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Xrayser: Picky patients’ tasting notes have me reaching for the bottle

"Issues of taste and palate appeal are something that we come across regularly in the pharmacy"

Patients who demand to know whether Calpol is good chambré are turning pharmacists into salbutamol sommeliers, says Xrayser

Like many people, the last 12 months of lockdown turned me to drink. So much so that I decided it was time for some serious continuing professional development (CPD) and so enrolled with the Wine and Spirit Education Trust (WSET) because CPD and drinking combined – what’s not to like!

I soon realised that issues of taste and palate appeal are something that we come across regularly in the pharmacy, most often in the selection of medicines for children.

Whether it’s paracetamol suspension for a grizzly, snotty, teething child held by a mother who’s gone so long without sleep she looks like Sadako climbing out the well in The Ring, or that urgent antibiotic to prevent sepsis, the first question we’re always asked is: “does it taste nice?”

Now, I struggle with the question because, once weaned, our baby was fed everything we ate and grew up actively seeking taste sensations beyond burger and chips. Then again, we may just have been lucky not to share the experience of friends who could only administer medicine to their kids through a combination of pleading, guile, and waterboarding.

However, there are times that a patient seems to really appreciate the taste and nuances of their drugs. When supervising methadone consumption, there are two types of client. Many are those with such busy lives that they rush in, chug back the day’s dose with a mobile phone clamped to their ear like some Wall Street executive juggling multiple short sells, then rush off with an obvious urgency to be back doing the deal. But then there are also the connoisseurs, those who take their time and stand before you savouring the emerald elixir like a 1985 Romanée-Conti Grand Cru, trying to decide whether to award it 93 or 95 Parker Points.

But by far the most exasperating are the patients who require a specific, obscure brand of generic drug. I’ve been told everything from “I get better dreams with that make of zopiclone” to the empirically pretentious “my child is better behaved on that company’s trimethoprim suspension”.

This strikes me as the same prejudicial misconception shared by the “ABC” movement of wine drinkers, where “ABC” stands for “Anything But Chardonnay”. Chardonnay is one of the most versatile grapes and is the constituent part of some of the world’s greatest wines including those from Chablis, Mâconnais and Champagne.

Just as Appellation d’origine contrôlée (AOC) requirements govern the quality of Chablis wines, regulations guarantee that drugs of whatever brand or make are manufactured to the same specification, yet that’s not good enough for someone who demands their sertraline is supplied by Rocking Horse Excrement Pharma. Honestly, it’s enough to drive you to drink.

A long-running C+D contributor, the identity of Xrayser remains a mystery, but his irreverent views are known by all. Tweet him @Xrayser

19 Comments

david williams, Community pharmacist

Had one patient,had to be blue sildenafil. OK, psychological impact is important, especially witrh erectile dysfunction. Sourced a "blue brand". Rx was private, I explained £4.00. I'm not paying for them, why when RX is free in Wales?  Says it all really

Richard Judge, Manager

I was lead to believe it tastes nice it probably doesn't work but if it tastes disgusting and makes your eyes water you know it's good for you. 

 

David Kent, Community pharmacist

The root cause of this is not as those crying crocodile tears would have us believe. I write as a pharmacist who is now  consumer and not a provider of medication. I qualified in 1968 when most Rx were proprietory and have lives and worked through all iterations of the generic v. proprietory debate.   Pharmacists used to help their patients not just look at them as a profit point which I firmly believe for most pharmacists , not all,is the present case.  The quality and acceptability of generic medication varies widely, in particular, the form/shape,/size of tablets.  have known of many elderly, and perhaps not so elderly people, who confronted with widely differing tablet forms have followed the instruction on the pack and taken both.  I was, on one occasion, provided with two deiferent generic forms in one box and the balance when collected was different again.   I am a pharmacist I can cope with it but many cannot, including my wife who has to check with me.

The root cause of this is not, as those crying crocodile tears would have us believe but, profit.  There is no doubt, in my mind, that the pursuit of profit comes before patient satisfaction and safety.  Most of these slightly dearer generics are stil below DT price.  Most wholesalers list the different brands availble on their systems and therefore the suggested time taken to source s a falcy.  I despai for the future of this profession.   I could cite a lot of other examples of bad practice but will not do so now.

 

 

, Community pharmacist

Nothing to do with expense-its the time involved in sourcing.  You clearly have no appreciation of the time pressures in modern pharmacy practice.

C A, Community pharmacist

Try working for a multiple, you don't get that level of control. You get whichever generic is available and if you want something else you're going to end up on the phone. Which is great, apart from the fact it can take the wholesalers 10 minutes to answer the damn phone if they're busy, and if the manufacturer that you want is out of stock they're as much use as a chocolate fireguard.

"Oh that brand is out of stock" "I've no idea when it'll be back in stock, try again in a few days"

And good luck explaining to the patient that TEVA stopped making that generic... "but I need it" 

Edward H Rowan, Locum pharmacist

You are correct - some of the standards that I see are woeful in terms of presentation - not helped by the poor manufacturers' packaging, but badly spelt labels, prescriptions for capsules where the instructions tell the patient to take tablets, and labels stuck on boxes obscuring useful information are all common. The patients are entitled to think that if we can't get simple things right, what else might be wrong?

Adam Hall, Community pharmacist

I (now) take a view that says "The Government won't pay me to indulge you, so either you take what I can get or you wait until I can get what you want at the price the Government will pay, or you take it somewhere else". The ones that make me laugh are those who insist on Almus brand - right up to the point I open the pack to show them the actavis/teva/etc on the strip inside. As for GPs who 'insist' the patient should have a particular brand - prescribe it that way or GET LOST!

janet maynard, Community pharmacist

Trying to source a particular brand is just so time consuming as well as expensive. During the last couple of weeks we must all have spent hours trying to source a brand of fluoxetine liquid that isn't pinewood and Bristol brand of Hydrocortisone tablets!

 

Paul Dishman, Pharmaceutical Adviser

Just say it's all you can get and blame Brexit

 

 

David Kent, Community pharmacist

Typical Ph Adv response

janet maynard, Community pharmacist

Tend to agree! (How are you- haven't heard from you for ages!)

Paul Dishman, Pharmaceutical Adviser

Very well, thank you Jan. Happily retired now with an OU degree in history, but still like to keep in touch with pharmacy. Yourself?

C+D Xrayser, Community pharmacist

You're right. I don't mind so much the odd pennies, but it's the hassle of trying to source. BUT - no sooner is my rant out about the need for a particular make, than the MHRA give ammunition to those people with low thyroid who insist on Jobe  Scure Pharma brand of levothyroxine! I wasn't sure how evidence based was their pronouncement.

Alexander Dale, Dispenser Manager/ Dispensing Assistant

Dearest Xrayser, I'd like to buy you a drink. I take it that bottles delivered care of Chemist and Druggist HQ will find their way to you?

V K P, Community pharmacist

MHRA can give all ammunition that they wish too. however, what makes it worse is that PSNC have advised that the pharmacy contact the GP to get the prescription ammended. What a joke! The dispensing fee is as it says on the tin- Fee paid for dispensing. where has the calling the GP come from?? There is no provision for OOS for Cat M products which is where majority of the problematic generics are listed. Cherry flavoured paracetamol suspension is what the child prefers. It would be interesting to see what the GPs would do if they were mandated to select the manufacturer of every generic product that they prescribed. as soon as they type atorvastatin, they will firstly be faced with a list of all atorvas which is not that long. they select the strength and then another list pop ups with all the manufacturers which they then consult the patient on for the preferred choice. Would the appointment last 10 minutes?? 

When will PSNC learn not to be a yes sir organisation and think outside box and shift some of the burden to the GPs? then the BMA and CCGs will sort out the DHSC and MHRA for the generic non sense.

Getting Shorter, Community pharmacist

One of my favourite things about my current workplace is that the owner is happy to lose a script rather than make us move heaven and earth sourcing RHE Pharma for particular patients. 

It's also back to the "we shouldn't do things for free" discussion - I'd bet you'll lose money dispensing that item. I understand that in (some parts of?) Australia, patients are allowed to pay to "top up" to a prefered brand from the basic price... we might just find out how important the make ~really~ is to people if they had to find the difference!

Alexander Dale, Dispenser Manager/ Dispensing Assistant

Australian here, can confirm. The system works well. In addition, the GP has a box to tick which allows brand substitution or switching, makes life so much easier. Also, universal charging is absolutely key. Everyone pays something towards the cost of their medication.

Getting Shorter, Community pharmacist

Just out of interest (to see if I'm right to be cynical!), how many people are happy to top-up to their preferred brand? (Understanding results may be skewed if there is a general expectation to pay something in the first place... even moreso in Wales than England as all scripts are free here.)

Stephen Gabell, Community pharmacist

We can do this in Ontario. Government covers the cost of the generic, patient (or their private insurance) pays the difference. Some manufacturers have plans to help cover the difference in cost between brand and generic.

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