[Basic] Skill of the week: Pharmacy and Poisons

[The Colonel]

I'd be really surprised if a modern pharmacist was doing any formulation on modern pharmaceuticals - formulation is a big part of R&D and is a lot trickier than it looks from the outside. Converting something to be taken internally (like a pill) into a topical would seem to be a step not to be taken lightly (or without extensive clinical trials). Also, quite a lot of modern actives are extremely potent and need special equipment to handle them prior to being formulated.

I can see some kind of herbalist doing that - as in European Traditional, Chinese or Vedic medicine - but not someone who has to deal with synthetic pharmaceuticals.

[malloyd]

Originally Posted by Myrion

No more difficult than it is with doctors or any other highly educated and skilled professional. There are organisations overseeing standards in the labs and I think they have to do periodic trainings. What makes you think it's particularly bad for pharmacies?

Probably because a lot of pharmacies in the US are retail storefronts staffed mostly by people who don't appear to have those skills. I believe all states still require you to have somebody on the payroll who theoretically does, but he may not be very visible, and may in fact not have done any of that since grad school. The sorts of pharmacies that do routinely change the form and dosage of drugs are called "compounding pharmacies" in the US, and are a good deal rarer than the ones that simply move pills from big bottles into small ones. There's one hit within 20 miles of here, vs. 17 pharmacies, though I assume the hospital has such capabilities to, and isn't showing on either of those maps.

[Myrion]

@malloyd
Ah, I see. Here, it's pharmacy (Apotheke) vs drugstore (Drogerie), with the drugstores usually having a much more anti-, er, pseudo-scientific, erm.. alt-med bent. They can't sell prescription drugs, are much more "wellness" oriented and some go as far as selling organic food etc.

@The Colonel
Well, that's what I used to think, too, but I actually know pharmacists now and that's what they told me that they do.
As I understand it, most of what they do has actually been tested, but is not lucrative to mass-produce for whatever reason. They also do have all the special equipment - as I mentioned, pharmacies will often actually have a lab in the back. (Which is where you'll find the pharmacist most of the time, whereas the store will be staffed by pharma assistants.)

[Celti]

Here in Phoenix, Arizona, you have your standard “corner-store” or drugstore pharmacy, which always has one and occasionally has more than one actual pharmacist on hand (with Pharmacy (Synthetic), and Physician as a secondary skill), who supervises several “technicians” who the customers mostly interact with (who have Professional Skill (Pharmacy Technician).

Anyone who has medical issues that require them to have more than one doctor that they see regularly has learned it is a good idea to cultivate a long-term professional relationship with their local pharmacist — more than once I've had one doctor prescribe something that had potentially-lethal drug interactions with someone another doctor had me on, and it didn't get caught until the pharmacist received my prescription to fill.

Most doctors nowadays are specialists — when I can afford the medical bills, I regularly see a “general practitioner” (really a specialist in general Diagnosis with a secondary in “everyday medicine”, who treats the little stuff and knows where to send me to treat the big stuff), plus a psychiatrist and an endocrinologist, and often the local urgent care center for e.g., acute infections and such. Each of them knows their speciality quite well, but more obscure things outside their speciality can trip them up, and they won't catch, e.g., that the fact that I take drug A (outside of their speciality) prolongs my QT interval, meaning any drug out of class B (within their speciality) can be dangerous.

The pharmacist, however, is a specialist in general Pharmacy skill. Their training is explicitly in making sure that all the medications a person is receiving are actually treating what the patient has, and won't cause adverse interactions with each other. They are yet another vital part of the modern medical system.

[The Colonel]

Originally Posted by Myrion

@The Colonel
Well, that's what I used to think, too, but I actually know pharmacists now and that's what they told me that they do.
As I understand it, most of what they do has actually been tested, but is not lucrative to mass-produce for whatever reason. They also do have all the special equipment - as I mentioned, pharmacies will often actually have a lab in the back. (Which is where you'll find the pharmacist most of the time, whereas the store will be staffed by pharma assistants.)

Given what I've encountered working within the pharma industry, I find this really odd. Most jurisdictions rely on organisations like the FDA or MHRA specifically to prevent people messing about with pharmaceuticals.

Certainly a UK pharmacist is expected to know enough med.chem to know what drugs do (in a general way), to spot potential bad combinations (like when some idiot writes their patient up for several paracetamol preparations at once or two drugs with mutually antagonistic functions) and to be able to make low level diagnoses. They can also supervise the portioning out of pills from bulk packs and similar operations but will not formulate - and are increasingly unlikely to sell miscellaneous chemicals like potassium permanganate or iodine as they might have done twenty or thirty years ago.

Still, Switzerland has always been a law unto itself, so if people are hand formulating from actives there it would be within the range of "stuff that people do".

[CoyoteGestalt]

Originally Posted by Celti

Here in Phoenix, Arizona, you have your standard “corner-store” or drugstore pharmacy, which always has one and occasionally has more than one actual pharmacist on hand (with Pharmacy (Synthetic), and Physician as a secondary skill), who supervises several “technicians” who the customers mostly interact with (who have Professional Skill (Pharmacy Technician).

A fun thing to make use of for game purposes: While it's far from universal, it wouldn't be unusual in parts of the US to encounter a pharmacy technician who does have some skill in Pharmacy, Chemistry, and/or Biology, along with Electronics Operation (medical or scientific) and possibly Hazardous Materials, just because pharmacy tech is a common part-time job for university students in those fields. Obviously, not all of them do, but it can be an interesting and useful background for a PC, or a spanner to throw in the works when the PCs are scamming a presumed-clueless technician to get the drugs they need for their scheme. ;)

[Celti]

Originally Posted by The Colonel

Given what I've encountered working within the pharma industry, I find this really odd. Most jurisdictions rely on organisations like the FDA or MHRA specifically to prevent people messing about with pharmaceuticals.

Certainly a UK pharmacist is expected to know enough med.chem to know what drugs do (in a general way), to spot potential bad combinations (like when some idiot writes their patient up for several paracetamol preparations at once or two drugs with mutually antagonistic functions) and to be able to make low level diagnoses. They can also supervise the portioning out of pills from bulk packs and similar operations but will not formulate - and are increasingly unlikely to sell miscellaneous chemicals like potassium permanganate or iodine as they might have done twenty or thirty years ago.

Still, Switzerland has always been a law unto itself, so if people are hand formulating from actives there it would be within the range of "stuff that people do".

There are certainly compounding pharmacies that will do custom formulations here in the United States, too. I know of at least four in my part of Phoenix, one within walking distance (at least in the winter). Their stock-in-trade is formulations that are either too rarely called for or not shelf-stable enough (or both!) to keep on hand at a normal pharmacy, therefore you submit your prescription to them and they cook it up for you. Almost as common a business for them is alternative formulations of more common medications — say your child needs this syrup, but the standard formulation uses a flavouring agent they're deathly allergic to. So you go to the compounding pharmacy, and they mix up a bottle of it with a different agent, and everyone's happy (except the parents when they find out insurance doesn't cover it).

In most countries, the overwhelming majority of drugs, even prescription drugs, aren't in a control classification that requires huge levels of oversight to deal with. If you've gone to pharmacy school, gotten your license and signed the various professional contracts then it's generally assumed you're not going to go willy-nilly compounding strange and dangerous medications — as for the ones you're supposed to make, there are fairly rigorously-tested formularies for the specific compounds they're likely to work with, developed during the research and trials of them; those plus general principles of the science make it no more dangerous than any other medical treatment (i.e., largely dependent on the dangerousness of the condition being treated and the skill of those attending).

[sir_pudding]

For the last two years of his life I had to order medication from a compounding pharmacy for my cat because it wasn't a medication that veterinary pharmacies normally carried. They would mix it with a supposedly chicken flavor syrup and ship it to me in a disposable cooler with cold packs.

[Anders]

Originally Posted by Myrion

Really?

Do they also study at university and if yes, why?
I mean, that just sounds like they're specialised salespeople.

Oh, and just to be clear, they do these modifications on doctor's orders!

No, they check the doctor's prescriptions, keeps an eye out for interactions and give advice if anyone wants to know more about the medicines they're buying.

[Humabout]

Originally Posted by The Colonel

I'd be really surprised if a modern pharmacist was doing any formulation on modern pharmaceuticals - formulation is a big part of R&D and is a lot trickier than it looks from the outside. Converting something to be taken internally (like a pill) into a topical would seem to be a step not to be taken lightly (or without extensive clinical trials). Also, quite a lot of modern actives are extremely potent and need special equipment to handle them prior to being formulated.

I can see some kind of herbalist doing that - as in European Traditional, Chinese or Vedic medicine - but not someone who has to deal with synthetic pharmaceuticals.

The in-patient pharmacists worked with the department coordinator to develop ten pediatrics compounds for the out-patient pharmacy while I was there, and I, as a tech, trained four other techs on how to mix them. The oharmacist just makes sure are using the right ingrediemts. Those happened to be converting tablets into a syrup, but I made enemas and topicals, too, in in-patient. Making drugs isnt hard, and developing the formularies is one of the jobs of a pharmacist. Especially the ones handling chemo or TPNs any goven day (they rotated at our hospital).