 29 through May 27 sponsored by University of Utah College of Pharmacy This course is designed to update pharmacy practitioners on the current therapeutic approaches to various diseases and to increase the confidence and competence of practitioners when they interact with patients and health professionals. Classes will be held on Wednesday evenings from 7:00 to 9:00. Ten contact hours (1.0 CEUs) will be awarded to participants who complete the entire series. Registration fee is $85.00 and must be received by April 21. The college will refund payment in full if the class fills up. Course #070-068-87-06. The University of Utah College of Pharmacy is approved by the American Council on Pharmaceutical Education as a provider of continuing pharmaceutical education. Mail check to Pharmacy CE, College of Pharmacy, University of Utah, Salt Lake City, UT 84112. For further information contact Bill Stilling at 581-6205. ****** \\e Single Source Pricing (continued from page 8.) most useful sources is an organization known as Pharmacists Against Drug Abuse or PADA. PADA offers three items that you will find helpful: (1) The Pharmacist's Guide to Drug Abuse, a manual for pharmacists; (2) The Kinds of Drugs Kids Are Getting Into, a manual for parents; and (3) a speech kit for helping pharmacists make effective presentations in their communities. TOLL-FREE You may obtain these materials from PADA by phoning toll-free to 1-800-222-PADA. Let us not lose sight of the fact that the fight against drug abuse must be waged as a full-scale war. We pharmacists are among the most important combatants in this war. We are the community drug experts with the know-how to educate children and parents. Once we are properly deployed, we can be the secret weapon in this war-the secret weapon that will lead our society to victory! I urge you to become involved! Today! UTAH PHARMACY DIGEST / APRIL 1987 does it have a pricing policy that allows me to compete on an even basis with everyone in my trading area? Pharmacist Thought #4: Now that I've added my markup or my dispensing fee, how can I explain the cost effectiveness of this medicine to the customer who is sick and probably would complain even if her prescription cost only a dollar? Now this is what I said I'd do if I were you. But I'm not you. Do I really believe you'll go through this detailed thought process on every prescription you dispense? Obviously not. But there are sone/v/n«p/eshere that I hope you'll consider, in general, that might benefit your business today, your customer relations, your relations with the research-based pharmaceutical industry, your long-term fiscal success, and the future innovations in therapeutics that make pharmacy such an exciting professions. This thought process, by the way, also helps to lead up to (continued on page 22) 11 New Lobby Decor New Look Outside UTAHPHARMA 95th Ann' FOUR SEASONS HE 747 East St. Geort ~ ~ April! Completely Remodeled Rooms ~~ Four Seasons Indoor­ Outdoor Pool Dixie's F~y Creamery Serv,ice With a Smile See You There! 12 A Pictur CTAH PHARMACY DIGEST / APRIL 1987 Exhibitors Open House CEUTICAL ASSOCIATION ml Convention Uof U Alumni Meeting ORT & CONVENTION CENTER i Blvd., St. George, Utah 84770 id, 24th and 25th, 1987 Preview of the All New lesort and Convention Center o Wholesalers Night Luau President's Reception Dinner UTAH PHARMACY DIGEST / APRIL 1987 13 Annual Convention Speakers and Programs C. Ann Mashchak, M.D. Dr. Mashchak graduated from Loma Linda University Medical School in Loma Linda, California where she was given an award for outstanding achievement in Internal Medicine. She also received her M.P.H. in Public Health Nutrition from Loma Linda University. She served a straight internship in Internal Medicine and then fulfilled her residency in Obstetrics and Gynecology at White Memorial Medical Center in Los Angeles, California. She currently serves as Assistant Professor in the Section of Reproductive Endocrinology and Infertility at Loma Linda University School of Medicine. She has received numerous awards and special recognition for her many achievements and has coauthored a number of medical articles. One of her most recent articles was on Estrogen replacement therapy and hypertension which was published in the Journal of Reproductive Medicine. Dr. Mashchak will be speaking to us on Estrogen Replacement Therapy - Evolving Indications and Delivery Methods. J. Richard Wuest, R.Ph., M.S., Pharm.D. Dick holds a B.S. in Pharmacy and an M.S. in Hospital Pharmacy Administration and a Pharm.D. degree, all from the University of Cincinnati. He has practiced in independent community pharmacies, chains (both staff and manager), hospitals (staff, director and assistant administrator) and the Air Force (both as an NCO and officer). He is currently Professor of Clinical Pharmacy at the University of Cincinnati College of Pharmacy where he teaches the Pharmacy Practice coursework, Medical/Surgical Appliances, Dispensing Lab and is Chairman of the Division of Pharmacy Practice and Administration. He has been appointed to the Ohio Board of Phar14 Karen Ann Bergmann, Pharm. D. Karen is a new and pleasant addition to the University of Utah College of Pharmacy Faculty. She is assistant professor of clinical pharmacy (clinical track). She is already serving as a consultant pharmacist to the Sandy Regional Convalescent and Rehabilitation Center as well as the West View Care Center. She will be speaking to us on cancer and new cancer therapies geared to update the pharmacists knowledge as well as spouses attending the Annual Convention. It is a seminar everyone will want to attend, as Karen is well qualified to discuss cancer due to the emphasis she has placed in understanding cancer and cancer therapy. She has worked in retail, chain and hospital pharmacy settings and so can relate well to the different aspects that each pharmacist must deal with daily. She has received numerous awards for her knowledge and ability to communicate effectively with those who attend the seminars and lecture programs she presents. She will also be most willing to talk with you one on one on any questions you may have on cancer. o macy by both a Democrat and a Republican governor and has served two terms as its president. Dick has served on the board of directors of his local community and hospital professional associations, and the Ohio State Pharmaceutical Association. He is also a member of the United States Pharmacopeial Convention's Pharmacy Practice Advisory Panel. Dick consults for numerous corporations including Merrell Dow Pharmaceuticals, and Automated Business Products. He is the Chief Operational Officer of University Consultants, a provider of continuing pharmacy education to thousands of pharmacists nationwide. He has given nearly 500 seminars all over the world, according to Dick, and even parts of Utah, and authored over 190 articles in dozens of journals. He has received the Distinguished Service Award from the National Association of Boards of Pharmacy and been recognized for excellence from the Pharmacy Education Foundation. He has received the Faculty Excellence Award from his student body, on three occasions and you will know why when you hear him speak in St. George. UTAH PHARMACY DIGEST / APRIL 1987 Convention Speakers and Programs Thomas A. Gossel, R.Ph., Ph.D. Thomas A. Gossel has accumulated 30 years experience in pharmacy practice. This includes positions in community and hospital settings. He currently serves as Professor of Pharmacology and Toxicology, and Chairman of the Department of Pharmacolpgy and Biomedical Sciences at Ohio Northern University, College of Pharmacy, Ada, OH. Additionallyx he consults to several pharmacy drug companies and manufacturers. He supports his county, state and national professional associations, and serves on several active state and national committees. Tom completed the requirements for licensure as a pharmacist in 1963. He earned the M.S. in Pharmacology-Toxicology in 1970, and Ph.D. in Pharmacology-Toxicology in 1972. He has been at Ohio Northern since 1972. Tom has presented nearly 600 seminars to pharmacists, nurses and physicians in 37 states, Jamaica and Switzerland. He has authored or co-authored over 250 professional articles which have appeared in a wide variety of pharmacy journals. He maintains a monthly column in US Pharmacist. He has also written six books and two book chapters. His most recent volume, ^Principles of Clinical Toxicology (1984) is a textbook for pharmacy students. A teacher at heart, Tom enjoys working with people much more than with laboratory animals. He is also a strong advocate of thinking positively, and enjoying life without complaining about events he has no control over. He has directed all personal and professional development toward these objectives. James G. Dickinson President, Ferdic Inc., Morgantown, West Virginia. Ferdic publishes two newsletters (Dickinson 's FDA and Dickinson's PSAO), and distributes numerous editorial products to trade and professional publications throughout USA and abroad. Author of "Dickinson's Pharmacy" column published in state pharmaceutical journals, "Washington Report" column in Pharmaceutical *$ Robert E. Slater Bob is Director of Customer Affairs and Trade Development for Marion Laboratories in Kansas City, Missouri. After receiving a marketing degree from the University of Mississippi, he spent 24 years with McKesson & Robbins wholesale drug company as a salesman, hospital representative, sales manager, and general manager of a wholesale drug branch. Bob joined Marion Laboratories' in 1974 as Manager of Merchandising and Distribution, was promoted to Manager, Marketing Services, then to Director of Marketing Services and Customer Affairs, and then to his present position as Director of Customer Affairs and Trade Development. Since joining Marion Laboratories he has continued his interest in the management area of business by developing two significant contributions to pharmacy management in the United States. The first is the course entitled "Effective OTC Merchandising." This program is utilized by many colleges of pharmacy as an aid in teaching merchandising. Bob has presented this program to numerous continuing education seminars and to 40 state pharmacy association meetings. Bob edited and published a 22-chapter text entitled Effective Pharmacy for Marion Laboratories. This text is utilized at almost every college of pharmacy in the U.S. and Canada in teaching pharmacy management courses, and is marketed by many colleges as a continuing education course. In addition to his role as editor and publisher, he acted as author of the chapter on "OTC Merchandising." Bob's most recent contribution to pharmacy management was his involvement in helping develop and edit a program entitled "FROM POTENTIAL TO PERFORMANCE: Choosing, Training and Motivating Employees." This program has been presented at several state association annual meetings, at the recent APhA Annual Meeting in Chicago and will be a part of NARD's Annual Meeting program in September in Las Vegas. In Bob's twelve years with Marion he has received three "Presidential Awards" and Marion's "George Grinham Creativity Award." Bob's talk, "Pharmacists Are Important... And Here's Why" is based on his personal belief that the public thinks pharmacists play a more critical role in health care than most pharmacists do. This presentation represents a 36-year accumulation of thoughts on why pharmacists should be proud of their profession. (continued on page 17) UTAH PHARMACY DIGEST / APRIL 1987 15 Human insulin for all. Humulin human insulin [recombinant DNA origin] ' Identical to human insulin. Humulin is the only insulin not derived from animal pancreases. Recombinant DNA technology makes the production of Humulin possible and virtually assures every insulin user of a lifetime supply. From Lilly . . . a dependable source of insulin for generations. Si nee 1922, when we became the first company to manufacture insulin, we have led the search for the best diabetes care products and, at the same time, maintained a constant supply of insulin for all insulin users. Our 24 formulations of insulin-including Humulin and all forms of lletin® (insulin)-are available through the widest retail distribution of insulin in the United States. Beyond that, we will continue to provide a wide range of diabetes service and educational materials for use by physicians, pharmacists, and diabetes educators. © 1986, ELI LILLY AND COMPANY Our Medical Division is on call. Our Medical Division staff is only a phone call away. Please contact them if you have any questions about our diabetes care products. Any change of insulin should be made cautiously and only under medical supervision. Changes in refinement, purity, strength, brand (manufacturer), type (regular, NPH, Lente®, etc), and/or method of manufacture (recombinant DNA versus animal-source insulin) may result in the need for a change in dosage. Lilly Leadership IN DIABETES CARE For information on insulin delivery systems, contact CPI: T-(800)-227-3422. Eli Lilly and Company Indianapolis, Indiana46285 "... there were times, deaf living with Alzheimer's disease Aging is inevitable-Alzheimer's disease is not. Even though a cure for Alzheimer's disease still eludes us, methods of treatment are available now that can, for a while at least, improve or maintain the patient's ability to function and slow the inevitable, progressive mental deterioration. Deterioration to the final stage of the disease progresses at different rates in different patients. Despite the mental impairment and loss of ability to function, Alzheimer's patients can live at home until late in their illness, when the patient receives proper medical care early on, and participates in a treatment program encompassing a wide range of community services and programs. The poignant portrayal of one family's life with Alzheimer's disease in THERE WERE TIMES DEAR, shares the struggles of Susanne, the devoted wife of Bob, an Alzheimer's victim, to maintain her home, her family, her marriage, her husband, herself. Susanne prevails. By continuing to adapt, she makes memories to sustain her as memory fails him. Susanne admirably and realistically illustrates how to live with a loved one with Alzheimer's disease by learning about the disease and ensuring proper treatment which includes gaining family support, utilizing community services, participating in support group activities, and providing drug therapy. $ Memory loss, confusion, depression, agitation, inManaging Your Pharmacy to a More Successful Future The health care industry is undergoing changes that are having a significant impact on hospital pharmacies. An informed, proactive response to these changes ensures the future well-being of the pharmacy department. DuPont has developed this program to identify the sources of change and to offer guidelines for responding to specific issues such as new trends in health care, pharmacy productivity, diversification opportunities, and effective management during a period of transition. Preparing for the future is the best way to ensure continuing success. And the DuPont pharmacy education program will do just that-help you manage your future in a changing environment. Program Content: A Modular Approach The "Managing Your Future" program is presented as a service by specially trained DuPont Pharmaceuticals representatives. We will have three outstanding presenters: Carol S. Doherty, Edwin "^Hessel and Robert Gaiser. The program consists of UTAH PHARMACY DIGEST / APRIL 1987 tellectual impairment, decreased attention span are not a normal part of aging. They are symptoms of a disease-the disease is dementia-the causes vary. In approximately 25% of the cases, the cause of dementia can be corrected, and the symptoms disappear. This form of dementia is called reversible. Poor nutrition, drug interactions, physical illness such as liver and kidney disease, fever, and chronic alcohol abuse are examples of the treatable causes. An accurate diagnosis and proper treatment by a physician early on are needed to correct these conditions before it is too late to "cure" the dementia. While many forms of dementia are reversible, several are not. About 50 to 60% of those patients with a non-reversible form of dementia are diagnosed as having Alzheimer's disease. More than three million Americans have Alzheimer's disease; it is mild to moderate in 11 to 12% of the cases and severe in 4 to 5%, depending on the length of the illness. Jim Dickinson (continued from page 15) Technology and Pharmaceutical Executive, "Pharmacy Practice'^ column in U.S. Pharmacist, "Washington Wrap-Up" column in Medical Device & Diagnostic Industry magazine, and occasional columns in the Pharmaceutical Journal of Great Britain. Emigrated to U.S. in 1974 and held assignments with the National Association of Retail Druggists (Chicago) and American Pharmaceutical Association (Washington) before becoming Managing Editor Weekly Pharmacy Reports ("The Green Sheet") and Senior Editor of FDC Reports 5 ("The Pink Sheet") in 1975. Became Washington Bureau Chief of Drug Topics in 1977. Founded Ferdic, Inc., in 1982, with wife Sheila; company name derives from her maiden name (Ferguson) and Dickinson. In addition to journalism products, the company produces and markets health information leaflets for consumers, distributed through retail pharmacies. four independent modules, each approximately 1 to 2 hours long, using 35 mm slides and a participant's notebook. The four modules represent a realistic approach to enhancing efficiency and maximizing opportunity in the hospital pharmacy. The four topics are: "Health Care: An Industry in Transition. " Presents an overview of trends in the industry, assesses their impact on the pharmacy, and examines the pharmacy's role in a changing environment. "Productivity Management: The Key to Success." Explores the increased emphasis on productivity within hospitals and identifies the steps in the productivity management process. "Creating Opportunity through Diversification." Reviews the rationale for hospital diversification and focuses on the development of a business plan. "Overmanaged and Underled. " Outlines motivational incentives and presents a human relations approach to personnel management. Discusses current management styles in terms of their influence on human relations in the professional environment. 17 World class advice for your every day problems. More than 50,000 pharmacists know these men and use their wisdom to solve everyday problems. Dave Schmidt and Harles Cone, Ph.D., gave them a better understanding of human nature and improved their ability to communicate. And many have profited from the good dollar sense of Allan Hurst and his fectures on financial planning, cash flow and store management. We're proud to have brought their Professional Development programs to your association meetings and conventions during the past 12 years. We hope they made your world better. ©1985 The Upjohn Company, Kalamazoo, K ONTINUING EDUCATION FOR PHARMACISTS VOL. IV, NO. 1 Correspondence Course 3. give some background information on remedies purported to prevent inebriation. Advising Consumers on OTC Products for Overindulgence in Alcohol and Food/ Alcohol Combinations Objectives by Thomas A. Gossel, R.Ph., Ph.D. Professor of Pharmacology and Toxicology Ohio Northern University Ada, Ohio and J. Richard Wuest, R.Ph., Pharm.D. T Professor of Clinical Pharmacy University of Cincinnati Cincinnati, Ohio Goals The goals of this lesson are to: 1. discuss symptoms of overindulgence in alcohol or food/alcohol combinations; 2. present OTC products that are safe and effective for treating symptoms of overindulgence; in the service of pharmacy This continuing education for Pharmacy article is provided through a grant from MERRELL DOW & LAKESIDE PHARMACEUTICALS Division of !> MERRELL DOW PHARMACEUTICALS INC. UTAH PHARMACY DIGEST / APRIL 1987 At the conclusion of this lesson, the successful participant will be able to: 1. differentiate between overindulgence in alcohol and overindulgence from food/alcohol combinations from the symptoms described; 2. state which OTC product ingredients have been shown to be safe and effective for treatment of overindulgence symptoms; 3. cite the reason why certain warning statements must be included on labels of OTC products for overindulgence; 4. cite the reasons why there are currently no OTC products to prevent inebriation; and 5. provide appropriate patient advice to pass on to consumers purchasing OTC products for treatment of symptoms of overindulgence. The quantity of alcoholic beverages Americans consume has been estimated to be three gallons per person each year. This calculation computes to approximately one ounce of absolute (100 percent) alcohol per person per day. Psychological and physiological consequences of chronic alcohol ingestion are devastating when one considers the organ degeneration, lost careers, and broken homes. There is no OTC product that wi\\leviate or minimize the occurrence of the effects of chronic alcoholism. There is one effect of periodic overindulgence that most persons who consume alcoholic beverages have encountered at least once, and many have experienced on numerous occasions! This is the syndrome of events that often follows overindulgence, i.e., the hangover. Hangover The term hangover describes a cluster or series of symptoms that occur several hours after ingestion of a "large" quantity of alcohol. Large is defined as an amount in excess of that which an individual can tolerate, and his system can metabolize without difficulty. As defined by FDA, hangover is "a condition consisting of a complex of symptoms involving the gastrointestinal, neurologic, and metabolic systems that follows recent acute ingestion. The symptoms may include nausea, heartburn, thirst, tremor, disturbances of equilibrium, fatigue, generalized aches and pains, headache, dullness and/or depression or irritability." A complete profile of symptoms is listed in Table 1. Hangover is not the same as alcoholism, which refers to chronic alcohol ingestion with resultant organ pathology. Symptoms of hangover involve a number of bodily functions. As stated above, they generally appear several hours after moderate alcohol intake and are most commonly experienced after awakening from an excessive alcoholic beverage intake. The slang expression that described this is, "the morning after the night before!" A number of studies with volunteers, and results of numerous surveys have defined symptoms of overindulgence in alcohol, as well as everindulgence from a combination of food and alrohol. Symptoms fall into four categories or clusters: heartburn, fullness, nausea, and associated nervous problems. It is of some interest that the FDA/OTC advisory panel which looked at the data concluded that there is a significant target population for whom overindulgence is accompanied by a symptom reported as upset stomach. 19 TABLE 1 Symptoms of Hangover I. Those Seen Commonly Depression Disturbed balance Dullness Fatigue Headache Heartburn Irritability Muscle aches Nausea Thirst Tremors II. Those Seen Occasionally Muscle weakness Anxiety Nasal discharge Backache Bad breath Nervousness Belching Nystagmus Burning eyes Pale skin Confusion Palpitations Perspiration Constipation Respiratory Diarrhea Dizziness difficulties Dry mouth Runny nose Shaking Faintness Shortness of breath Flushed feeling Sleeplessness Giddiness Hunger Sluggishness Stomach ache Insomnia Sweating Lassitude Tension Loss of appetite Loss of taste Tinnitis Tiredness Malaise Melancholy Vomiting Another relatively interesting point is that the panel could not find an identifiable single OTC drug product ingredient that relieved all of these symptoms. Home Remedies Through the years, a number of home "cures" have been advocated to treat overindulgence and hangover. These included exotic remedies such as owl's eyes and eggs, raw or cooked fish, ashes from various woods, myrrh, wearing a garland of celery or parsley around the neck, rolling naked in the snow, basking in saunas, and sniffing pure oxygen. Even drinking additional alcohol has been tried following the notion of "taking a hair of the dog that bit you!" Alcoholic-based beverages such as the Bloody Mary, Singapore Sling, and Suffering Bastard reportedly were originated to reduce the intensity of the symptoms of hangover. Research to date has failed to show that alcohol cures or minimizes symptoms of overindulgence or hangover. OTC Remedies Americans have self-medicated themselves for overindulgence and 20 hangover for years with OTC products such as Alka-Seltzer (aspirin, sodium citrate), Bromo Seltzer (acetaminophen, sodium citrate), and Pepto Bismol (bismuth subsalicylate). Ingredients in these products are concluded to be safe and effective analgesics (e.g., aspirin and acetaminophen) or antidiarrheals (e.g., sodium subsalicylate). When the panel reviewed the evidence for these agents to treat symptom clusters, it found much confusion and overlap as far as hangover and overindulgence. Overindulgence in food/alcohol combinations normally produces symptoms of upset stomach (primarily heartburn, fullness and nausea) that appear within an hour of consumption and persist up to 24 hours. Symptoms of hangover, on the other hand, generally do not appear for several hours to a day. The panel noted that many of these same symptoms are also produced by other, more serious causes. The conditions may be indistinguishable from each other. For example, nausea may occur jn conditions such as uremia, ketoacidosis, hypercalcemia, cerebral edema, peptic ulcer, and cancer. It may be associated with pregnancy, motion sickness, stress, headache, and fright. Heartburn may result from gastric hyperacidity, acute hyperemia or gastritis. Since these responses are presumably caused by different mechanisms, a product intended to treat symptoms resulting from one cause may not effectively treat similar ones resulting from a different cause. Therefore, the panel separated the conditions for which these OTC drug products might be used into three distinguishable categories: TABLE 2 OTC Drug Products for Relief of Symptoms of Overindulgence 1. Upset stomach due to overindulgence in food/alcohol combinations • Acetaminophen/sodium citrate • Aspirin/sodium citrate • Bismuth subsalicylate 2. Hangover (drugs used in combination) • Analgesics • Antacids • Stimulants 3. Prevention of inebriation • Activated charcoal* • Fructose* *Some, but inconclusive evidence of efficacy 1. relief of upset stomach due to overindulgence in food/alcohol; The conclusion on combinations of ingredients is somewhat unusual. The panel recommended that combinations are therapeutically better than single ingredient products. This belief resulted primarily from the clinical experience of panel members. Their view was that people have traditionally found it convenient to treat hangover symptoms with an analgesic for headache, antacid for upset stomach, and caffeine for fatigue or dullness. Since other advisory panels had reviewed the previous three dru^? groups and reported on their effectiveness for the respective symptoms, this particular panel waived the need for clinical studies to document safety and effectiveness of the appropriate combinations as long as they met all the other criteria for Category I status. These criteria included proper labeling and documentation to show that all ingredients add to the total therapeutic activity claimed by the manufacturer. Table 3 lists OTC combination drug products cited as effective in relieving hangover symptoms. 2. relief of hangover symptoms; and OTC's With Proven Effectiveness 3. prevention of inebriation. There was a fourth potential category, prevention of hangover. The panel could find no evidence that any drug would prevent this. Results of the advisory panel's deliberations on the above three categories are presented in Table 2. Bismuth Subsalicylate. In 1975, the advisory panel that reviewed OTC gastrointestinal drugs found bismuth subsalicylate (active ingredient in Pepto Bismol) to be an effective antidiarrheal in doses of 0.5 to 2 grams taken three to four times daily. UTAH PHARMACY DIGEST / APRIL 1987 TABLE 3 OTC Combination Product Ingredients for Relief of Hangover 1 Aspirin, citric acid, sodium bicarbonate (in solution) 1 Acetaminophen, citric acid, sodium bicarbonate (in solution) 1 Aspirin, caffeine, aluminum hydroxide, magnesium carbonate 1 Acetaminophen, aspirin, caffeine, magnesium trisilicate, magnesium carbonate, and aluminum hydroxide gel This particular panel also evaluated the ingredient for treating symptoms of overindulgence in food and alcohol. It reported that doses of 325 mg taken up to 8 times daily at intervals of 0.5 to 1 hour (maximum of 4.2 grams/day) are safe and effective for this purpose. There were some safety concerns regarding bismuth subsalicylate. But the panel rejected their importance stating that the concerns related to different bismuth salts, or subjects taking doses significantly greater than 4.2 grams daily. One potential toxic action related to bismuth subsalicylate is the possibility of salicylate overdose in persons who take high doses of aspirin concomitantly. In a test that meas_ured salicylate levels following in<^gestion of Pepto Bismol in recommended doses, an average blood level of 13.7 mg/100 ml was recorded. This was less than the minimum salicylate level (20 mg/100 ml) at which tinnitus (usually the first symptom of aspirin toxicity) appears. The panel reported that symptoms of overindulgence in alcohol and food represent a temporary condition that only requires short-term treatment. There is little danger involved, but the potential for toxicity nevertheless exists. Therefore, it recommended that the following warning be placed on the label of products containing bismuth subsalicylate: ".This product contains salicylate. If taken with other saJicylatecontaining preparations, such as aspirin, and ringing in the ears occurs, discontinue use. If taking oral medication for a n t i c o a g u l a t i o n (thinning of the blood), consult a physician before taking this product." llTAH PHARMACY DIGEST / APRIL 1987 The warning about not taking the product if the patient is taking an anticoagulant relates to a potential drug interaction between salicylate and warfarin (Coumadin®). Salicylate displaces warfarin from its albumin binding sites, possesses intrinsic hypoprothrombinemic effects (reduced formation of prothrombin), and in acetylated forms (i.e., aspirin) inhibits platelet adhesiveness and aggregation. All these can decrease clotting mechanisms. Each action is additive to the action of warfarin, and serious bleeding episodes may occur in susceptible individuals. Concurrent use of these agents is not an absolute contraindication but for patient safety, it is best not to self-medicate with salicylates without consulting a physician. Sodium Citrate. The second drug found to be safe and effective for OTC use in relieving symptoms of upset stomach due to overindulgence in a food/alcohol combination is sodium citrate in solution. OTC products can be marketed as effervescent tablets or granules that are dissolved before ingesting. The citric acid and sodium bicarbonate that comprise the effervescent product are placed in water to release the active ingredients: sodium citrate along with carbon dioxide (the fizz) and other chemicals. The total daily dose recommended by the advisory panel for persons under age 60 is 17.2 grams, taken in divided doses. The total daily dose for patients over 60 is one-half this, or 8.6 grams. This reduced dosage is necessary because geriatric patients are more likely to experience difficulty excreting sodium from the kidney than their younger counterparts. Two warnings are required on the labels of sodium citrate solution products. The first is, "If you are 60 years of age or older, the maximum daily dose should not exceed of this drug." (The space is to be filled in with the total number of dosage units that comprise the 100 mEq.). The second is "If you are on a sodium-free diet, do not take this product except under the supervision of a physician." The first warns about the total daily limit. The other advises consulting a physician before using the product if the purchaser is on a salt- free diet. This latter warning is suggested because the total doses are 200 mEq and 100 mEq respectively, which is too much sodium for a person on a low-salt diet. Because pain and/or headache often accompany nausea, heartburn and fullness of hangover and overindulgence, sodium citrate combined with aspirin (e.g., Alka-Seltzer) or acetaminophen (e.g., Bromo Seltzer) have been found to be safe a,nd effective OTC combination ingredients. Again, these must be available in a dosage form that will be taken as a liquid rather than as a tablet or capsule. The above findings led to a point of controversy. There are some experts who believe that these aspirin/ antacid combinations are potentially dangerous to persons who already have gastric upset, because aspirin causes increased gastrointestinal blood loss. This particular panel and FDA concluded that the gastric erosion caused by aspirin occurs as it crosses the stomach's mucosal cells on its way into the blood. In the presence of a strong buffer (such as sodium citrate), aspirin is converted to sodium acetylsalicylate which is not absorbed by the cells of the gastric mucosa in significant amounts which cause gastric damage. The panel continued by stating that clinical studies have yet to show significant blood loss, gastric erosion or damage to stomach tissue. It recommended a Category I status for the combination. The labeling of combination products containing acetaminophen, antacids, salicylates or stimulants must contain appropriate cautionary statements for each ingredient. Those that relate to salicylates are: "If symptoms persist, or new ones occur, consult your doctor"; "Stop taking this product if ringing in the ears occurs"; "If taking medication for an anticoaguJation [thinning of the blood) effect, consult a doctor be/ore taking this drug;" and "Do not take this product if you are allergic to salicylates such as aspirin." For products containing acetaminophen, the recommended warnings are, "If symptoms persist or new ones occur, consult your physician;" and "For occasional use only." 21 Can Inebriation be Prevented? Two substances have been promoted for preventing inebriation. These are activated charcoal and fructose. As far as FDA is concerned, both are safe, but neither has yet been proven effective for this indication. Activated Charcoal. Activated charcoal adsorbs congeners in alcohol in vitro. All alcoholic beverages contain congeners, a term meaning "of the same kind." Essentially, congeners provide the characteristic odor, color and taste of the individual beverages. The term fusel oil is often used to describe them but this is technically incorrect since fusel oil is officially the oily residue left behind after ethanol is removed from a distillation process. Alcohol congener content and concentration vary among different beverages, and more than 400 compounds have been identified in various alcoholic drinks. These include acetaldehyde, ethyl formate, ethyl acetate, methanol, n-propanol, butanol, and amyl alcohol. There is convincing evidence that it is the congeners of alcohol that cause the symptoms of hangover. There is also a strong feeling that they contribute to the overall development of intoxication. For example, one study found a higher incidence of severe hangover in subjects drinking bourbon (greater congener content) than in those ingesting vodka (lower congener content). And when the various congeners are ingested alone, they all produce symptoms identical to those experienced in hangover. Activated charcoal is safe in antidotal doses up to 120 grams. Its adsorptive action on alcohol per se is limited to 300 to 400 mg ethanol per gram activated charcoal in vitro. Whether or not significant clinical benefit results with activated charcoal in modifying inebriation has not been shown. Fructose. Fructose (levulose, fruit sugar) is claimed to prevent alcoholic intoxication. It is safe in oral doses up to 150 gm/day. Fructose is rapidly removed from the blood so it does not affect blood sugar levels, and it does not require insulin for its movement across cellular membranes. Fructose action on blood alcohol levels has been of interest for almost 50 years. While some clinical studies have assessed fructose response on lowering blood alcohol levels, there are no studies that specifically support its role in preventing inebriation. It has been given orally and intravenously before, during, and after ethanol ingestion. Some authorities report that fructose can enhance elimination of alcohol, most likely by increasing its rate of metabolism. Others dispute this claim and state that any effect it might have on lowering blood alcohol levels is insignificant. FDA stated its concern that products claimed to minimize or prevent inebriation may actually present a potential health threat. One national group concerned with highway safety reports that each year about Single Source Pricing (continued from page 11) my final point and that is: What can we do together to serve your customer better? I've always believed that you have the toughest job in the whole health care delivery system. That's because you get the patient as a customer when she feel she worst and has to pay you for the privilege of feeling lousy. You have to say to Mrs. Jones:.. ."and that will be $16." And she says: "What, for only 20 little capsules!" And together, we haven't done anything to make that dialogue any easier. Is there something we can do, either within our industry associations, or as Norwich Eaton? Can we help write a set of questions and answers that help you respond to issues involving the cost effectiveness of Pharmaceuticals and of your services? Or can we print a folder that you can give the customer to explain these issues, or to send to all your 22 25,000 automotive deaths and thousands more serious disabilities are due to intoxicated drivers. Such^ products may impart a false sense of security to persons consuming alcoholic beverages. They drive when they should not and the end result could indeed be disastrous to the drivers and to innocent victims. Nevertheless, manufacturers have been encouraged to pursue studies to ascertain whether or not activated charcoal and fructose are effective for their claimed indications. At the time of publication of this article, these studies were not in progress. Consumer Advice The best advice for treating symptoms of overindulgence and hangover is to not imbibe in the first place! Since this advice is unlikely to be heeded, there are several OTC products that have been found to be effective for the resulting upset stomach and hangover. They include Alka-Seltzer, Bromo Seltzer, and Pepto Bismol. Taken as directed, these products pose no problems to most individuals. However, people with special medical problems (e.g., those with aspirin sensitivity, patients taking anticoagulants and persons on lowsalt diets) should carefully read the product labeling to assure that it wiyfc not aggravate their conditions. Geriatric individuals should be reminded that their dosage is less than that of younger persons. They should also inform their physicians that they are taking these products. A customers before they need the products or services? Or can we produce a videotape they can watch while their prescription is being filled? Or a radio commercial you can air in your geopraphic area - or play on a cassette unit in your store whie the prescription is being filled? We'd be delighted to work with PPSI or NARD on any or all of these ideas to help you at the point of sale so that it doesn't become a point of conflict. We really are partners in this job of helping make sick people feel better. The more we act as partners, the better off the people will be. At Norwich Eaton, we feel uniform pricing is a vital part of the equation; but good communication is the key: our communications with you; your discussions with us; and your dialogue with your customers. We at Norwich Eaton stand ready to cooperate wherever we can. Thank you for inviting me here. UTAH PHARMACY DIGEST / APRIL 1987 DITROPAN (oxybutynin chloride) Tablets and Syrup GAVISCON Tablets and Liquid SILVADENE® Cream (1% silver sulfadiazine) OS-CAL® 250 Tablets OS-CAL 500 Tablets OS-CAL® Chewable Tablets NITRO-BID Capsules (nitroglycerin) 2.5 mg, 6.5 mg, and 9 mg NITRO-BID® Ointment (nitroglycerin 2%) CARAFATE® Tablets (sucralfate) 1 gm JMM CARDIZEM Tablets (diltiazem HCI) 30 mg and 60 mg Unique products with unique for pharmacy M PHARMACEUTICAL DIVISION MARION LABORATORIES. INC Utah Pharmaceutical Association EXECUTIVE BOARD MINUTES February 19, 1987 The status of the PSAO organization, RPUI, was discussed. The first bid to a major health care provider is being prepared and made ready for submission. The necessity for PSAO's in Utah is becoming more apparent each day. A status report will be made next month. The 1987 budget was reviewed and approved. Publications for media were approved and more are available. The 1987 legislature has been a very positive experience. The pharmacists who contacted their legislators and gave such great follow-up are to be commended. The concern over physician dispensing was discussed. It needs to be monitored. Mail Order Pharmacy was discussed and a complete report will be given in regular board meeting. First Aid Station at the State Capitol during the legislature was a tremendous success and UPhA received a letter of appreciation from the legislature. It was suggested we do an article on leaders in pharmacy each month. Input for this program must come from pharmacists throughout the state. Utah Pharmaceutical Association BOARD MINUTES OF TRUSTEES MINUTES February 19, 1987 Executive Board Minutes were reviewed. Del Rowe, UPhA Legal Counsel, gave an update on the pharmacy mail order status in the state of Utah. A resolution has been prepared to present to the Board of Governors of the Salt Lake Area Chamber of Commerce outlining the harm and effect of mail order pharmacy to the citizens of Utah. The resolution will be presented on March 10, 1987. Improved patient counseling was discussed and programs are being planned to help the pharmacists. Annual Convention is well planned and all activities and meetings will be great. Committee Reports were presented: Rob Holbeck reported on PSAO activitiy as a help to retail pharmacy. Bill Stilling discussed the upcoming C.E. program at the University of Utah. Bob Peterson commented on the fervor over mail order pharmacy and the need for annual convention resolutions. Frank Robles asked all pharmacists to complete the UPhA speakers faculty forms as printed in the January 1987 Digest. Russ Hulse outlined the USHP annual meeting. Their subject is high blood pressure. The C.E. session registration for Sunday starts at 7:30 a.m. on Sunday, March 28. John Downs the SAPhA representative reported on their activities at the U of U School of Pharmacy. Their awards banquet is planned for May 18, 1987. Todd Ebert was commended on his help on the legislative effort. FOR SALE MAKE YOUR IBM PC-AT with 3 P.M. Pharmacy Software Write to: John Shumway P.O. Box 9 Duchesne, Utah 84021 [phone] RESERVATIONS TODAY FOR ANNUAL CONVENTION 24 UTAH PHARMACY DIGEST / APRIL 1987 * o Active Ingredients, CompuPhase 3m has everything you need ... it's the total pharmacy computer system. CompuPhase 3™ is an enhanced version of National Data Corporation's DataStat™ system, an IBM based product which has been installed in over one thousand pharmacies! 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At Grant-Hatch and Associates, Inc., though, our professionals are trained to keep your insurance needs in step with the times. We are an independent insurance agency, built on a history of tradition and service. We can use our knowledge to protect you and put your insurance dollars where you will receive the greatest benefit and protection. The Utah Pharmaceutical Association is pleased to announce their endorsement of the Utah Pharmaceutical "Package Policy" now offered through Grant-Hatch and Associates. This new program is designed to meet the property and casualty insurance needs of UPh A members by offering excellent coverage, service and pricing, along with a "Premium financing" program to facilitate enrolled pharamcies. 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