The Pharmacist Who Says No to Drugs (reported in AARP!)

[Guest guest]

The Pharmacist Who Says No to Drugs

-Armon Neel tells patients how to save money and lives

 

By Bill Hogan

September 2004

 

http://www.aarp.org/bulletin/prescription/Articles/a2004-08-26-pharmacist.h=

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Ruby Gifford has come to see Armon B. Neel Jr. out of fear and perhaps desp=

eration.

Gifford, 86, hasn't been feeling well lately, and the list of symptoms that=

have prompted

her to come to Neel's office in Griffin, Ga., might mark her as a hypochond=

riac in the eyes

of many doctors. The problems run from dizzy spells and falls to osteoarthr=

itis and back

pain, from uncontrolled high blood pressure and erratic pulse rates to anxi=

ety and

depression. Then there are the skin rashes, hives and other allergic sympto=

ms that seem

to have come out of nowhere.

 

 

Gifford's 60-year-old daughter has brought her to the Wednesday morning app=

ointment,

and the two wait anxiously in Neel's conference room, where he meets with p=

atients. Neel,

however, isn't a doctor. He's a pharmacist whose specialty is determining w=

hether people

are taking the right medications—and in the right doses—for what ails them.=

Neel, 66,

hasn't worked behind a prescription counter since the early 1970s, when he =

gave up

dispensing drugs for a career that would often put him on a collision cours=

e with the

doctors who prescribe them.

 

 

" If I could find out what's causing all these allergies, " Gifford begins. (=

Her name has been

changed in this story to protect her privacy.)

 

 

Neel asks to see the blood pressure log she's been keeping at his request, =

along with all

the medications she's been taking. Gifford reaches down, produces a freezer=

-size Ziploc

bag that's bulging with prescription drugs, and places it on the table. The=

n comes another

Ziploc bag, this one full of over-the-counter medications.

 

 

Neel quizzes Gifford about the prescription drugs, one by one. " What about =

that? " he asks.

" How did that one do? "

 

 

He then asks Gifford about Ultracet, a pain medication that she's taking. " =

I never have

headaches, " she says. " My aches are all from falls. "

 

 

" Tell me about the falls, " Neel says. " Tell me how long it was after taking=

this pill that it

happened. "

 

 

Neel gently guides Gifford through the entire inventory. He explains that A=

ldactone, the

blood pressure medication she's been taking, isn't the drug of choice in he=

r case and may

in fact be responsible for some of her other health problems. As he looks t=

hrough

Gifford's records, he sees that her doctor, in attempts to control her hype=

rtension, has

tried four different ACE inhibitors, two beta-blockers and two alpha-blocke=

rs. Nothing has

worked, and Gifford has had allergic reactions to all of them. Neel seems s=

tupefied.

 

 

" There wasn't a need to go to the second one after the first one did you ha=

rm, " he says.

" They're in the same family. You need a calcium channel blocker instead. "

 

 

Next, Neel zeroes in on Mobic, the NSAID (nonsteroidal anti-inflammatory dr=

ug) that

Gifford's doctor has prescribed for her osteoarthritis. " There are certain =

drugs you just

don't give old people, " he explains, and NSAIDs are among them. It turns ou=

t that the

doctor has ordered yet another NSAID, in the form of Voltaren eye drops. " T=

here's a newer

product that's better than this, " Neel says.

 

 

Gifford seems relieved but at the same time disturbed. " I don't want to go =

back to this

doctor, " she says. " She never checked anything before she gave it to me. "

 

 

Neel promises to put everything in a written report by the end of the week.=

" Some of these

things, " he says, pointing to all the medications spread out on the table, =

" we might just

chuck in the trash can. "

 

 

Neel hits the road later in the day to make his way to two nursing homes in=

rural Georgia,

where he will review the charts of dozens of residents and carry on his cru=

sade against the

overmedication of geriatric residents in long-term care facilities. Neel do=

es this two or

three days a week, nearly every week, and has been doing it since 1968. He'=

s one of a few

thousand consultant pharmacists nationwide who specialize in identifying, r=

esolving and

preventing medication-related problems that affect, and afflict, older peop=

le.

 

 

" You see so many cookie-cutter approaches to taking care of old people, " Ne=

el says.

" Almost 100 percent of the people I see as outpatients are overmedicated, b=

ecause the

ones I see are the ones who are having problems. If I go into a long-term c=

are

environment, it's about 80 percent. "

 

 

Typically, medication levels in nursing homes can be cut in half or better.=

" If I can get the

drug therapy management correct, " Neel says, " there are fewer hospital stay=

s, fewer

hospital admissions, lower labor costs involved in care and a better qualit=

y of life for

residents. "

 

 

Neel is a rebel with a cause—namely, advancing the idea that pharmacists mu=

st serve and

protect the people who take the medications they dispense. " I get paid by t=

he patient, " he

says, " not the doc. " The way he sees it, pharmacists are often a patient's =

last line of

defense in a nation of doctors who, more often than not, don't know much ab=

out the

drugs they are prescribing and the geriatric population they are treating.

 

 

The renegade streak goes way back. In 1963, just two years out of pharmacy =

school, Neel

opened an apothecary shop in Griffin that, just like a doctor's office, had=

a carpeted

reception room and a separate consultation room. He also set up prenatal co=

unseling

programs as well as hypertension and diabetes clinics. Neel thought the new=

approach

would earn praise; instead it drew ridicule from many of his peers.

 

 

In the late 1960s, Neel, at the request of a friend, started doing some cli=

nical consulting in

nursing homes, and what he saw both shocked and transformed him. " Here was =

a brand-

new population of people, and nobody had any earthly idea how to take care =

of them, " he

recalls. " Back then you'd see Mellaril [a powerful antipsychotic drug] brou=

ght in by the

truckload. They used it as a chemical restraint. Nursing homes back then di=

dn't have a lot

of help, so the best help they had was to drug the patients. I knew it wasn=

't humane, and I

fought it from day one. "

On Wednesday night Neel is driving to a mom-and-pop motel in rural Georgia =

that he has

stayed in many times. It's not far from a county-owned nursing home Neel co=

unts among

his six institutional clients.

 

 

The next morning at 9, Neel is stationed at a small desk near the nursing d=

irector's office.

He has brought along a notebook computer, portable printer and a supply of =

blank forms

and printed materials. He knows just about everyone, it seems, by name.

 

 

The doctor who serves as the nursing home's medical director doesn't seem t=

o care for

Neel's approach to a job—mandated by federal law—that others see as rubber-=

stamp

work. The doctor doesn't talk to Neel, choosing to deal with him mostly thr=

ough the

nursing staff.

 

 

Throughout the day Neel will type his medication-related suggestions on a f=

orm of his

own design (printed on a pink slip of paper so as to stand out in the patie=

nt's medical

records) that directs the patient's physician to check a box that says " Acc=

ept " or " Reject "

before signing and dating it.

 

 

The medical director rejects, almost without exception, Neel's suggestions.=

He evidently

takes umbrage at being second-guessed by a pharmacist—something, Neel says,=

that's

not at all unusual. Neel finds the lack of engagement troubling. " He's here=

once a month, "

he says. " Maybe five minutes per patient. That's all they're required to do=

.. "

 

 

Neel begins working his way through a tall stack of blue loose-leaf binders=

that contain

the patient charts and other medical records. Today he's reviewing the char=

ts of residents

who are taking nine or more prescription medications simultaneously.

 

 

It's important on at least two counts that Neel—or someone like him—review =

the

medications these people are receiving. First is safety. The risks of adver=

se effects expand

exponentially with the number of medications " onboard, " partly because they=

indicate the

presence of numerous diseases or other medical problems and provide an oppo=

rtunity for

both drug-disease and drug-drug interactions. Second is cost. " The rule of =

thumb, " Neel

says, " is $100 a drug. " That's per patient, per month. Thus the cost of hav=

ing someone on,

say, 15 different medications—many of which may be unnecessary or even harm=

ful—is

$1,500 a month, or $18,000 a year.

 

 

First up today is the chart for a 68-year-old man who is on many drugs, inc=

luding

Nitrofurantoin, an antibacterial that's prescribed for urinary tract infect=

ions. Neel enters

the man's age, weight, height and information from his blood work into a ca=

lculator

programmed with certain formulas he uses over and over. Neel explains that =

toxic levels

of the drug will build up in the man's system because his kidneys aren't as=

efficient as

they used to be.

 

 

Why would a doctor prescribe it? " Because, " Neel says, " it works in young p=

eople. " (A new

study in the Archives of Internal Medicine found that 20 percent of outpati=

ents 65 and

older were prescribed " at least one drug that should generally be avoided i=

n elderly

people. " )

 

 

The next chart is for an 89-year-old woman who's on 13 different prescripti=

on

medications, including Zantac, which raises an immediate flag for Neel. The=

re are no blood

chemistry tests in her charts, but Neel quickly computes her probable renal=

clearance at

32.5 cubic centimeters a minute. " This tells me right off the bat she shoul=

dn't be taking

it, " he says. He then types his suggestion to the doctor: " Zantac dose too =

high/could lead

to `hepatic shutdown' ... resulting in serious patient adverse events. "

 

 

Neel opens the next chart, that of an 82-year-old woman who's on 17 differe=

nt

medications, including, for type 2 diabetes, a prescription drug called met=

formin. He's

dumbfounded at first, then angry. He reads the suggestion slip he typed out=

a month and

a half earlier: " patients with serum creatinine clearance less than 60cc-m =

use of metformin

is contraindicated and places the patient at high risk for lactic acidosis,=

which is fatal in

most cases. "

 

 

In a little while, Neel joins the staff for lunch in the cafeteria and spen=

ds much of the time

soaking up details about residents that may prove useful in his work. On th=

e way back

from lunch Neel stops to visit with them in their rooms or in the hallway.

 

 

Neel rises early the next morning to drive to another nursing home about 20=

miles south.

There, too, he has a combative relationship with the facility's medical dir=

ector.

 

 

As soon as Neel arrives at the facility, he searches out a 73-year-old resi=

dent who's been

there since February 1999. The man, who has advanced Parkinson's, brightens=

instantly.

When Neel first looked at his chart, the man was on 20 milligrams of the an=

tipsychotic

medication Zyprexa, a daily dose that by any measure is therapeutic overloa=

d; he's down

to 2.5 milligrams a day, and soon, Neel says, he may be off the drug entire=

ly. The man's

old symptoms, among them nonstop yelling, have all disappeared, and now he =

sometimes

comes to sit quietly next to Neel as he works.

 

 

The physician overseeing the man's treatment told Neel and the nurses that =

he would

never be able to walk again. But walk he now does—and walk and walk. He vis=

its other

residents in their rooms and likes to sit near the main nursing station—the=

hub of activity.

" I gave him his life back, " Neel says matter-of-factly.

 

 

One problem, as Neel sees it, is that few of the 300 or so doctors who trea=

t patients in the

facilities he visits have a specialty in geriatrics. How many do? " Maybe tw=

o, " he says.

" They're not up to date with the physiology of the geriatric patient as it =

relates to the

chemistry of the drug. That's the easiest way to put it. "

 

 

Neel reviews a few more patient charts, producing more small pink suggestio=

n slips, each

numbered sequentially, as he goes. A little while back he passed the 300,00=

0 mark.

 

 

At another nursing home, where Neel has known the medical director for some=

25 years,

the success of a collaborative approach is clear. " If I write up a suggesti=

on to paint the

nose blue, " Neel jokes, " when I go back the next time, the nose is blue. " T=

he daily cost per

patient for drugs at the nursing home is down to $7.22, the lowest in Georg=

ia and just

over half the statewide average.

 

 

Neel will be back in Griffin before suppertime, where he'll finish the writ=

ten report that he

promised Ruby Gifford before leaving for a weeklong vacation with his wife,=

children and

grandchildren. He doesn't yet know that Gifford's physician will be angered=

by her

decision to seek out his help and will refuse even to read Neel's 17-page r=

eport.

 

 

So Armon Neel soon will help Gifford find a new doctor. He isn't one to pas=

s the buck. " I've

always gotten along well with old people, " he says. " They've always been sp=

ecial to me. " A

mischievous smile breaks. " And I really like 'em now, 'cause I'm one of 'em=

.. "