drug

Pharmacy in World War II: The Military

/ Jordyn Redwood / Leave a comment

Sarah Sundin concludes her series today on WWII and the role of the pharmacist. Wasn’t the information amazing? You can find Part I and Part II by following the links.

Welcome back, Sarah!

While researching the military medical system for my World War II novels, I read about physicians and nurses, dentists and veterinarians. But where were the pharmacists? In the civilian world, the physician prescribes medication, the pharmacist purchases, compounds, and dispenses, and the patient or nurse administers. I discovered the wartime military system differed. As a pharmacist I was baffled and intrigued.

On February 14th, I discussed the role of the pharmacist in the 1940s. On February 16th, I described the local drug store and how its role changed during the war, and today I’ll review the rather shocking role—or lack thereof—of pharmacy and pharmacists in the US military.

Drug Distribution in the Military

In the US Army and Navy, outpatient prescriptions were filled at base or unit dispensaries, while inpatient orders were filled at hospital pharmacies. Both dispensaries and pharmacies were staffed by enlisted personnel—pharmacy technicians in the Army and pharmacist’s mates in the Navy—under the control of physicians. In 1936, the pre-war Army had forty graduate pharmacists serving as enlisted technicians.

Pharmacy technicians did not need any previous health care background or education. They went through a three-month program based on practical training rather than scientific understanding.

Medical Administrative Corps

For decades, pharmacy organizations had lobbied for a Pharmacy Corps with commissioned pharmacists. Indeed, most nations had similar corps. However, the US Army Medical Department was run by physicians. They thought of pharmacists in a condescending manner as businessmen rather than professionals, and they saw the drug distribution system as adequate.

The Medical Administrative Corps was formed in 1920 as a compromise. The MAC was responsible for administrative duties within the Medical Department, including medication procurement and distribution. In 1936, the MAC was permitted to commission sixteen pharmacists, with future appointments in the MAC restricted to graduate pharmacists.

The number of officers in the MAC increased during the war. In 1943 six hundred graduate pharmacists served as MAC officers—but none of them served as pharmacists.

Options for Pharmacists

Since most draft-age pharmacists had four-year bachelor’s degrees, they were eligible to serve as officers. While physicians, nurses, dentists, and veterinarians were commissioned as officers and placed in appropriate positions, no such guarantee was available for pharmacists.

Upon enlistment, pharmacists could apply for the Army Officer Candidate School, but upon graduation, they could be assigned anywhere. Pharmacists served as infantry officers, artillery officers, and in many other divisions. Even if they happened to be assigned to the MAC, as noted above, they did not practice their profession.

If a pharmacist wanted to compound and dispense medication, his only option was to serve as an enlisted technician, with pay and privileges far below that of an officer.

Fight for a Pharmacy Corps

The American Pharmaceutical Association (APhA) renewed the legislative battle for a commissioned Pharmacy Corps. While the Surgeon General’s office argued that “Army pharmacy was simpler than civilian practice. The department’s three-month pharmacy technician course was sufficient preparation. There was little compounding. Since medications were furnished in tablet form, ‘any intelligent boy can read the label’” (1).

These arguments did not sit well with pharmacists—or with the general public. Dr. Evert Kendig of the APhA argued that “Army pharmacy technicians were given responsibility beyond that legally permissible in civilian life even as the Army misused its professional pharmacists” (1). Several incidents were reported of prescriptions improperly filled by technicians and of blatant physician prescribing errors that would have been caught by a pharmacist. Public opinion tipped the scale, and on July 12, 1943, President Roosevelt signed legislation authorizing the formation of the Pharmacy Corps.

Pharmacy Corps

The Pharmacy Corps was authorized to commission seventy-two pharmacists. However, the military moved slowly. In January 1944, after receiving 900 applications and conducting two-day written examinations, physical examinations, and interviews, twelve officers were commissioned. By January 1945, the Pharmacy Corps had only commissioned eighteen pharmacists. The other officers’ slots were filled by former MAC officers.

The drug distribution system did not change by the end of the war, but the formation of the Pharmacy Corps laid the groundwork for post-war reforms.

Resources:

  1. Ginn, Richard VN. The History of the US Army Medical Service Corps. Washington DC: Center for Military History, 1997. (Accessed February 6, 2011 at http://history.amedd.army.mil/booksdocs/HistoryofUSArmyMSC/msc.html).
  2. Worthen, Dennis B. Pharmacy in World War II. New York: Pharmaceutical Products Press, 2004.

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Sarah Sundin is the author of the Waves of Freedom series (Through Waters Deep, 2015, Anchor in the Storm, 2016, and When Tides Turn, March 2017), the Wings of the Nightingale series, and the Wings of Glory series, all from Revell. In addition she has a novella in Where Treetops Glisten (WaterBrook).

Her novel Through Waters Deep was a 2016 Carol Award Finalist, won the 2016 INSPY Award, and was named to Booklist’s “101 Best Romance Novels of the Last 10 Years.” Her novella “I’ll Be Home for Christmas” in Where Treetops Glisten was a finalist for the 2015 Carol Award. In 2014, On Distant Shores was a double finalist for the Golden Scroll Awards from both AWSA and the Christian Authors Network. In 2011, Sarah received the Writer of the Year Award at the Mount Hermon Christian Writers Conference.

A mother of three, Sarah lives in northern California, works on-call as a hospital pharmacist, and teaches Sunday school and women’s Bible studies. She enjoys speaking to community, church, and writers’ groups, and has been well received.

Pharmacy in World War II: The Drug Store

/ Jordyn Redwood / Leave a comment

We’re continuing with Sarah Sundin’s series on the role of the pharmacist in WWII. You can find her first post here.

Welcome back, Sarah!

In the 1940s, the local drug store was more than just a place to get prescriptions filled and pick up toothpaste—it was a gathering place. If you’re writing a novel set during World War II, it helps to have an understanding of this institution.

As a pharmacist, I found much about my profession has changed, but some things have not—a personal concern for patients, the difficult balance between health care and business, and the struggle to gain respect in the physician-dominated health care world. On February 14th, I discussed the role of the pharmacist in the 1940s, today I’ll describe the local drug store and how its role changed during the war, and on February 18th,  I’ll review the rather shocking role—or lack thereof—of pharmacy and pharmacists in the US military.

Welcome to the Corner Drug Store—1939

Perkins’ Drugs stands on the corner of Main Street and Elm, where it’s stood all your life. Large glass windows boast ads for proprietary medications and candy, and a neon mortar-and-pestle blinks at you. When you open the door, bells jangle. The drug store is open seven days a week, sixteen hours a day, so you know it’ll always be there for you. To your right, old-timers and teenagers sit at the soda fountain on green vinyl stools, discussing politics and the high school football game. The soda jerk waves at you.

You pass clean shelves stocked full of proprietary medications, toiletries, cosmetics, hot water bottles, hair pins and curlers, stockings, cigarettes, candy, and bandages. You know where everything is—and if you can’t find it, Mr. Perkins or his staff will be sure to help you.

The owner, Mr. Perkins, is hard at work behind the prescription counter with good old Mr. Smith and Mr. Abernathy, that new young druggist Mr. Perkins hired last year. Mr. Perkins greets you by name, asks about your family, and takes your prescription. He has to mix an elixir for you. If you don’t want to wait, he’ll be happy to have his delivery boy bring it to your house. But you don’t mind waiting. You have a few items to purchase, and you’d love to sit down with a cherry Coke.

Welcome to the Corner Drug Store—1943

Perkins’ Drugs still stands at the corner of Main Street and Elm. Large glass windows boast Army and Navy recruitment posters and remind you that “Loose Lips Sink Ships.” The neon sign has been removed to meet blackout regulations. The store is open for fewer hours since Mr. Smith retired and Mr. Abernathy got drafted. Mr. Perkins hired Miss Freeman. Not many people are thrilled to have a “girl pharmacist,” but if Mr. Perkins trusts her, that’s good enough for you. Perkins’ Drugs and Quality Drugs on the other side of town alternate evening hours so the town’s needs are met.

A placard on the door reminds you that Perkins’ Drugs is authorized by the Office of Civilian Defense as a pharmaceutical unit, meaning the store will provide a kit of medications and supplies for the casualty station in case of enemy attack. You pray the town will never need it.

Bells jangle when you open the door. The soda fountain is closed. Mr. Perkins can’t buy metal replacement parts for the machine, the soda jerk is flying fighter planes over Germany, and sugar is too scarce a commodity.

A barrel stands by the door. You toss in five tin cans, washed, labels removed, tops and bottoms cut off, and flattened. Mrs. Perkins at the cash register thanks you.

You pass clean shelves with depleted stocks. Proprietary medications, cosmetics, toiletries, and medical supplies remain, but rubber hot water bottles, silk and nylon stockings, hair pins and curlers, candy, and cigarettes are in short stock—or unavailable. Most of the packaging has changed. Metal tins have been replaced by glass jars and cardboard boxes. You pick up a bottle of aspirin and a tube of toothpaste, double-checking that you brought your empty tube. Without that crumpled piece of tin, you couldn’t purchase a replacement. Tin is too dear.

At the prescription counter, Mr. Perkins greets you by name and asks about your family. Miss Freeman gives you a shy smile and you smile back. There’s a war on and women have a patriotic duty to do men’s work so men are free to fight. Mr. Perkins frowns at your prescription for an elixir. He’s used up his weekly quota of sugar, and his stock of alcohol and glycerin are running low. Would you mind capsules instead? Of course not. Mr. Perkins phones Dr. Weber and convinces him to change the prescription. Mr. Perkins can’t have the prescription delivered—he doesn’t qualify for extra gasoline and he couldn’t find a delivery boy to hire anyway.

You and Mr. Perkins discuss war news as he sets up a wooden block with little holes punched in it, then lines the pockets with empty capsule halves. He weighs powders on a scale, mixes them in a mortar, then fills the capsule shells. After he sets the capsule tops in place, he puts the capsules in an amber glass bottle with the familiar Perkins’ Drugs label.

You buy a few War Bonds. Your wages are higher than ever with the war on, and with all the shortages there’s nothing to buy. Besides, War Bonds are a solid financial investment and your patriotic duty. On a poster by the counter, a smiling pilot leans out of his plane and reminds you: “You buy ‘em. We’ll fly ‘em. Defense Bonds and Stamps.”

Mr. Perkins thanks you for your purchase, and you thank him for his service. War or no war, you know Perkins’ Drugs will always be there for you.

Resources

My main source was this excellent, comprehensive, and well-researched book: Worthen, Dennis B. Pharmacy in World War II. New York: Pharmaceutical Products Press, 2004.

http://www.lloydlibrary.org (Website of the Lloyd Library and Museum, which has many articles and resources on the history of pharmacy).

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Sarah Sundin is the author of the Waves of Freedom series (Through Waters Deep, 2015, Anchor in the Storm, 2016, and When Tides Turn, March 2017), the Wings of the Nightingale series, and the Wings of Glory series, all from Revell. In addition she has a novella in Where Treetops Glisten (WaterBrook).

Her novel Through Waters Deep was a 2016 Carol Award Finalist, won the 2016 INSPY Award, and was named to Booklist’s “101 Best Romance Novels of the Last 10 Years.” Her novella “I’ll Be Home for Christmas” in Where Treetops Glisten was a finalist for the 2015 Carol Award. In 2014, On Distant Shores was a double finalist for the Golden Scroll Awards from both AWSA and the Christian Authors Network. In 2011, Sarah received the Writer of the Year Award at the Mount Hermon Christian Writers Conference.

A mother of three, Sarah lives in northern California, works on-call as a hospital pharmacist, and teaches Sunday school and women’s Bible studies. She enjoys speaking to community, church, and writers’ groups, and has been well received.

Drug Screens

/ Jordyn Redwood / Leave a comment

I think there is a general misconception in the public that all drugs can be detected by a basic blood or urine drug screen. This is not true.

First, when is a drug screen done?

There are several instances where we would likely run a drug screen. Here are a few.

1. You are having suicidal ideation. Suicidal ideation means you are having thoughts/feelings of hurting yourself and either you have presented or someone has brought you to the ED. This is fairly standard to see what might be in your system. What also will be added will be an acetaminophen (Tylenol) and salicylate (Aspirin) level. These are blood levels.

2. You are acting crazy. Meaning– you’re hearing and seeing things that aren’t there. There are gait disturbances, a decreased level of consciousness. Perhaps even seizure activity. A common set-up for this scenario is a child or teen that begins to act funny at school. Here, there is a concern for ingestion and it will be best to sort out what we might be working with.

3. An actual ingestion in any age group. The history will be looked at very closely but if it is— toddler got into grandma’s medicine cabinet (this happens more often than you would think) and the youngster just flat out began to go through boxes/bottles swallowing everything in sight– he will get a urine drug screen.

A urine drug screen can be an effective screening tool. But it definitely does not rule out all substances. That is the most important thing to know.

So– the following drugs are on a basic drug screen. It may also be called a “drugs of abuse” of panel. Something along those lines.

1. Amphetamines— interesting thing about this is some ADHD drugs contain amphetamines so kiddos on these will show positive. If they are on an ADHD med in this drug class– it doesn’t mean that they are not also abusing other types of amphetamines.

2. Barbiturates: The Truth Serum Drugs (Amytal Sodium, Phenobarbital and Luminal). But, do these drugs really act as truth serum? Interesting article here: http://www.damninteresting.com/the-truth-about-truth-serum/

3. Benzodiazepines: Drugs like Valium, Versed and Ativan are in this drug class.

4. THC: Tetrahydrocannabinol. Cannabis. The active ingredient in marijuana.

5. Cocaine

6. Opiates: Stuff of the opium poppy seed plant. Morphine, Fentanyl, Vicodin, Lortab, Codeine

7. PCP

Notice what is not on the basic drug screen? Alcohol… we would have to test separately for this.

Is this what you thought was on a drug screen?

Drug Abuse in America: Part 2/3

/ Jordyn Redwood / Leave a comment

Have you been to an ER in the last decade? If so, do you remember being asked about your pain level? The infamous question in the adult realm, “Sir, can you rate your pain on a scale of 0-10… zero being no pain and ten being the worst pain you’ve ever had in your entire life.” Every wonder why this was? Maybe you weren’t even in pain and they still asked you. Do you remember being in the ER perhaps two decades ago where there wasn’t a big push to know what your pain was? Maybe, you weren’t even asked.

What is JCAHO and what might it have to do with the drug abuse problem in the US?

JCAHO is an abbreviation for Joint Commission on Accreditation of Healthcare Organizations.  It is an organization made up of individuals from the private medical sector to develop and maintain standards of quality in medical facilities in the United States.Okay, great Jordyn, how can this possibly relate to the prescription abuse problem in the USA?

Joint Commission comes out with goals for medical care of patients. In the 90’s, one of their thoughts was that pain was not being adequately addressed among healthcare professionals so it became a standard for them to have us ask, evaluate and treat patients’ pain.

This Time magazine piece gives a nice consensus about how well intentioned bureaucracy intrusion can have disastrous effects on how medical care is delivered and ultimately leads to consequences for the patient:

“The U.S.’s opiate jag began, like so many things, with the best of intentions. In the 1990s, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) — the accrediting body for hospitals and other large care facilities — developed new policies to treat pain more proactively, approaching it not just as an unfortunate side effect of illness but as a fifth vital sign, along with temperature, heart rate, respiratory rate and blood pressure. As such, it would have to be routinely assessed and treated as needed. “It was a compassionate change,” says Barber. “Patient-advocacy groups pushed hard for it.” And, she points out, drug companies did too, since more-aggressive treatment of pain meant more more-aggressive prescribing.

But the timing was problematic. The new JCAHO policy went into effect in 2000, which was not only about the time the new opioids were hitting the market but also shortly after the Federal Trade Commission began allowing direct-to-consumer drug advertising. When market, mission and product converge this way, there’s little question what will happen. And before long, patients were not only being offered easy access to drugs but were actually having the medications pushed on them. No tooth extraction was complete without a 30-day prescription for Vicodin. No ambulatory surgery ended without a trip to the hospital pharmacy to pick up some Oxy. Worse, people with chronic pain were getting prescriptions that could be renewed again and again.”
What other government policies do you think are having a negative effect on patients?
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Drug Abuse in America: Part 1/3

/ Jordyn Redwood / Leave a comment

Dr. Edwards is here for his monthly post and I thought his topic of choice was very timely. He sent me a piece on dealing with chronic pain patients in the ED. This is a problem for every ED… including pediatrics.

In the past two years, I’ve been shocked by the number of chronic pain patients we are seeing in those under the age of 18. If you’re writing an in-depth novel with an ED worker in the center, this is one area of conflict you could explore.

How do we deal with these patients? Is there a component of drug addiction in this patient population? To say no for all cases would not be the truth either.

I think this trend bodes for some introspection on all of us. Here is Dr. Edwards post. On Wednesday and Friday this week I’m going to explore this topic more in depth and why there might be such an explosive prescription drug abuse problem in the US… and believe me… there is.

Desperately Seeking

Frank J. Edwards, MD

I hadn’t been practicing emergency medicine very long when I saw this particular patient, a thin woman in her mid-seventies wearing an old fashioned lace-collared evening gown.

“Doctor, I’ve passed another kidney stone,” she said.

My mind’s eye narrowed.  Was this a narcotic seeker?  Kidney stones are like white-hot ice picks thrust into one’s flank and violently twisted, over and over again.  Marine drill sergeants cry with kidney stones.  But there she sat smiling.  I was young.  Did she take me for an easy mark?

“Oh really,” I said.  “Are you looking for some medication, ma’am?”

“Heavens no,” she said.  “I thought you might like to see it.  I have these things all the time.”

“See it?”

Out of her cloth handbag, she fished a chunk of coarse roadbed gravel and plopped it in my hand.  Driving in the hospital entrance that muggy Sunday morning I had noticed a pile of similar stone.

“You can keep it if you like, doctor,” she said.

Since then, I’ve seen hundreds of patients feigning illnesses, but unlike the lady of the road gravel, they definitely want something more than the smidgeon of attention and sympathy she needed.   They may have headaches, back spasms, abdominal cramping or severe pelvic pain, but kidney stones do remain a common theme.  And, unlike her, they come in writhing and wincing.  When asked to give urine, they may prick their fingers and squeeze a drop of blood into the sample so the dipstick comes back positive. 

The typical drug seeker will have a genuine history of a disease characterized by recurrent episodes of agonizing pain.  Along with kidney stones, such conditions include migraine headaches, lumbar disc disease, fibromyalgia, inflammatory intestinal disorders (Crohn’s disease, for example), and pelvic problems such as endometriosis and interstitial cystitis.   Thanks to the powerfully addicting properties of the narcotics used to treat their pain, a handful gradually awaken in the labyrinth of Morpheus, from which escape is very hard.


These patients generate a swirl of negative emotions in healers.   You want to give everyone the benefit of the doubt, but you do not like the sense of being manipulated.  You do not want to reinforce their addiction, but on the other hand, you understand they are suffering.  You just do not really know how much of the suffering is physical pain and how much is . . . whatever.   And, Lord help the healer who pigeonholes a drug seeker and misses something disastrous.  Drug seekers get sick too.

So you examine them carefully and maybe run some tests, and you look for the usual clues.  Drug seekers often frequent many local EDs.  They’ve had multiple work-ups that never reveal anything new.  If you are blessed with the ability to look up records on the Internet (an innovation which can’t come too soon), you may discover they were in the ED at a hospital down the road just last week and neglected to mention it.   They are allergic to all the non-narcotic pain relief options and they know exactly which agent on the menu works best.  They demand the dose IV and require amounts that would kick most opiate virgins into a coma.
  
I know some healers who pretty much give in and give the drug seeker whatever he or she wants just to sweep them out quickly, and who may even discharge them with substantial prescriptions for more narcotics (a real mistake).  Other healers get angry and point to the door immediately.  Most of us are in the middle somewhere, but it is never a happy situation.  At some level, you feel like a drug dealer.  I assuage my conscience by counseling them on the dangers of secondary addiction, and try referring them to pain centers.  I’ve also stopped calling them drug seekers.  They are chronic pain patients until proven otherwise, which removes some of the tendency to pass judgment.

Regarding the danger of cynicism, not long ago, a doctor going off duty passed me a back-pain case.  His plan was to give this young man a single shot and send him packing in the hope he wouldn’t darken our doorway again.    The patient had admitted to visiting an urgent care center the day before and had furthermore confessed to heroin abuse in the past.

Slam dunk drug seeker, right?   Wait a minute.  How many of them volunteer a history of heroin abuse?  That’s either a pretty dumb drug seeker, or a rare instance of honesty.   I sat down and listened to his story, got a sense of his personality and observed the concern of his girl friend.  Then I re-examined him and ended up ordering a CT.  The next morning he had surgery for a severely herniated lumbar disc. 

Then, there are the true professional patients—few in number and slippery—who ply their ailments to score drugs for the street trade.   One patient I recall from many years ago made a circuit of EDs from Florida to Virginia.  He had a draining bone infection—chronic osteomyelitis of the tibia—from a motorcycle accident.  If he took his antibiotic, the wound would start to heal.  If he stopped taking his antibiotic, the wound would boil and drain pus.  He could literally shut it off and on like a faucet.

It was very hard to argue with such an ugly wound, and he reeled me in like a catfish on Valium.  Until I saw him again a few months later at an ED on the far end of North Carolina.  With a different name.

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Frank Edwards was born and raised in Western New York.  After serving as an Army helicopter pilot in Vietnam, he studied English and Chemistry at UNC Chapel Hill, then received an M.D. from the University of Rochester.  Along the way he earned an MFA in Writing at Warren Wilson College.  He continues to write, teach and practice emergency medicine. More information can be found at http://www.frankjedwards.com/.