Most chronic illness and pain sufferers take medications. We require synthetic and natural interventions to live our lives. Certain meds make things significantly better, others keep us at maintenance levels, and some have the very heavy burden of keeping us alive. Because of this dependency, our relationships with medical providers and pharmacists are of the utmost importance. We trust that they are making the best decisions and actions to soothe our aliments. Even with extensive research and a hard-earned knowledge of our conditions, we are ultimately reliant on their expertise and “do no harm” moral compass.
Unfortunately, these fields aren’t always filled with honorable individuals. There is also the innate fallibility of human nature. People make mistakes, bad choices, and dumb decisions. This is where being both a medical advocate and a careful patient come in. Sure, you might be labeled as “difficult”, “demanding”, or “bitchy”, but your life is worth a few uncomfortable interactions.
Today, I went to my local pharmacy. Being that I have recently moved, I am still getting to know the pharmacists and people working behind the counter. Most of my medications are filled through a simply process and, while they see me frequently, our interactions are brief.
I am meticulous with my medications. I make it a habit to learn what each pill looks like, know whether they are generic or name brand, and notice differences in formulas from one manufacturer to the next. Tracking usages, playing with dosages, tapering up or down, tracing where side effects come from, and having an awareness of how doctors/insurance companies/pharmacists react when I fill my prescriptions… it is all part of managing my health in the best way possible. And yes, it’s basically a full time job.
Pain medication refills and monitoring are fraught with nuisances. From judgments to battling for adequate care, it’s a nightmare that I’ve written about many times over. Here’s a new problem: Someone working at the pharmacy either innocently incorrectly filling your pain pills or, the sadly more realistic option, pocketing them.
A few weeks ago, I filled a pain prescription that I’ve been taking low dosages of for years. The drug falls just outside of the opioid label nonsense, but it still has a high chance for abuse among vulnerable people. The size, shape, and printed code on each pill is standard. There hasn’t been a variation in the single generic manufacture of this medication for years.
After picking up my bottle and heading home, I did what I always do, put it in its standing spot and go about my day. When I shook out my first dosage (2 pills), I noticed that one of the pills looked different. It caught my eye to the point where I took a picture of the two side by side. But, the bottle didn’t note a mixed or new manufacturer, so I assumed that this new pharmacy just didn’t put that type of notice on their bottles. Maybe it was on the paperwork that I had already thrown away. Three days into this refill, I was miserable and experiencing some new symptoms. Nothing dramatic or worthy of an emergency visit. I chalked it up to a typical no-trigger flare and stress.
I dealt with the worsening flares and symptoms for about two weeks before I decided that something was definitely wrong. I ran through my possible suspects list. Nothing. I started down some wild theories and considered that I may be developing a new illness. But, something in my head kept poking at those pain pills. They had seemed less effective this time around, and that discrepancy in the way they looked just didn’t sit right.
Pouring out my remaining pills, I threw each of the suspicious ones in a baggie. There were only about 10 left. I subbed in 10 of my spare backup pain pills (If you are a responsible and nonaddictive personality, I highly recommend keeping a small supply of critical medications. It has saved my butt more than a few times.) and decided that I would dispose of them in the next few days. In the interim, I had a different prescription ready for pickup at my pharmacy. Standing at the counter I asked the white coat wearing cashier, “I’m new here. Is it common to put two different pills in one container without noting it on the bottle?” She said that they always place a sticker or hand written note if there is a change in appearance. A cotton ball would also separate the two different pills. I asked to speak to the head pharmacist.
Going into detail, I explained what had happened. He asked to see the picture and attempted to figure out if there was a different version of the same medication. There wasn’t. After some lengthy sleuthing, he found a matching pill. It was a type of medication used primarily to treat sleep disorders.
I take my pain medication between two to three times a day. Mostly, during daylight hours. This news means that I have been taking large doses of sleeping pills multiple times a day for nearly three weeks. Mystery solved!
The pharmacists apologized, made a note in my account about the error, and is going to “look into” the mistake. I am so fortunate that whoever made the decision to alter my pills didn’t substitute a more dangerous drug. I’m not exaggerating when I say that interactions with my other medications and my already compromised body could have lead to a deadly outcome.
TRUST YOUR INSTINCTS. I knew that something was off and I tried to push that feeling away. Thankfully, I ended up listening to myself. I should have done it so much sooner. It’s tiring and difficult, but we have to keep our alertness levels up. We have to check and double check that we are making instinctual decisions that either get backed up or changed through a deep dive into the issue. We are our only advocates.