While attending the 11th Congress of the European Association of Hospital Pharmacists meeting in Switzerland last week, I took the opportunity of visiting some pharmacies. On Saturday, I took a bus and traveled about two hours to Chamonix, France, a town in the French Alps. During the day, I spent time observing the pharmacists' interactions with the patients in one pharmacy, and, in another pharmacy, I talked with a pharmacist to learn more about the way they practice pharmacy. This is what I learned:

1. The patient presents a computerized printout list of drugs (prescriptions) from a single page that was prepared at the physician's office.
2. The pharmacist takes the printout and goes to the stock and "pulls" the packages.
3. The entire, unopened packages are presented to the patient containing only the manufacturer's labeling. On occasions where the prescribing directions are different from the manufacturers labeling, the pharmacist hand writes the new directions on the package.
4. The patient signs the back of the printout signifying receipt of the drugs.
5. Once weekly, the pharmacist presents the signed printouts to the government and electronically downloads the bill created when the patient was "checked out" at the register. The pharmacy receives a check for the prescriptions dispensed.
6. The patient does not pay anything at the pharmacy.
7. There is very little, if any, counseling at the pharmacy.
8. The patient takes the commercial packages and uses them.
9. There is no drug-drug interaction, drug-disease state interaction, or drug-food interaction checking at the pharmacy.
10. It is a very fast and efficient way of dispensing medications.
11. The entire operation can occur with limited conversation.
12. Basically, the pharmacist performs the role of a clerk.

On a positive note, the pharmacies receive two orders per day from their wholesalers. This allows them to keep minimal stock on hand and have a quick turnover on all their stock. This also allows them to operate efficiently from a small pharmacy, as large storage areas are not required.

Now, let's think about what changes are occurring here in the US:

First, many medications are now being paid for by the government. One reason the operation in France is so fast and efficient is that there is no co-pay. The patient simply takes the prescription and leaves. No co-pay would certainly speed things up here if there was only one plan instead of many.

Second, we are seeing more and more medications in unit-of-use packages. This allows for easier dispensing, as well as for automated machine dispensing.

Third, prescription drug package or labeling information is now becoming available on an FDA website; freely available to all.

Fourth, the workload in many pharmacies is getting so great that there is minimal patient consulting occurring due to lack of time; the mail order pharmacies track the amount of time a pharmacist spends on the phone with patients and wants it kept to a minimum.

Fifth, reimbursement for patient counseling and monitoring is woefully inadequate, or nonexistent.

Let's hope that we don't get to the point that we are clerks. We have a lot to offer, but it is going to take a lot of political activity on the part of all pharmacists to reaffirm our role in patient care and consulting.

Oh yes, I should add that compounding pharmacists don't generally have to worry about a lot of these issues. More later�

Loyd V. Allen, Jr., Ph.D., R.Ph
Editor-in-Chief

The citations and abstracts include thirty-six articles on the topic of N-acetylcysteine and 22 others on the various topics mentioned on the Compounders' Network List during the last week, including 10 articles on inhaled glutathione in cystic fibrosis.

Here is a sampling of articles that can now be found on CompoundingToday.com:

• Black PN, Morgan-Day A, McMillan TE et al. Randomised, controlled trial of N-acetylcysteine for treatment of acute exacerbations of chronic obstructive pulmonary disease (ISRCTN21676344]. BMC Pulm Med 2004; 4:13.
• Demedts M, Behr J, Buhl R et al; IFIGENIA Study Group. High-dose acetylcysteine in idiopathic pulmonary fibrosis. N Engl J Med 2005; 353(21): 2229-2242.
• Grinberg L, Fibach E, Amer J et al. N-acetylcysteine amide, a novel cell-permeating thiol, restores cellular glutathione and protects human red blood cells from oxidative stress. Free Radic Biol Med 2005; 38(1): 136-145.
• Salsano F, Letizia C, Proietti M et al. Significant changes of peripheral perfusion and plasma adrenomedullin levels in N-acetylcysteine long term treatment of patients with sclerodermic Raynauds phenomenon. Int J Immunopathol Pharmacol 2005; 18(4): 761-770.
• Yuta A, Baraniuk JN. Therapeutic approaches to mucus hypersecretion. Curr Allergy Asthma Rep 2005; 5(3): 243-251.

More than 8,000 visitors came to CompoundingToday.com during the month of March. Here is a listing of the top tools and resources accessed:

4,729   Formula Downloads
1,796   Standard Operating Procedures
   440   Abstracts and Citations
   237   NaCl Equivalent Value
   223   Patient Advisory Leaflets
   173   Veterinary Transdermal Tool
   146   Preservative and Antioxidant Tool
   131   Oral Vehicle Tool
   128   Disinfectant Tool - Product Information
   112   Flavoring Tool - Veterinary Recommendations

This Regulatory Update has been provided by the International Academy of Compounding Pharmacists. For more information, www.iacprx.org.

Wyeth Docket Update
As you may know, IACP mounted a campaign last October to oppose Wyeth's Citizen Petition that asks for restrictions on BHRT. IACP filed comments and has called on other organizations and individuals to do the same. We have good news! As of Friday, March 24th, over 24,000 patients, physicians, and pharmacists had filed comments on the FDA Docket to oppose Wyeth's Citizen Petition. Comments opposing Wyeth's Citizen Petition are being filed at rates of over 1,000 per day. Haven't filed your comment yet? Go to www.iacprx.org/GetActive to file yours today! Also, get your patients and physicians involved at www.savemymedicine.org.

IACP Files Addendum to Comments Opposing Wyeth's Citizen Petition
The recent U.S. Supreme Court ruling Gonzales v. Oregon gave compounders additional ammunition to fight a Wyeth petition that asks FDA to unduly restrict pharmacy compounding practice. Gonzales v. Oregon undercuts Wyeth's petition in two ways. First, the majority opinion gives great deference to state regulation in regulating the medical profession. Second, the court also ruled that federal agencies cannot selectively read into statutes to impinge upon areas traditionally regulated by the states. On March 4, IACP filed an addendum to its original comments to the Wyeth docket. The addendum highlights this case and applies its precedent to the Wyeth issue.

Disposable Microspatula
Need a quick disposable microspatula? Take a clean plastic straw and cut it at a sharp angle with a clean razor blade. This will actually make two disposable microspatulas that can be used and then discarded.