Joshua Seemu­n­gal

Se­nior In­ves­tiga­tive Jour­nal­ist

joshua.seemu­n­gal@guardian.co.tt

Some med­ical doc­tors in T&T have been un­der­cut­ting phar­ma­cies by il­le­gal­ly sell­ing phar­ma­ceu­ti­cal drugs di­rect­ly to pa­tients, in turn, putting pa­tients’ health at risk, a Guardian Me­dia in­ves­ti­ga­tion has re­vealed.

The in­ves­ti­ga­tion al­so con­firmed that some doc­tors have been work­ing with drug whole­sale com­pa­nies to by­pass phar­ma­cies, send­ing pa­tients di­rect­ly to dis­trib­u­tors with pre­scrip­tions and or­ders.

While go­ing straight to dis­trib­u­tors or get­ting med­ica­tion from doc­tors of­ten saves pa­tients some mon­ey, the ac­tion is po­ten­tial­ly life-threat­en­ing.

“The prac­tices re­ferred to above are very con­cern­ing and pose a se­ri­ous risk to pa­tient health. Doc­tors are trained to di­ag­nose and treat. Phar­ma­cists are trained to dis­pense and man­age pa­tient-spe­cif­ic needs re­gard­ing med­ica­tions,” said Phar­ma­cy Board Sec­re­tary/Trea­sur­er San­jay Mo­hammed.

“When ac­tions are tak­en to cir­cum­vent ei­ther of these pro­fes­sion­als, the pa­tient is put at se­vere risk.”

The Phar­ma­cy Board met with phar­ma­ceu­ti­cal whole­salers this past week and breach­es of the law were iden­ti­fied. A cease and de­sist or­der was is­sued to the of­fend­ing whole­salers for the fol­low­ing:

• ↓Sales of drugs to per­sons com­ing to whole­salers with a doc­tor’s or­der.

• ↓Re­fusal to sell in­tra­venous/in­tra­mus­cu­lar prepa­ra­tions to phar­ma­cies/phar­ma­cists.

• ↓Fa­cil­i­ta­tion of sales of phar­ma­ceu­ti­cals to un­li­censed es­tab­lish­ments (gro­ceries, OTC shops, etc).

Phar­ma­cies were al­so warned to stop:

• ↓The sale of third-sched­ule items with­out a pre­scrip­tion.

• ↓Car­ry­ing on a busi­ness of a phar­ma­cy with­out a li­cence.

• ↓Op­er­at­ing a phar­ma­cy with­out a phar­ma­cist present.

Guardian Me­dia ob­tained copies of Phar­ma­cy Board no­tices sent to phar­ma­ceu­ti­cal whole­salers, di­rec­tors, phar­ma­cists and dis­trib­u­tors on June 18 and 20.

The first no­tice, “Il­le­gal Prac­tices in the Dis­tri­b­u­tion of Phar­ma­ceu­ti­cals,” was sent by the Phar­ma­cy Board’s Sec­re­tary/ Trea­sur­er. It was a warn­ing to drug whole­salers that the Board would in­ves­ti­gate all in­stances of breach­es, utilise mys­tery shop­ping mech­a­nisms for ev­i­dence gath­er­ing, and take steps to pros­e­cute guilty en­ti­ties.

“All whole­salers are in­struct­ed to cease and de­sist this prac­tice im­me­di­ate­ly and con­tin­ue to sup­ply on­ly au­tho­rised per­sons/es­tab­lish­ments un­der the Phar­ma­cy Board Act. It ap­pears that a doc­u­ment (Doc­tor’s Or­der) is pro­vid­ed by Med­ical Prac­ti­tion­ers to fa­cil­i­tate the above ac­tion. Whole­salers are re­mind­ed that this doc­u­ment is a fraud­u­lent rep­re­sen­ta­tion, un­eth­i­cal, and does not meet the re­quire­ments of the Phar­ma­cy Board Act.

“Fur­ther, in ac­cor­dance with Sec­tion 43 of the Phar­ma­cy Board Act, whole­salers are re­mind­ed that Med­ical Prac­ti­tion­ers are al­lowed to sup­ply on­ly “rea­son­able quan­ti­ties of such drugs or de­vices as may in the course of the prac­tice of his pro­fes­sion be ren­dered ur­gent­ly nec­es­sary for the treat­ment of his pa­tient,” the no­tice stat­ed.

Two days lat­er, the Board is­sued a sim­i­lar warn­ing to med­ical doc­tors. The no­tice was en­ti­tled, “Il­le­gal Prac­tices in the Health­care Sec­tor.”

“Med­ical Prac­ti­tion­ers are in­struct­ed to cease and de­sist im­me­di­ate­ly the sell­ing of drugs at their of­fices and con­tin­ue to sup­ply on­ly drugs deemed ur­gent­ly nec­es­sary in rea­son­able quan­ti­ties, in ac­cor­dance with Sec­tion 43 of the Phar­ma­cy Board Act,” the June 20 no­tice stat­ed.

With the Phar­ma­cy Board set to en­force ex­ist­ing laws, some phar­ma­cists ex­pressed con­cern that con­sumers will have to pay more to ac­cess med­ica­tion.

They said pa­tients will now have to pay to see a doc­tor to ac­cess med­ica­tions that were pre­vi­ous­ly avail­able over the counter (OTC). Third-sched­uled drugs are not sup­posed to be sold OTC.

“Phar­ma­cists/phar­ma­cies are not al­lowed to sell cer­tain drugs (the ma­jor­i­ty of the drugs found in a dis­pen­sary) with­out a pre­scrip­tion. (Types list­ed in the no­tice).

“For ex­am­ple, olfen, met­formin, pred­nisone, Ka­m­a­gra, Ar­cox­ia, Cataflam, Omez, etc,” the Phar­ma­cy Board’s Sec­re­tary/Trea­sur­er wrote.

Oth­er ex­am­ples of drugs that will now re­quire pre­scrip­tions are asth­ma drugs, di­a­betes med­ica­tion and some weight loss sup­ple­ments.

“In the ide­al health­care set­ting, en­forc­ing the laws is per­fect. So you’ll have to see a doc­tor to ac­cess med­ica­tion. But in our cur­rent set­ting, I don’t think it is fea­si­ble. Some peo­ple will opt to go with­out med­ica­tion be­cause some of them can’t af­ford to see a doc­tor every sin­gle month.

“In the clin­ics, they put peo­ple’s ap­point­ments six months apart. Cus­tomers will have to pay more and will have to wait longer to get their med­ica­tion.

“We should put things in place prop­er­ly. It may take an ad­just­ment pe­ri­od, but I haven’t seen any­thing yet about an ad­just­ment pe­ri­od,” a south-based phar­ma­cist said.

How­ev­er, the Phar­ma­cy Board as­sured that the price in­creas­es would not be sig­nif­i­cant.

“The cost in­crease to the pa­tients will not be sig­nif­i­cant­ly high­er, since there are many phar­ma­cies that car­ry low­er re­tail prices, some even low­er than the dis­trib­u­tor/whole­salers. Pa­tients have many phar­ma­cies to choose from and, there­fore, have a choice they can ex­er­cise in favour of bet­ter ser­vice and prices.

“This will not af­fect the wait times for med­ica­tions, as long as they are in stock,” Mo­hammed said.

The Phar­ma­cy Board al­so sought to ease con­cerns that the sys­tem would not be able to cope with the laws be­ing en­forced.

“There have al­ready been changes to stream­line process­es and re­duce turn­around time, and the Board is con­stant­ly re­view­ing process­es with the view to max­imis­ing the in­volve­ment of tech­nol­o­gy across the sec­tor.

“This would sig­nif­i­cant­ly im­pact the ad­min­is­tra­tion of pub­lic health. The laws cur­rent­ly pro­hib­it the ad­ver­tis­ing of third-sched­ule drugs (most drugs in a dis­pen­sary), and there­fore, on­line ac­tiv­i­ty re­gard­ing these drugs is not sup­port­ed at this time.

“The phar­ma­cy board is cur­rent­ly un­der­tak­ing a com­pre­hen­sive re­view of the Phar­ma­cy Board Act to iden­ti­fy and de­vel­op pro­posed amend­ments to strength­en the in­dus­try and im­prove reg­u­la­tion. The en­force­ment of these laws is im­por­tant to ad­dress many of the com­plaints that the Phar­ma­cy Board has re­ceived from mem­bers of the pub­lic in re­cent times,” Mo­hammed said.

An­oth­er phar­ma­cist be­lieved some­thing had to be done be­cause too many doc­tors were bla­tant­ly sell­ing drugs to their pa­tients, cut­ting the busi­ness from the phar­ma­cies.

“They would usu­al­ly give the pa­tient the med­ica­tion and cov­er the cost of the med­ica­tion.

“Some doc­tors are ac­tu­al­ly writ­ing the pre­scrip­tion with the note and telling them to go to the com­pa­nies and buy the drugs, ver­sus go­ing to the phar­ma­cies,” she said.

Mixed feel­ings from cus­tomers

A cus­tomer from south Trinidad said her doc­tor writes or­ders to get in­sulin straight from the dis­trib­u­tor.

“The phar­ma­cy board now says it’s il­le­gal so that means I have to go on­ly to the phar­ma­cies to get my med­ica­tion.

“Usu­al­ly, when I go to Smith Robert­son, there are plen­ty of peo­ple lin­ing up wait­ing on med­ica­tions, but ac­cord­ing to the phar­ma­cy board, that is go­ing to stop now,” she said.

A moth­er from west Trinidad com­plained about a re­cent neg­a­tive ex­pe­ri­ence with her 11-year-old son. A med­ical doc­tor sold her a drug as part of the vis­it, but it was the wrong one.

“The doc­tor pre­scribed an adult-lev­el/strength med­ica­tion for him for ton­sil­li­tis. When I re­turned, a sec­ond doc­tor ex­pressed con­cern, ask­ing if he had ab­dom­i­nal pain, blood in the urine or vom­it­ing be­cause those were the po­ten­tial re­ac­tions he could have faced, if he had a bad re­ac­tion to the strength of the drug he was giv­en.

“The med­ica­tion was not sup­posed to be ad­min­is­tered to a child his age. The doc­tor told me that many doc­tors are us­ing gener­ic drugs from In­dia that are catered to cus­tomers who can’t af­ford brand-name drugs. The gener­ic drugs, they said, don’t have the same ef­fi­ca­cy,” she said.

An­oth­er pa­tient from west Trinidad ad­mit­ted that his doc­tor in Diego Mar­tin reg­u­lar­ly gives him med­ica­tion from his desk.

“My car­di­ol­o­gist does this in a smart way where he ei­ther owns or part­ly owns a phar­ma­cy and tries to get me to buy the heart med­ica­tion from him but I go to an­oth­er phar­ma­cy be­cause they give bet­ter dis­counts through in­sur­ance.

“They should be in­ves­ti­gat­ing some of these doc­tors, though,” he said.