From the Mobile Register

On Jan. 9, 1997, Shamika Rudolph of Mobile stopped by a Dauphin Street drugstore to get a prescription filled for an infection.

Today, part of a bone in her leg is dead and she faces knee replacement surgery at least twice in her lifetime, her lawyer says. The culprit: erroneous instructions by the pharmacist that caused her to take almost twice the prescribed dosage of steroids over several weeks, according to her lawsuit against a national chain.

The excess Prednisone caused her legs to swell and the veins in her knee to shrivel and die, says the lawsuit, which was settled for a undisclosed amount.

Rudolph's lawyer, Toby Brown of Mobile, along with a number of national studies, suggest the case and others like it are at least partly the result of too few pharmacists filling too many prescriptions.

"The demand for prescriptions is rising, and these stores are understaffed," Brown said.

A 1997 survey by Drug Topics magazine, an online resource for pharmacists, showed that 53 percent of respondents admitted making drug errors in the previous two months.

"Our respondents seem to have little doubt about where to point the finger of blame," the article said. "Too many prescriptions, too few hands, too little time."

Pharmacists themselves agree the shortage is acute, especially in Mobile.

"We've got a mess on our hands. The shortage has really become pretty severe," said Lee Evans, dean of Auburn University's Harrison School of Pharmacy.

The situation is the worst for pharmacists with little backup, who fill hundreds of prescriptions a day, he said. With little time to double check their work, mistakes can and will happen, Evans said.

"You can go home at night and wonder if you killed someone," Evans said.

Pharmacies are not required to report errors to the Alabama Board of Pharmacy, leaving authorities with no clear way to track the types of mistakes, and where and why they're occurring, state officials said.

Records in Mobile County Circuit Court show dozens of lawsuits in recent years against drugstores, with most settled for small amounts or dismissed by the court. Others have resulted in substantial, but confidential settlements, lawyers said.

"Mistakes are a concern," said Jerry Moore, executive director of the Alabama Board of Pharmacy. The agency oversees pharmacists' licenses - there are 6,500 pharmacists licensed to work in Alabama - and consumers can report complaints to it.

The pharmacist shortage has also had a predictable side effect: It has sent pharmacists' salaries sky-rocketing.

Starting salaries of as much as $85,000 are commonplace for recent pharmacy grads, who will study for two years as undergraduates and then another four years to gain their doctorate of pharmacy.

The most aggressive drug stores - usually national chains - will offer to lease cars or pay off student loans as a signing bonus, industry watchers say.

Changes in the drug business over the last 20 years have caused the shortage, pharmacist say.

Dean Parker, owner of Heritage Pharmacy, graduated from Auburn University's school of pharmacy in 1973 and worked in Talladega for four years before coming to Mobile.

He took over the pharmacy on Spring Hill Avenue in 1976, when Providence Hospital was still located directly across the street, and many patients came to the pharmacy after seeing doctors across the street.

When Providence moved out to west Mobile in 1989, Parker saw no drop-off in business. In fact, business got better.

Parker likely benefited from a national trend: During the 1990's, spending on prescription drugs skyrocketed. From 1990 to 1998, spending on drugs doubled to $91 billion, with drug sales increasing about 12 percent every year, according to a study done by the Henry J. Kaiser Family Foundation, an independent philanthropy focusing on the major health care issues facing the nation.

Three things drove that rapid increase, according to the study:

* Higher drug prices. Retail prescription prices increased an average of 6.7 percent a year since 1991, faster than the average inflation rate of 2.6 percent.
* More prescriptions written. Between 1992 and 1998, the number of prescriptions grew from 1.9 billion to 2.6 billion, an increase of 37 percent. And although older people tend to fill more prescriptions, the Kaiser study found that an aging population played only a minor role in the growth.
* More new drugs. The top selling prescriptions are newer, higher priced brand name drugs, the result of more research and development conducted by drug companies. Research and development spending increased from $7 billion in 1988 to $21 billion in 1998. New drugs approved by the U.S. Food and Drug Administration grew from an average of 19 approvals a year in the early 1980s to an average of 38 approvals a year in the late 1990s.

Against a backdrop of increasing drug sales, Parker decided to specialize in compounding drugs, which means creating drugs with unique dosages or delivery devices, such as a suppository or topical gel.

"If you want to go into retail business, you have to develop a niche," Parker said.

Even outside of the retail business, though, opportunities have exploded for pharmacists.

Pharmacists are being drawn away from the corner drugstore to work in hospitals with doctors, or in clinical setting where they treat patients with chronic conditions such as diabetes or asthma. Some drug companies even want licensed pharmacists to fill their senior sales positions.

Jim Easter, the chief of Pharmacy Services for Mobile Infirmary Medical Center who oversees about 30 pharmacists, said he has to fight for every hire he makes, enticing students with the opportunity to work in a hospital setting.

"There's just so many opportunities for kids who want to go into pharmacy," he said.

Amy Herndon, a 25-year-old pharmacist who graduated from Auburn in 2000, interviewed at hospitals around the Southeast to find a position as a clinical pharmacist, who goes on rounds with doctors evaluating drug regimens assigned to patients. She now works at the University of South Alabama Medical Center.

"The job market is in our favor for recent grads, and really for anyone. It just depends on what you want to do," she said.

Herndon didn't consider working in a retail pharmacy, even though she knew she could make a higher salary, she said.

"I heard they were offering a BMW if you'd sign up for five years. You hear those stories," Herndon said.

Instead, Herndon opted to take a Mobile-based faculty position with Auburn, teaching pharmacy students who train in Mobile. Herndon spends her days at the USA Medical Center working in family practice medical services.

In the clinical setting, pharmacists act as advisers to the physicians, she said.

"Pharmaceuticals is a growing business, and it's expanding every day. It's hard to keep up with the new drugs, and that's a role clinical pharmacists can play, keeping doctors up to date," she said.

The crunch won't let up until pharmacy schools graduate more students and the industry makes necessary procedural changes, say industry watchers.

Evans of Auburn University said the pharmacy school there needs more funding for recruitment and retention. Auburn is one of two pharmacy schools in the state; the other is at the private Samford University in Birmingham.

Pharmacies also need to automate more, using robots or machinery to remove drugs from shelves, put them into pill bottles an affix labels, Easer said.

Mobile Infirmary uses an automated system to fill prescriptions at night, which licensed pharmacists check in the morning, Easter said.

Pharmacy technicians are also expected to take on more of the physical labor of filling prescription bottles, said Lucinda Maine, Theodore native who now works in Washington D.C., as a senior vice president with the American Pharmaceutical Association, a professional society of pharmacists.

Perhaps most importantly, pharmacists also desperately need to cut down on the amount of time they spend haggling with insurance companies over prescriptions. That kind of work takes up to 30 percent of many pharmacists time, Maine said.
But that likely won't change quickly, said said. Insurance companies want to keep costs down, and making it more difficult to get prescriptions filled slows down spending."

"The complexity of that process reflects the attempts to try and control the rapid escalation in drug costs," she said.

Nevertheless, Maine said she sees the future of pharmacy as exciting. "The bottom line reason why is that medication use is finally reaching a point where people don't take it quite as much for granted'" she said.

"Today, medicines are more powerful, they're more expensive and people are becoming aware of that fact that when you don't use them right, they can be dangerous. The professional best-equipped to help them with their medicine is the pharmacist."

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