Tuesday, April 30, 2013

Farewell To Walgreens Pharmacy and a Tsk-Tsk Too

The mortar and pestle, one of the internationa...

A Judgment Call


Walgreens Pharmacy has served me for years, been a partner in my medical care, and been a friend at times when I felt as if the entire system was against me simply because I live with pain every day.  (I have also been a long time customer of the entire store)  This connection has been built over many years, and as with any part of the management of my pain or other medical issue, is  very important.  I knew the various staff, I was comfortable.  It is sad to lose that.

I am not a 'pharmacy-hopper' or a 'doctor-shopper'.  I create long-lasting partnerships in my pain management, including the pharmacy at which I choose to fill prescriptions.  After decades of spine and knee surgeries, various procedures, trials and novel treatments, all performed by respected surgeons (Neuro and Ortho) Pain Management physicians and the well-known clinics they practice in; I am a credible and compliant patient with a medical history starting with severe trauma going back to my teens.

One thing that does change over the years is employment, health status, etc., and I have been a customer with various insurances, and also a cash pay customer.  One year I paid about $12,000 cash for prescriptions, and I did not spread that love around to other pharmacies, that was all for Walgreens.  Ouch.

So why am I leaving Walgreens pharmacy?

Let's start with the phone call.

I was returning a call from the Walgreens pharmacist who was refilling some medications I had submitted via the convenient text & email refill alerts they offer.  He had said on the message that there was a "problem with one of the medications" and needed to talk to me.  I thought I may know what he was referring to with one of the refills, and was shocked to find out what the 'problem' really was.

Asking what he wanted to talk to me about, the pharmacist said something about a new Walgreens policy regarding pain medications and that he couldn't refill the Soma prescription.

Soma, or Carisoprodol, is a muscle relaxer.  Granted, it definitely helps with the deep pain and the movement restriction of severe muscle spasms (ergo why it has been prescribed to me for years) but I beg to differ on his wording.  I asked him if he could repeat what he had said.

"We at Walgreens in an effort to protect ourselves and our customers, have a policy regarding certain medications and in all good faith, I cannot dispense this medication at this, or any other Walgreens."  I was a bit taken aback and asked him to please repeat himself, and I grabbed a pen & paper.  He stated this again, and was definitely reading this statement off a paper.  I asked him if this meant that no Walgreens now would fill Soma, and the pharmacist read the same thing to me.  He chose to do this instead of talking to me like a person.  He was completely ignoring my pertinent, non-argumentative questions.  This was very aggravating and I felt it necessary to be 100% clear on what the pharmacist was attempting to get across to me.

I said that I need him to clarify this.  He began a another script-reading and I stopped him.  I told him I am a nurse, I am not arguing with him, I just needed to understand exactly what he was telling me.  Had Walgreens implemented a new rule that certain medications were not to be filled?  That doesn't make much monetary sense.  Was there some problem with my profile on their system?

Or was this a judgment call?

He refused to speak to me on a human level, and began to re-read the same thing.  At this point, I realized there was no getting through to this Pharmacist on the phone.  I asked him for his name, and he gave me his first name, which I already had from his voice mail.  I asked for his full name, and he hesitated, saying, "I don't usually give my last name", and proceeded to tell me.  I asked him to spell it, and he did.  I thanked him and hung up.  I was never angry or rude, I was calm and respectful.

Speechless, I began writing down everything that was said.  I looked his name up on the licensing board, and he looked to be related directly to Walgreens.  My friend then called the store and asked for the name of the store manager, who was not in at the time.  The assistant manager was eager to help, and gave the name of the Pharmacy manager when asked.  The Pharmacy manager is one and the same as the script-reading Pharmacist. Helpful assistant manager asked if he could do anything else, and at the time, that was all that was needed.

Recently, Carisoprodol was introduced into the DEA Schedule as a Schedule IV.  After January 11, 2012, Carisoprodol prescriptions are limited to 6 fills per prescription.  (Initial plus 5 refills)  I was aware of this change and my doctor's office also, letting me know last year that the doctor would need to write a new prescription to comply with the refill limits due to this change.  (The Walgreens I've gone to for years also alerted me to this)  Nothing else changed in the filling or refilling of this medication that affected me in any adverse way.

Until now.

Unable to find anything else that would clue me into why this one Pharmacist refused to refill this medication, I decided to go in person, and meet face to face.  We had spoken on the phone late, and I went in to his pharmacy the next day.  Unfortunately, he was not in, and would return after the weekend.  The Pharmacist there was not contracted with Walgreens, and was one of the nicest people I have met lately.  Smiling, he answered what he could of my many questions, letting me know that he could not fill the Soma because of what the other Pharmacist had done, and he was unable to override the manager.  I expressed my frustration with the pharmacy manager including his lack of communication skills and his inability to just talk to me and explain the situation.  It was recommended that the prescription be transferred across the street to another pharmacy, I agreed, and that was that.  The Soma was filled with no problem.  Yet I was not finished with this.  Too many unknowns.  I dislike unknowns in my own medical care.

A few days later, it was time to fill my monthly pain medication.  I have filled this same med at Walgreens Pharmacy for years, just as I have with my Soma.  I decided to take the security prescription to the same Pharmacist that had denied my Soma prescription.  I felt this would most likely not be a simple fill like usual, as this med is a Schedule II.  I was not looking for a challenge, I was hoping to simply meet the Pharmacist and let him see me, hear me, and understand that I am a stable and compliant patient, not a drug-seeker, or anything close to that.  If that was his reasoning for denying to refill the Soma, he made that call before he ever left me a voicemail that something was wrong with one of my prescriptions.  I could have easily filled this medication at the Walgreens by my physician's office where I have been a customer for years.

Again I went in, and again, the Pharmacy manager was not there, and again, the really nice Pharmacist that doesn't work for Walgreens was.  I had to laugh when handing him the prescription for my pain medication saying, "I imagine this will not go over very well considering what happened with my Soma."  He had more information this visit about the new rules that required the pharmacy to contact my physician, who then needed to write very detailed notes about my pain, if 'weaker' meds had been tried out, etc., and that this documentation would take a few days, leaving me without medication during this time.  I still wanted to speak to the manager.  My back was in severe pain and I was unable and unwilling to make a third trip back.  I realized then that I was not meant to meet the Pharmacist that had denied me a medication that allows my body some freedom of movement, some sort of help for the severe muscle spasms I have all day long.  I realized filling any type of medication related to pain was going to be a problem here.  I also realized that this Walgreens Pharmacy was not one that I wanted to be a customer of.  (Excluding the non-contracted Pharmacist from all of this-- he was so helpful, with excellent customer service skills and would be a perfect Pharmacy manager).

It didn't take long for me to decide that because of this one Pharmacist's judgment call, who has never met me, who only has a computer screen to 'know' me through, who never said, "why don't you come in tomorrow and I can explain this to you in person"; because of that I am now done with Walgreens Pharmacy altogether.

I recently moved just a few miles further south, and the Walgreens I speak of (with the Pharmacist and his interesting customer service style) would have gotten all of my business, both in the Pharmacy, and in the store.  It is convenient in location, it is the same familiar layout, all the little things that go with a place frequently shopped.  I did my best to try and establish a new and hopeful long-term relationship with the Pharmacist.  No attempt was made to contact me after I had gone in, and I made every effort to speak to him in person.

After my experiences in both nursing and as a patient, I understand there are some people that simply won't budge, who refuse to open up, and are all too quick to judge.  Decades of Pain Management have taught me to not waste time in any part of the treatment of my daily pain.  Let's all remember:  I live with severe spinal pain.  I am the patient here.  I am not the nurse, the manager, or the lawyer who must plead their case.  

When Walgreens Corporate receives my letter including my blogs address so they can read this, will they care?  Take note?  Respond?  Or am I just a person that really doesn't matter to them, even if I am a long-time loyal customer?  However it all shakes out, it took only one, one employee, one Pharmacist, one Pharmacy Manager; to quickly bring down what many other Walgreens Pharmacy employees have worked hard to build with me.  Tsk-tsk, Mr. B., you should be ashamed.

Oh, and when I filled my meds across the street, it definitely was personal.          



Gentle Hugs....



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Thursday, March 21, 2013

Costotransversectomy Video

The second Thoracic spine surgery I had was in 2001, called a Costotransversectomy, with discectomy and fusion.  At T-9/10, I had an anterolateral disc protrusion, causing severe upper back pain.  A highly respected and recommended spine surgeon in Arizona was doing a newer (at the time) anterior approach through endoscopy for cervical and thoracic spines.  I was excited at the thought of a few band-aid scars and the easier recovery from a spine surgery without the large paraspinal muscles being cut!

After reviewing my studies, he suggested that the surgeons go with a more traditional approach, and do open back surgery.  My Neurosurgeon chose Costotransversectomy, removing a piece of the rib (costectomy) the herniated disc material (corpectomy) and finishing with the hopeful added stability with a fusion of the T9/10 vertebrae.

Costovertebral articulations. Anterior view.
Costovertebral articulations. Anterior view. (Photo credit: Wikipedia)
Costotransversectomy was first performed in 1894, by Dr. Menard.  In this surgery, the spine is accessed through an open back incision, the proximal rib that attaches to the thoracic vertebrae creating the Costovertebral joints, is cut so as to allow a clear view and room to work on disc, tumor, spur, etc.  The simple fact that the ribs are 'in the way' for many thoracic procedures, lends to the use of this approach, and also used for surgery on anterior or lateral herniations, osteophytes, etc.  The transverse process of the vertebrae is then cut, leaving a nice view and area to work.  This surgery can only be done in the thoracic spine.  

Costotransversectomy is a combination word, like most medical terminology.  Costo: ribs.  Transverse: the transverse process of the vertebrae.  Ectomy: the act of cutting out.  ('ectomy' is usually preceded by the name of what is to be cut out, i.e., Tonsillectomy- here it is the rib and transverse process).

I found a video of a Costo, and may I note here that I have nothing to do with the soundtrack.  Thank the rockin' surgeons at University of Southern California Neurosurgery !!

In this operation, the patient is having work done at the same level as my surgery: T9 to T11.  There is also work done on this patient above at T7.  It is the approach via Costotransversectomy that is exactly like mine,  showing the cutting and resection of the rib and transverse process to visualize the needed area, and it is always interesting for me to see what my spine has had done to it!  Also in this video the surgeons insert hardware, and I did not have any put in.  Although twelve years later I feel as if the hardware shown in this surgery may give some feeling of stability to my spine.

Note the cut paraspinal muscles and the retractors necessary.  Minimally invasive surgery now completely eliminates the need for this, lessening recovery time, and even post-surgical pain.

Enjoy!!    Those of you that can watch surgeries that is.  ;)


Gentle Hugs....




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Tuesday, February 26, 2013

Cervical and Lumbar Spines: Welcome To The Party!

The trauma to my spine encompassed all levels and the subsequent attempts to correct the damage have revolved (mainly) around my Thoracic spine.  This 12-vertebrae level that attaches to the ribs, has been the main source of my pain- but now, the other injured areas in two of the remaining spinal levels are coming out to play.

It is time to formally welcome: Cervical and Lumbar spines to the party called my Life in Pain.

The severe trauma that my spine went through at age 16, is now (at 53) rapidly and suddenly showing in the two spinal levels more commonly known to have disc and spur issues, pain, and/or surgeries.  The Thoracic spine is not a level to routinely find herniations, etc., nor to have spinal surgery performed on.

The Cervical and Lumbar spines, however, are often seen on the surgical board for the day.  It is common to see procedures and other attempts at 'fixing' these two spinal areas, much more than in the Thoracic spine.

The most uncommon part for me right now, is that I do not know which level to pay attention to, from one day to the next.  Even seeing a Spine surgeon is challenging due to the fact that I may be there to see the doc about one level, and the day of the appointment, that level is quiet, yet the other level is screaming out in pain.  (This is common to find in Spine patients with a history of spinal trauma/surgeries, and must be accounted for in a patient with a c/o spinal pain; also seen in the randomness of how pain may one day be off the charts, and the next day feel tolerable.)


The Newest Guests and what they bring to the table:

Cervical Radiculopathy Upper extremity, R side, shoulder, arm, hand, thumb, index finger. (Six shooter)  L arm/fingers suddenly numb on occasion.

Lumbar Radiculopathy  Lower extremity, R side, sciatica, anterior thigh, numb below knee, to toes.

Radiculopathy:  The consequence of nerve root damage (from any cause) is known as a radiculopathy (L. radicula = little root; pathos = disease) When the exiting spinal nerve is compressed, usually by disc or arthritic spur, causing severe pain and tingling, leading to numbness of the extremities.

In my Cervical spine, there are again a number of Osteophytes.  At C6-C7, they are seen, also disc herniations are a strong possibility of another source of compression.  This level's soft tissue studies are not completed as of this writing.  C6-7 is the level that would innervate the exact areas I feel painful tingling, electrical shocks, numbness, severe muscle spasms, etc.  When the exiting spinal nerve root is compressed, causing radiculopathy, the patient can trace 'like the best anatomist', along the exact nerve path.

For the Lumbar spine, the soft tissue study has been done, and this was ready to be seen online during the visit.  However, when I went to the spine surgeon's, the L-spine was not the issue. (Oddly, to match, the entire office system had gone down, rendering my Lumbar CT scan irretrievable online.)  That day, that appointment hour, it was all about my Cervical spine.  This physician was interested in  my entire history of spinal trauma at a young age, the subsequent surgeries and procedures, and he was also very open about his feelings when I relayed the past year's hard work of titrating down the long-acting opiate medication completely to nothing.  He was not only moved that I had done that by choice, but obviously very pleased to hear me say that I would never agree to any long-acting opiate in my Pain Management again.

So I am there for a spinal level that isn't even hurting at the time.  Trauma/ injuries to multiple spinal levels will often alternate from one level to another.  From day to day, down to even hours.  I told him about the C-spine showing up suddenly and painfully after a recent rear-end hit and run.  He immediately said, "Let's look at that, since that is what's hurting you right now."

I had just gone to the ER for this sudden, scary and very painful Radiculopathy.  One of the best ER visits I have ever had. (That is another post--to give kudos--well-deserved by some outstanding medical personnel.)  I was in so much pain and with the quickening numbness down my right arm to my fingers, I had to push through the instant, 'No I will not go to the ER for any type of spine-related pain', block wall in my head that instantly arises when I am faced with seeking help for severe pain arising from my spine, and just do it.  Most Chronic Pain patients understand this aversion.

So spine doc does some UE (Upper Extremity) strength and reflex tests, feeling and looking strong there, no apparent muscle weakness, and next step is a Nerve Conduction study.  Gotta start the ruling out process.  Carpal tunnel?  Or Cervical spine?  We both know the answer.

Either way, the focus has shifted, and the pain is not from and in 'just' my Thoracic spine anymore, but also from the levels above and below-- Cervical and Lumbar are joining the party.  They came out to play, and they play hard.  May as well give the 'newbies' a nice welcome.  ;)  


Gentle Hugs.....

~~~~~~~~~~~~~~~~~~
'Did You Know'..........That we have 8 cervical roots?  Yet only 7 cervical vertebrae..... 

*Because there are only 7 cervical vertebrae despite 8 cervical roots, the root number exiting between two vertebrae is always the number of the lower vertebra.  For example, the C5 root exits between the C4-C5 vertebrae and would be effected by a C4/5 disc herniation; the C8 root exits between C7-T1 vertebrae and would be compressed by a C7-T1 disc. 

Pain due to a C6 and C7 radiculopathy radiates from the neck and from around the shoulder into outer aspect of the arm and forearm.  C6 radiculopathy may cause pain and numbness along the dorsal aspect of the thumb and index finger, C7- pain and paresthesia may radiate into the middle finger.*  Exactly what I am experiencing.  Down to the exact fingers and location of pain.

*Thanks to Neuroanatomy from Wisconsin U.  An excellent resource!

Friday, January 18, 2013

Over The Counter Medications in Chronic Pain

Many patients that suffer from chronic pain use a myriad of different medications, try various modalities, and will try almost anything in an attempt to obtain some sort of respite from the unrelenting assault to the body and mind.


Recently having ended nearly a decade of pain management physician-prescribed Morphine for the chronic pain in my spine, I find that the use of OTC (Over the Counter) medications are finding a definite place in my changing arsenal of treatments.


When opiates are prescribed and used as a part of your Chronic Pain Management program, it is common to see non-opiates either blended with the opiate, or used as an adjunct medication.


The most common OTC med found in opiates is Acetaminophen  or APAP.  (Brand name Tylenol)  Most people have had some experience with Vicodin, being the most widely prescribed medication in the U.S.  Vicodin (brand name) or Hydrocodone (generic) is mixed with APAP, and shown as the bottom number in all forms of the drug.  Example= 5/500 means that there is 5 milligrams of Hydrocodone, and 500 milligrams of APAP.  These are seen in the brands Loracet, Loratab and Norco.


There are dosage limits with any medication, and in the use of Acetaminophen, it is very important not to exceed 4,000 milligrams.  Especially with long-term use, damage to the liver can occur, among other issues.  I advocate patient education, and learning about the medications you use, including the dosage limits, is something everyone that is prescribed medication could benefit from.  Your doctor loves a well-educated patient!



Coated 200 mg ibuprofen tablets, CareOne brand...
Coated 200 mg ibuprofen tablets
(Photo credit: Wikipedia)
Also seen mixed into opiates is the OTC med Ibuprofen.  Commonly used with Hydrocodone, this medication can be found under the name brand 'Vicoprofen' for example.  The maximum dose per day of this OTC medication is 2.4 grams, or 2400 milligrams.  800 mgs. 3 times a day.


Used to augment a prescribed opiate, or alone as an adjunct to a non-opiate pain management program, these easy to obtain and relatively affordable over the counter medications are an excellent way to help manage your pain.  Along with many, many others who experience life with the constant companion called PAIN, I understand that my pain is managed, not obliterated.  That is reserved for after surgeries now, and living life without a long-term opiate pain medication is awesome--not only in it's clarity, but also in it's depth of my experience of pain.


I believe that when a chronic pain patient comes to a deep understanding that life will most likely be pain management vs. (total) pain relief, life will feel less on edge.  If we lower expectations, and move towards acceptance of the situation, what we are dealing with this day, this pain, this life, well, it may just seem a little more tolerable.


Even a little less pain is a very good thing.  



Gentle Hugs....
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