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The high cost of medications: A bitter pill to swallow

From the May 20, 2004 issue

Problem: According to a February 2004 poll conducted for the Associated Press, one out of every three respondents said that paying for prescriptions is a problem for their families (visit for details). Of those, three out of four said they had put off filling their prescriptions or cut back on doses because of the cost. One in ten people also admitted to buying prescription medications illegally from Canada, Mexico, or another foreign country to get a better price.

Of course, these alternatives to the high cost of prescriptions are not necessarily safe. Clearly, taking partial doses of prescribed medications or delaying treatment due to cost constraints places patients at risk for harm. And while lawmakers debate bills that would make it legal to purchase prescription medications from foreign countries like Canada, FDA claims it is difficult to verify that foreign drugs are safe. Certainly, there are Internet-based pharmacies in Canada and other foreign countries that are providing safe medications to US citizens. Yet, FDA has also intercepted thousands of counterfeit medicines coming into the US from foreign pharmacies, some even claiming to be from Canada. Furthermore, if problems arise during treatment, patients may be reluctant to tell their healthcare providers that they purchased their medication from a foreign country, or that they were unable to take their medication as prescribed due to financial difficulties.

For example, a woman with a serious bleeding problem waited several days before admitting that she had filled her prescriptions in Mexico. She had presented to the ED with bleeding gums, conjunctival bleeding, and ongoing pain, swelling, and discoloration of her foot for several days after stubbing her toe. Her lab tests looked dangerously similar to a warfarin overdose; her PT was 105, INR 13.9, and PTT 91.8. But the patient denied taking warfarin and claimed she had no exposure to rodenticides. She was admitted to the hospital, and at one point, her physician actually refused to let visitors bring in any food for the patient because he was worried that someone was trying to poison her! Two days later, the patient finally told her physician that she had recently purchased a prescription for ALTACE (ramipril) 5 mg in Mexico. When her family brought the medication into the hospital, staff noticed that the prescription label said “Altace 2 Day,” but the manufacturer’s label underneath the pharmacy label said “warfarina” 5 mg. The patient had been taking 5 mg of warfarin twice daily for 3 weeks.

Another patient found it difficult to tell her healthcare provider that her prescription benefits had run out. In November, her physician had given her a prescription for an antihypertensive medication to control her newly diagnosed hypertension. Sadly, she was too embarrassed to tell her physician that she could not afford to fill the prescription until January, when her insurance limits renewed. When her blood pressure was still elevated in December, her physician increased the dose. Then in January, when her prescription benefits were reinstated, she filled the newer prescription for the higher dose. Her blood pressure dropped dangerously low and she had to be hospitalized for treatment.

Safe Practice Recommendation: There are no easy solutions to the high cost of prescription medications. But often there are safer alternatives for patients than cutting back on doses or purchasing medications from a foreign country, where FDA oversight does not exist. Consider the following:

Assess financial capability. Often, the first obstacle is not knowing that a patient cannot afford to fill a prescription. Thus, every patient’s ability to purchase prescription medications should be assessed upon admission in a way that will not embarrass them. In fact, you may want to add prompts to admission assessment forms to specifically ask patients whether they have recently cut back on doses or delayed filling prescriptions due to financial constraints. While the number of uninsured Americans has never been higher, keep in mind that patients who have insurance may also find it a real financial burden to purchase their prescription and over-the-counter medications.

Consult with a pharmacist. If patients suggest that they might encounter financial difficulties with obtaining prescribed medications upon discharge, consult with a pharmacist who can communicate with the attending physician to suggest less costly medications, or ask the physician to provide samples from his office to tide the patient over until other sources of financial assistance can be located. If samples will be offered to the patient after discharge, the pharmacist should ensure that there are no allergies, cross allergies, or serious drug interactions possible between the sample medications and any other medications being taken. The pharmacist should also remind the patient to ask the doctor for written directions that can be kept with the samples for reference.

Direct patients to assistance programs. There are many government-sponsored, pharmaceutical company-sponsored, and private patient assistance programs that can help eligible patients obtain lifesaving medications at no cost, or at a significant discount. For example, direct patients to the following resources, and be sure your social services and case management departments are aware of their existence:

-Helping Patients (

--BenefitsCheckUp (

--Medicare (

--RxAssist (

--Needy Meds (

Alert patients to the risk of buying medications from Internet sources. Unknown to the patient, some Internet-based pharmacies are not properly licensed, or the medications may originate from a foreign country where counterfeit drugs are rampant. Advise patients to make sure that the Internet pharmacy they intend to use is properly credentialed. To do this, tell them to look for the National Association of Boards of Pharmacy (NABP) Verified Internet Pharmacy Practice Sites (VIPPS) seal on the website to ensure proper licensing and safety. NABP is investigating the possibility of providing properly credentialed Canadian pharmacies with VIPPS certification. Other verification sources are also being sought in Canada to provide consumers with confidence that medications purchased online are safe.

Investigate problems. If clinical problems arise, don’t assume that patients have been taking their medications as prescribed. Always ask patients about medication compliance in an empathetic, non-threatening way before changing the plan of care or increasing the dose of previously prescribed medications.

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