Sunday, March 25, 2012

Research: Pharmacists and Pharmaceuticals in Your Writing


The Rockville 8 welcomes licensed pharmacist Dave Hopkins to answer questions related to pharmacists and pharmaceuticals. Dave graduated in 1990 from The George Washington University with a Bachelor of Science Degree in Biology. In 1993, he completed his Bachelor of Science Degree in Pharmacy from the University of Maryland, Baltimore. He has worked in retail pharmacy since 1988 and has been a licensed pharmacist since 1993. Currently, he owns and manages his own retail pharmacy in Maryland which he has done since 2004. Dave answers questions for the Rockville 8.

We welcome your questions as well so if you have any research questions or any other questions, ask away!

1. What things relating to pharmacists or pharmaceuticals are unrealistic when you see them on TV, in a movie, a book or some similar venue?

Actually, I rarely see pharmacists portrayed on TV or in literature. The TV series 2 and ½ Men had a periodic pharmacist role and he was usually seen taking furtive sips from a codeine cough syrup bottle. Amusing but not really flattering or realistic. And of course who could forget the impoverished pharmacist who sold Romeo the poison with which he ultimately committed suicide? More flattering characters can be found most anywhere. I Googled the topic and there are several web pages that discuss the lack of pharmacists in fictional literature and I have included one of them here.

http://pharmacist.hubpages.com/hub/PHARMACISTS-IN-FICTIONAL-LITERATURE

2. What is a common misconception the general public has regarding pharmacists?

I think, historically, we are often perceived as boring, curmudgeonly old men who hide in our pharmacy lab, avoiding the general populace. In a more contemporary setting we are seen as harried, overstressed gatekeeper’s who keep someone from getting their medication and blaming it on ‘insurance restrictions’ or the like.

3. What is your favorite part and what is your least favorite part of your job?

My favorite part is interacting with my patients and improving their health outcomes through my knowledge of pharmaceuticals. I always enjoy answering health related questions and get a real satisfaction when I can positively affect someone either through question/answer or by the medication I provide. My least favorite part is dealing with insurance companies. Despite what many people seem to think we don’t get a thrill from telling you your refill is too early or some medication isn’t on your insurance plans formulary. While I can empathize with someone over their frustration, I also must say my least favorite part of the job is being barked at over insurance issues, mainly since I have no control over them.

4. Beside you, what resources are there available to writers if they have a question?

All states have local pharmacist associations. In addition there is the American Pharmacist’s Association as well as several other national pharmacy trade groups. Most pharmacies receive free trade publications (such as Drug Topics) which describe current trends in the pharmacy profession. Finally every state also has a board of pharmacy which regulates all pharmacists as well as pharmacies operating in the state. In Maryland the board of pharmacy falls under the purview of The Department of Health and Mental Hygiene and the website is www.mdbop.org.

5. What would you like to tell writers that we haven’t covered here?

Pharmacists often work in different settings and have different skill sets accordingly. I have spent the bulk of my career working in retail pharmacy settings and my skills are very different than a pharmacist who has spent many years working in a hospital, a long term care facility, or perhaps a mental health facility. The one thing that remains constant among any competent pharmacists is the knowledge of medications and the uncanny ability to read extremely poor handwriting. This includes dosing, side effects, and their prescribed uses (yes when you get an antibiotic filled the pharmacist knows where and what your infection is based on the antibiotic prescribed). If you wish to have a hospital pharmacist in your writing then you should sit and talk to a hospital pharmacist about their job. The same goes for a pharmacist in any other setting. Most pharmacists are more than ready to talk about what they do and the amount of training they received in order to do it.
I hope this was helpful, after all I would love to see a story someday that had a pharmacist as the protagonist, or at least a secondary character more flattering than Shakespeare’s pharmacist.

16 comments:

  1. Wow, Dave~ I can't believe I'm the first to comment.

    Interesting post. I really like our pharmacy guys, Glenn and Gary. Always so helpful. My question is about drug side effects. I know I could research this on my own, but since you're here.....:)

    I'm plotting out a RS where the bad guy uses a medication prescribed for a child (a six-year-old) and gives it to an elderly woman. I need/want the med to cause increased dementia in the woman. Got any suggestions?

    Thanks so much for taking the time outta your day to help us!

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  2. Thanks, Dave, for guest blogging with the Rockville 8! And thanks to Lisa for bringing you here. Your advice on how to research pharmacy and pharmacists is great stuff.

    Lynda -- your comment already has me wanting to read your RS!! LOL! Can't wait to see what Dave has to say . . .

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  3. Hi Dave,

    Thanks for joining the Rockville 8; it's great to have an expert on the blog.

    I write mysteries and so I'm always looking for a unique and undetectable way to kill people. I'm not the only one. Agatha Christie kept a notebook of poisons from which she doled out death. But I digress...

    I'm curious about how pharmacists in places like CVS keep tabs on their cold and sinus RX. I know these drugs are carefully monitored because of their use in making meth.

    I also want to ask you about how people who purchase their drugs from online sites using prescriptions from a variety of doctors keep from mixing incompatible drugs--or maybe they do? what's your experience been?

    Thanks!

    Shellie

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  4. Hi Lynda -

    A couple of choices might work:

    First a medication for ADHD (attention hyperactivity deficit disorder) in a significantly high dose could cause agitation, confusion, possible hallucinations and/or a dementia like state. This would be pronounced in a patient that has kidney disease which reduces renal clearance and therefore causes higher levels of the drug to circulate in the body. Children as young as 6 years old often aren't prescribed these medications, but I have seen it and certainly children as young as 8 are put onto them. Possible medications include Ritalin (methylphenidate), Adderall (mixed amphetamine salt), Concerta (extended release methylphenidate), or Focalin (dexmethylphenidate). Any of these meds could be crushed and given with food with the exception of the Concerta which cannot physically be crushed due to dynamics of the tablet.

    Another option would be high doses of pain medication, especially liquid morphine which is sometimes given to children for serious health issues. Morphine liquid comes in a 20mg/milliliter strength. This is very potent, children usually receive .5ml per dose or less. An elderly adult who received 3-5ml would certainly be 'out of it'. As a liquid it could easily be applied to food or drink.

    Two problems with both of these medications are that, one, the body develops tolerance to the drug rapidly so it would take more and more per dose to put the patient in a 'dementia like state'. Two, is that both of these drugs would appear in any standard toxicology screen.

    A third, and perhaps in your situation's better choice, would be hydroxyzine hydrochloride tablets which are an older antihistamine that is used in both children and adults. As an antihistamine it can be prescribed for allergic reactions but it is more often used now for its sedative qualities. It can be used to help insomnia or treat anxiety especially in patients where the prescriber wants to avoid a habit forming drug such as a true sleeping tablet or a narcotic sedative. Hydroxyzine is converted in the body into cetirizine. This could be important for your story because cetirizine has been patented and marketed as an over the counter antihistamine for several years now in the United States under the tradename Zyrtec. In other words adding Zyrtec to hydroxyzine is like doubling the dosage, and Zyrtec is easily purchased in any pharmacy since it doesn't require a prescription. In small doses it produces simple sedation but in larger doses it can produce lethargy, hypersomnolence (excessive sleeping), hallucinations, confusion, forgetfulness, and possible seizure or convulsions.

    Hydroxyzine hydrochloride is freely soluble in water which means it could be dissolved in a number of drinks and would only need something with flavoring to cover the taste. It is metabolized in the liver (vs being excreted through the kidneys) so a patient with liver disease would once again suffer more side effects from a lower dosage since a compromised liver means it would take longer to metabolize the medication. Hydroxyzine would not show up on a standard toxicology screen.


    Let me know if these choices wouldn't work in your story and I'll see if I can come up with something else.

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  5. OMG, DAVE!!

    You have been sooooo helpful to me. Thank you, thank you, thank you!

    Absolutely using hydroxyine hydrochloride is the route I'm gonna take. You've made the most complicated part of my plotting out my story a total breeze now. If I haven't said it enough, let me say it one more time:

    THANK YOU!!

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  6. Ah, this is an interesting topic! You're right, I don't remember reading much about pharmacists in novels. Ha, maybe this blog will change that. :)

    Ok, here's my question for Dave, and don't feel bad if you don't have any experience with this because it's, well, really bad. Have you heard of Scopalamine? It's also called Columbian Devil's Breath or Burundanga. There is a lot of misinformation and exaggeration about it online, so I'm not sure how far I can take this in my current project.

    What I'm trying to find is a drug in either powder or spray form that - when blown or sprayed in someone's face - would render them either confused, easy to manipulate, or even just take them down. Fast.

    If I'm to believe the info online, Burundanga can do this, but a lot of the stories seem far-fetched. Even for a fiction writer. LOL

    Thanks for any info at all!

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  7. Thanks, Evie. It's great to be here. I've enjoyed answering everyone's questions.

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  8. Shellie,

    Undetectable poisons...remind me not to get on your bad side! But I'll throw this one out for you anyway. Potassium chloride or calcium chloride are electrolytes in the body that are critical for proper muscle function, specifically cardiac muscle function. An overdosage of either, usually through injection, will lead to cardiac arrest. The elevated levels of either electrolyte would be detectable during an autopsy, but if we are talking about an elderly patient who may succumb to a heart attack naturally then there is a good chance no autopsy would be performed unless the family demanded and paid for it.

    On to your questions. Pseudoephedrine is a nasal decongestant that some enterprising methamphetamine home cooker figured out can be transformed into methamphetamine with a host of chemicals that can be purchased without regulation. It is a messy, smelly process involving highly flammable chemicals that often results in a fireball and the death of the cookers. At that time meth cookers would go into large drugstores or mega-marts and buy all the tablets off the shelf and use them to cook. The first attempt at regulation was to ban the sale of bulk ephedrine (the precursor to pseudoephedrine) and to require that the pseudoephedrine tablets be packaged in packages of no more than 30 tablets and for them to be packed into blister packs. Methamphetamine cookers then began going from store to store and purchasing many packages of the medications and then sitting around popping the pills out of the blister packs in order to be used in the cooking process. This became known as 'smurfing' on the street.

    After the Combat Methamphetamine Act of 2005 was passed the pseudoephedrine containing tablets are now required to be kept behind the counter of the pharmacy or in a locked case and the customer must show identification to purchase them. In addition to showing photo identification, the patient must sign for the medication and it is tracked in a store computer because the law limits the amount of pseudoephedrine (in milligrams) that can be purchased in a day. However there is no 'national' type database to stop criminals from going to many different locations and purchasing the tablets. In each store the purchase data is usually stored on computer, although some small pharmacies still use handwritten logbooks, and is available to law enforcement agencies if there is a suspected problem.

    Ordering drugs through the mail can definately lead to medication interactions, just as going to multiple brick and mortar pharmacies can as well. Any pharmacy has a computer that tracks what you are taking and automatically checks for interactions between medications. If the computer thinks there is a problem it alerts the pharmacist who then makes the judgement call of whether this is a concern or not. These computer programs are set to be hypersensitive in that they alert the pharmacist of every possible interaction that may occur, no matter how minute the chance. Patients who go to multiple pharmacies run a real risk of having these interactions occur since they are not being screened at one central facility. As for how patients determine if there is an interaction, I really don't know. I have had patients call and ask me about medications filled at other pharmacies and I usually refer them to the pharmacy where the prescription was filled. There are a slew of legal reasons why I can't counsel a patient about medication filled somewhere else. I would guess they either don't bother or they troll the internet looking for answers.

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  9. Dave ~ Thanks for joining Rockville8 this week to share your expertise. I love the post! Here's my question: I'm planning a romantic suspense where the villain strikes by "injecting" a drug/poison into the bloodstream during a procedure. What kind of drug or plant extract would allow the victim to leave the "outpatient care facility" seemingly fine, but hours (or even days later) come down with symptoms that would/could lead to death. And would there be an antidote? Also, ideally, I'd like the drug/extract to seem at autopsy like a natural occurance in the body or have broken down. Any suggestions?

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  10. One more question for you, Dave. (See, now I'm on a roll) . . . I've written a historical novel--set in 1811 Regency England. There's a secondary character who ingests an herbal/plant extract that allows him to fake his death in front of witnesses. His heart-beat becomes slow and so shallow his vitals can't be detected. (Rather like The Illusionist). Any recommendations about what kind of drug could fake this death (something that's been around and maybe known for hundreds of years)?

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  11. From Dave Hopkins:

    Shellie,
    Undetectable poisons...remind me not to get on your bad side! But I'll throw this one out for you anyway. Potassium chloride or calcium chloride are electrolytes in the body that are critical for proper muscle function, specifically cardiac muscle function. An overdosage of either, usually through injection, will lead to cardiac arrest. The elevated levels of either electrolyte would be detectable during an autopsy, but if we are talking about an elderly patient who may succumb to a heart attack naturally then there is a good chance no autopsy would be performed unless the family demanded and paid for it.
    On to your questions. Pseudoephedrine is a nasal decongestant that some enterprising methamphetamine home cooker figured out can be transformed into methamphetamine with a host of chemicals that can be purchased without regulation. It is a messy, smelly process involving highly flammable chemicals that often results in a fireball and the death of the cookers. At that time meth cookers would go into large drugstores or mega-marts and buy all the tablets off the shelf and use them to cook. The first attempt at regulation was to ban the sale of bulk ephedrine (the precursor to pseudoephedrine) and to require that the pseudoephedrine tablets be packaged in packages of no more than 30 tablets and for them to be packed into blister packs. Methamphetamine cookers then began going from store to store and purchasing many packages of the medications and then sitting around popping the pills out of the blister packs in order to be used in the cooking process. This became known as 'smurfing' on the street.
    After the Combat Methamphetamine Act of 2005 was passed the pseudoephedrine containing tablets are now required to be kept behind the counter of the pharmacy or in a locked case and the customer must show identification to purchase them. In addition to showing photo identification the patient must sign for the medication and it is tracked in a store computer because the law limits the amount of pseudoephedrine (in milligrams) that can be purchased in a day. However there is no 'national' type database to stop criminals from going to many different locations and purchasing the tablets. In each store the purchase data is usually stored on computer, although some small pharmacies still use handwritten logbooks, and is available to law enforcement agencies if there is a suspected problem.
    Ordering drugs through the mail can definitely lead to medication interactions, just as going to multiple brick and mortar pharmacies can as well. Any pharmacy has a computer that tracks what you are taking and automatically checks for interactions between medications. If the computer thinks there is a problem it alerts the pharmacist who then makes the judgment call of whether this is a concern or not. These computer programs are set to be hypersensitive in that they alert the pharmacist of every possible interaction that may occur, no matter how minute the chance. Patients who go to multiple pharmacies run a real risk of having these interactions occur since they are not being screened at one central facility. As for how patients determine if there is an interaction I really don't know. I have had patients call and ask me about medications filled at other pharmacies and I usually refer them to the pharmacy where the prescription was filled. There are a slew of legal reasons why I can't counsel a patient about medication filled somewhere else. I would guess they either don't bother or they troll the internet looking for answers.

    ReplyDelete
  12. From Dave Hopkins:

    Misty,
    Congratulations you did have me stumped with the term burundanga and I had to do a little research. As you are aware burundanga is a naturally occurring form of scopolamine. Scopolamine is found natuarlly in a number of other plants worldwide and has been used medicinally for thousands of years. Early Chinese reported using jimson weed, in which scopolamine occurs naturally, as part of a general anesthesia recipe to help treat battle wounds. This recipe was duplicated in the early 19th century and used to perform numerous surgeries by Shutei Nakagawa.
    Scopolamine falls under the category of anticholinergic agents which all affect the involuntary smooth muscle in the human body. Involuntary smooth muscle is located in the lungs, intestines, pupils, heart, and urinary tract. Scopolamine blocks the activity of the neurotransmitter acetylcholine in these tissues which leads to death in large enough doses. In extremely small doses it is still used to treat motion sickness, urinary urgency issues, diarrhea and some eye issues. It can be administered as a tablet, a transdermal patch or as drops. In large doses it is fatal and is accompanied by difficulty breathing, cardiac arrythmia, convulsions, hallucinations, extreme lethargy, loss of inhibition and pronounced memory loss. These effects can be countered by administration of the drug physostigmine which blocks the activity of scopolamine at the nerve synapse.
    Taking these side effects into account German scientists, including the infamous Dr. Mengele, experimented with scopolamine as a true serum. Results were mixed, but there is no doubt that the memory loss and loss of inhibition was enticing to the Nazi's for extracting information from prisoners of war. In this manner scopolamine was usually injected but it could be ingested if the dose was large enough.
    So what does all this mean for your burundanga? I am afraid that there is no evidence of any incident where scopolamine, the active ingredient in burundanga, was 'blown' into the face of a subject to induce a stupor. All the reported cases of scopolamine toxicity I could find in scientific literature were of people who had ingested food or drink that was laced with the drug. In this manner there is no doubt that a stuporous, trance-like state would occur; but not from casual inhalation. One source I found did report on cases of people soaking marijuana in scopolamine solution before smoking in order to attain a greater hallucinogenic state. Marijuana by itself does not cause hallucinations except in very large doses. I suppose it takes all kinds of people to make the world go 'round.
    Unfortunately I could find no other reliable sources for a sedative-hypnotic which would cause stupor from such casual contact as being blown in the face.

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  13. From Dave Hopkins:


    The traditional answer to this would be arsenic. Arsenic kills with only a trace amount, breaks down quickly, and it is detectable only by a test known as the Marsh Test (named after nineteenth century British chemist James Marsh), which is a highly specific forensic test. The test is only performed when poisoning is suspected. Acute symptoms of arsenic poisoning include: vomiting, abdominal pain, diarrhea, dark urine, dehydration, vertigo, delirium, shock, and eventually death.
    The problem with arsenic in a story with a current setting is its inaccessibility. Arsenic use is extremely limited and only available in the mining and timber industries in any large amounts. Lumber used in outdoor settings, known usually as treated lumber, used to be impregnated with a number of chemicals to prevent rotting. One of those chemicals was arsenic, but arsenic is now no longer used in this country, mainly since this timber is often used in playground settings around children. Long gone are the days of Kesserling’s two little old ladies poisoning men with elderberry wine laced with arsenic. In those days arsenic was freely available in drugstores for use as rat poison.
    Perhaps a better choice for an outpatient facility would be botulinum toxin. Botulinum toxin is produced by the bacterium clostridium botulinum and can only live in the absence of oxygen. It is closely related to clostridium tetanii, the bacteria that causes tetanus poisoning, or lockjaw. Traditionally c. botulinum would cause food poisoning in improperly stored, or canned, foods and it is deadly poisonous in only trace amounts. Stored food that is contaminated is often swollen (the can) or foul smelling and should be disposed of in a way that no living creature can access it.
    It has been estimated that a teaspoon of the pure toxin could kill over a billion people. That’s some serious ju-ju.
    However in the interest of science botulinum toxin is used for a legitimate medical purpose. Yes it’s used to treat wrinkles. Botox is an extremely dilute solution of toxin that is injected, just under the skin, directly into wrinkle. The local action of the toxin weakens the muscle tissue under the skin, causing the muscle to relax, and the wrinkle magically vanishes. The effect lasts 3-4 months. The toxin has also been used in several optical procedures as well as to try and treat migraine headaches.
    Perhaps some unlucky soul could be injected with an overdose of toxin before leaving, or perhaps a large dose of toxin could be put on his or her food and then be consumed? Maybe the unlucky soul could consume a small amount, which then takes several days or weeks to colonize the host and then cause symptoms. Botulism toxin blocks muscular neurotransmitters causing what is known as flaccid paralysis, the patient loses all muscle tone. The classic symptoms of botulism include double vision, blurred vision, drooping eyelids, slurred speech, difficulty swallowing, dry mouth, and muscle weakness. Constipation may occur. The doctor's examination may reveal that the gag reflex and the deep tendon reflexes like the knee-jerk reflex are decreased or absent. This flaccid paralysis will eventually lead to death through what is called descending paralysis (head to feet), suffocation and loss of vital organ function. These symptoms can begin to occur as early as a few hours or as late as 10 days later depending on the amount the patient is exposed to. Botulinum poisoning is often diagnosed by the presence of the toxin in either the patient’s blood serum or stool.
    If the poisoning is caught early then an antitoxin may be administered. The patient will most likely still need hospitalization and medical intervention, but outcomes are generally positive. If the poisoning is far progressed then the patient would need to be put on a ventilator until such time that the toxin is removed and the muscular nerve endings rejuvenate themselves. This could take several weeks.

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  14. From Dave Hopkins:


    The short answer is that there is no such compound. But I did come up with, and it’s a bit of a stretch, is tetrodotoxin. Tetrodotoxin (or TTX) is derived from the poisonous pufferfish and is a well-documented toxin that is lethal. It works to block nerve transmissions, which cause it to interfere with heartbeat and respiration. Pufferfish poisonings have been documented as far back as the 1700’s when Capt. James Cook’s crew received a mild poisoning from eating improperly cooked pufferfish. The entrails were thrown to hogs onboard the ship and eaten raw. There were no survivors amongst the hogs.

    So why am I telling you about this? You only want to fake death, not actually kill. It’s because in looking up your question I came across a number of unsubstantiated claims of TTX being used to induce a sleeping or zombie-like state by voodoo practitioners in both Haiti as well as the southern United States. The claims are totally unsubstantiated. I am going to include several web links you can check out. These are not scientific pages, but rather pages that talk more about zombie history and genre in general. Have fun looking at them and maybe you can find some inspiration! Also Google the name Clairvius Narcisse.


    http://www.kingofthezombies.com/2010/09/tetrodotoxin-pharmacological-source-of.html
    http://science.howstuffworks.com/science-vs-myth/strange-creatures/zombie1.htm
    http://en.wikipedia.org/wiki/Zombie
    http://www.straightdope.com/columns/read/1324/how-do-i-go-about-creating-a-zombie
    http://www.biology-online.org/articles/dead_man_walking.html
    http://lizzy-huitson.suite101.com/zombies-voodoo-and-tetrodotoxin-the-truth-behind-the-myth-a249784

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  15. Thank you so much, Dave! Wow. You've given me some great information to further research. You are a treasure trove. Thanks again for taking the time to be our guest this week. I've enjoyed your responses!

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  16. Dave,

    You're a wonder! Thanks for stopping by the R8 and sharing your expertise with us!

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