Lawfully Addicted: Chain Pharmacy's Role in Our Opioid Epidemic | Ray Carlson, R.Ph., Author

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 Mike Koelzer, Host: [00:00:00] Ray, for those that haven't come across you online, introduce yourself and tell our listeners what we're talking about today.

Ray Carlson, RPh: My name is Ray Carlson. I am a pharmacist and I own RC compounding, pharmacy. It is a pharmacy in Poland, Ohio, and I also own RC Outsourcing. It's a 5 0 3 facility located in Lowville, Ohio. and have, uh, worked a lot of different aspects of the profession, over probably the first 25 years.

 Then just, kind of got tired of it and wanted to do my own thing. I always knew I wanted to be my own boss and that's led me to where we are here. I have been battling a particular aspect of the profession that I have written a book about.

And Which is titled Lawfully Addicted Chain Pharmacist's Role in Our Opioid Epidemic. 

Mike Koelzer, Host: All right, Ray, I'm gonna cut to the chase. About three weeks ago I saw some and it said, " Chains, they're getting sued for this much money because of the opioid thing. And my thought is well, they were legal prescriptions and.

I can't imagine a pharmacy, unless there's really nefarious things going on, it just seems like it's not the pharmacist's problem. And then I thought, well, I don't know what the hell goes on in chain stores. What do I know? And I said, I should talk to somebody about this.

Well then I remember that I had you set up who wrote the book on this. 

Ray Carlson, RPh: Uh, 

Mike Koelzer, Host: cutting to the chase ray, which side do I come down on?

Ray Carlson, RPh: you come down on the side of a nefarious non-compliance with dispensing law. That is what has brought about the ability of so many individuals to become addicted to prescription pain medications. We know 75% began with prescription pain medications, but the bookstarts in the late, mid to late eighties and how pharmacies operated.

And then slowly we crept away from adherence to dispensing laws. Most specifically, we're talking about over 90. Over 90 were passed by the federal go. In order to thwart the abuse and misuse of prescription drugs, that's very clear. No one can read through that law and tell me that its intent was not to prevent exactly what we have been seeing these past 20 years.

And so accordingly,the state's,promulgated their rules subsequent to over 90 if they wanted federal money, stating that they would enforce pharmacists adherence to over 90. And it wasn't just for federal dollars, at least in Ohio anyhow, and I believe most other states too, they made it mandatory for all prescriptions dispensed.

 The law lays out three things a pharmacist is supposed to do. and really when you think about it, these individuals got in a room, the legislators, and they said, okay, what's a pharmacist supposed to do? Let's make sure that they do it.

So they receive prescriptions. What are they supposed to do when they receive a prescription? There's 12 bits of information a pharmacist is supposed to obtain from the patient. So name, address, birthdate, whatever the medications are you on, your disease states and, have you had any previous reactions to a drug?

Do you have a medical device? And those sorts of things. So that's the first, that's the first section of the law. The second section of the law is that, 

Mike Koelzer, Host: Ray, let me stop you for a second there. I'm not looking for a cop out on this, but refresh me, is that law for every pharmacist or does it officially have to do with billing? the federal government.

Ray Carlson, RPh: Well, in the state of Ohio, and in most other states, it's for every pharmacist

Mike Koelzer, Host: law of the

Ray Carlson, RPh: that is, right. That for outpatient,

you're talking outpatient, a Walgreen, cvs Independent Pharmacies Mail order, they all need to adhere to OBRA 90. If they are billing, if they're billing the federal government for funds, which, now you've got Medicare Part D and you've gotta have Medicaid.

Those are your two main

ones. 

Mike Koelzer, Host: what if they're not,

Ray Carlson, RPh: If they're not, it doesn't matter in Ohio, because Ohio said, Hey, this is a good idea. We want it for all prescriptions.

Mike Koelzer, Host: Ohio does do it for all

Ray Carlson, RPh: yes, and I believe all others do

too, you 

but it's state specific. Those are found in the administrative codes of the various states.

So, the law was passed in 1990. The states had three years to enact their own rules that would force compliance with over 90. And so in 1993. By 1993, the boards of pharmacy had to have something in place. And with respect to dispensing, again, the purpose of the law was to thwart the abuse and misuse of prescription drugs.

This is 1990. 1993, the board of Pharmacies passed their own rules, specifically stating what a pharmacist must do. Again, first, first section when receiving the prescription. The second section is doing drug utilization review. [00:05:00] over 90 is called drug use review, over 90 dash drug use review. So the second part is doing drug utilization. The pharmacist must take the opportunity to make sure that the drug that the physician has prescribed for the patient is appropriate for that patient. Based on the information that the pharmacist received when he received the prescription, he or she received the prescription, those 12 or 15 bits of information.

Okay, so the pharmacist is using his education and his knowledge at that point for drug utilization

review. If the pharmacist believes that it is a legitimate prescription for a legitimate medical purpose, then it's okay to print the label, put the pills in the bottle, and put the label on the bottle.

The third section was that the people felt it important enough to have interaction with the pharmacist, that the law actually states in some way. The patient must be personally informed of their right to be counseled by. 

Pharmacist now the pharmacist then would go over probably, there's 20 different things listed that the pharmacist should talk about with the patient.

So how do you store it? What happens if you miss a dose? adverse reactions that you might be on the lookout for? All of those sorts of things are the third section covered in counseling. So then there's other miscellaneous parts of the law about entering patient information that is pertinent to that patient. And interestingly enough, the law set up what required that the states set up what was called a drug use review board so that every state would. evaluate the drug use through the data that was being transmitted to the state and determine whether or not there were any patterns of abuse and misuse.

Now, again, you're talking about 1990. It really wasn't until 2006 where we had reached the point at which the opioid epidemic was going to do what the opioid epidemic was going to do. But we had an opportunity prior to that had we had adherence to the law, had chain pharmacies not diminished the value of dispensing down to a dollar.

Had they not have thrown metrics into place had they not have gotten into bed with the insurance companies that were issuing new cards every other day, and all the confusion and paperwork that went along with that, had that not have happened and the pharmacist had the opportunity or the ability to adhere to over 90. the law would've worked, it would've worked to have, first of all, it would've caught that Oxycontin was addictive. So irrespective of whether or not the FDA did or did not allow a particular, drug to be marketed that, either was or was not addicting as it was claimed, and whether studies were, skewed in some way, it really shouldn't have mattered because we should have caught that earlier than what we did.

I mean, it was like a pharmacy realized that the drug was addictive. Bef at the same time the public realized it was, and it was the pharmacy's responsibility because of this law to have seen these patterns of overuse, and abuse. our state drug review board. You can go to the website and you can see the meeting minutes.

Sometimes the meetings only lasted 50 minutes. There's pharmacists and physicians supposed to be evaluating the data and you can go back years and just see that, we're not really sure what they discussed, but the minutes don't discuss anything about seeing that there is a problem developing with opioid use.

So it's pretty much across the board that the intent that the people had when they passed this law was ignored and the rest of the profession unfortunately allowed this to happen. We were crying for years. There's just no way you can comply with this law in 60 seconds.

And the State Board of Pharmacy here, we just did a survey and I don't. But I think the average prescription being filled right now in retail is one every 45 seconds. We can't even get into a mail order pharmacy to see just how many, I think probably the average there is six seconds. They're filling a press, two or 300 prescriptions an hour.

These pharmacists are, while having to, adhere to the same laws and rules that any other outpatient pharmacy would. The CVSs of the world

Mike Koelzer, Host: Some of the things you've Named here, we've named, the state knows, the manufacturer.

We've named the public, we've named pharmacist, we've named chain pharmacists and chain pharmacies in your disgust with this, put some of those in order for me of their, culpability, Give me number one

Ray Carlson, RPh: number one is definitely the chain pharmacist themselves.

Mike Koelzer, Host: themselves. 

Ray Carlson, RPh: themselves. And not because they did not fight back against their supervisors, because I worked at a chain pharmacy for a number of years and I didn't, I couldn't. There were a couple of times I quit that,I'd had enough and a lot of walking away.

But that's not enough. That's not what the public expects from an educated individual that is making so much money. civic responsibility needs to be taught in the colleges more [00:10:00] than what they're doing now. So part of the blame is on the colleges for not instilling this sense of civic responsibility, but you cannot have 65% of the profession not joining a professional association.

Chain pharmacists are the only group that does not have their own national organization. You have a national organization representing independent pharmacists, hospital pharmacist consulting, I think you have an enteral and parenteral nutrition pharmacy association. You have pharmacy law, you have people, you have a group representing the boards of pharmacy.

You have groups representing how it is, you do not have a national association, a professional association, not a union representing 65% of the profession. What did anybody think was gonna happen? The country is based on democracy. It's based on a system in which individuals in an area get together locally and express concerns about something they've been seeing.

And I talk about this in my book, maybe Joe down at Joe's Pharmacy notices his patients are becoming addicted to Oxycontin, or notices an adverse reaction to a drug. And they get together once a month at their local group with a beer and they just talk to Fred up the street or Mary down the road and she's noticing the same thing.

Well, lo and behold, this group puts a little letter together and gives it to their association president, who then takes it to the state association spring meeting and you have a resolution to bring to the state Ohio Pharmacist Association spring meeting. Hey, we see a problem with Oxycontin. Is anybody else around the state noticing the same thing?

If so, then you end up passing a resolution that you bring to the House of Delegates for, to A P H A and a P H A then passes a resolution and gives it to the CEOs and the elected leaders to then forward to legislators and those who can change something. But when you have, we're not even sure of the numbers.

A P H A is a little bit, uh, OIC OIC on what the actual numbers are that join last I'd find 'em, 62,000 A P H A members. Well, 32,000 are pharmacy students. , we have the same ratio as pharmacists association, probably more than half of the members are students. We go to meetings. We see more students there sometimes than what we see actual pharmacists.

So if a P H A has 62,000 members and 32,000 are students that leaves 30,000 pharmacists members, how many of them are executives and deans and academia and directors of this, or CEOs of that? How many have actually paid their own membership dues and have actively involved themselves based on their own advocacy?

so to think that maybe you have 175,000 chain pharmacists alone, and maybe only one in 15 or one in 18 join anything. from, where are you going to get the input on what's going on behind the counter to, to decide what's the best course of action to take. You're gonna leave it up to your elected leaders just to do a survey.

I see. A P H A now is issuing a survey. Okay. A P hE wants to know how it is for pharmacy members. Is that what they're calling 'em? Pharmacy? I don't know. They call, they got all these politically correct names. Now. Name are stakeholders. How are stakeholders? What? What's, how do they believe, how do they believe PBMs are affecting patient care?

Okay, well, so at least I give it to 'em. They're finally coming around to the fact that the PBMs are affecting patient care, whereas before it was just all about dollars. . Okay, so you have the product and you have the service and the transaction. Nobody wants to talk about the service. It's all been about the dollar, the dispensing, you're only getting reimbursed a dollar to the dispenser.

Now they got the claw back fees and how much money they're making on rebates and how much this and that. They've been focused on the dollar. They've not focused on the service part of it, at least a P h A is reaching out to see the connection between PBMs and the service, because as I say in my book, there's where the Achilles tendon is for the PBMs, but you do not gather this kind of information in a survey and just leave it up to the elected leaders these decisions are to be made by committees.

They're to be made by the House of Delegates. The House of Delegates are made up of representatives from around the country who have a vested interest in the outcome. They're energetic. We've got cash. We're educated, we should be donating to,forward the initiatives that passed in the House of Delegates.

That's what you take to the senators. That's what you take to our elected officials is the fact that our group has come together and this is what we feel about this. This is what we would suggest be done. And if it's not done well, you know what? We've got hell of a voting block. Pharmacists are a hell of a voting block.

Again, we got cash. We talk to hundreds of customers a day, and they all trust us. And we tell 'em who we could tell 'em who to, who we like and who we don't like in the upcoming election. if,some of the chains [00:15:00] allow us to have these kind of conversations,

Mike Koelzer, Host: When we talk about the Chain Pharmacist Association, something pops into my mind. N A C D S, 

Ray Carlson, RPh: that's a 

trade group.

Mike Koelzer, Host: of the companies, right. Not the pharmacists.

Ray Carlson, RPh: A C D S is a trade group. You have to be an owner to join, you have to own five or more stores. Your membership dues are based on your gross revenue,

Mike Koelzer, Host: But there's not one for pharmacists

Ray Carlson, RPh: Correct. That can join, that can be elected, that can sit on committees with a house of delegates. I mean, you have, Lord knows how many state associations that represent practice settings.

I mean, we have an Ohio Hospital Pharmacist Association and they have a National Hospital Pharmacist

Association. You don't have an Ohio Chain Pharmacist Association. You don't have a national association. There's one union, I think maybe in the Chicago area, but NA CDs is a trade association.

And Walgreens, who knows how much they pay a year for membership

dues. 

Mike Koelzer, Host: devil's advocate. So the chain pharmacists get together. It sounds too simple to say they're going to do this and it's gonna march onward to the steps of Washington. Aren't other associations, albeit, not completely, don't they have a percentage of chain problems, chain challenges that they've done this so maybe it's not a hundred percent, but have they done it 20% for the chains, or isn't that strong enough?

Ray Carlson, RPh: Possibly 20%, but 20% of the chain pharmacists don't even join. I mean, you're talking about umbrella associations like a P H A. You're talking about in Ohio, our umbrella association is opa, though, how pharmacists association, any pharmacist can join A P H A or opa. So the initiatives that these umbrella associations take up would be based on the cross section of the representation of the members.

So if the most of the members are hospital,independent, administrative,

uh, clinical, they're gonna advocate those issues,

Mike Koelzer, Host: If the federal thing was said, you know what? We're going to represent this very small minority of our constituents. We're gonna take the chain pharmacist issues and do it, maybe, but the fact is that's not happening. Right.

Ray Carlson, RPh: There's nobody in the room to have conversations about what's going on behind the counter if those individuals behind the counter are not in the room. And so it's that which comes first, the chicken or the egg. And the chain pharmacist will say, well, they don't do anything for me. And you say, well, they, yeah, you're probably right because you're not there.

You have to do it, so that's democracy. and that probably comes back to the civic education part of it. This, that these chain pharmacists don't understand. What do you do at this point here? , you're not going, you're not going to admit that we have allowed, dispensing rules to be, violated for all these years.

The associations aren't going to admit this. the stuff I've been trying to do for the past 10 years, and remember one of those efforts was I sued the Ohio Board of Pharmacy. So I first went through the local association. We had no local association I received, this is all in my book.

I received a copy of a contract from a PBM that told me I was not allowed to say anything negative. Well, I don't take insurance, but I found it in, I found it intriguing that they had sent me one and I saw, well, is anybody else signing these contracts? Saying the pharmacist is not allowed to say anything negative about the doctor, the patient, the plan, anything like that.

It's a restriction, especially when we have an opioid epidemic going on. So that was kind of like the straw that broke the camel's back for me. I started to get involved back with OPA and I wanted to get our local association together again. We had disbanded years ago. And so here, this is funny because. I got in my car on Route 20 in the very northeastern corner of Ohio, and I just started around the route, started down Route 20 heading east towards Cleveland, and I hit every chain pharmacy on every corner and walked in. I looked, I was looking like I was a member of the Board of Pharmacy, walking in with my clipboard and my propaganda saying, Hey, we gotta get our local association up and going again.

And I hit all the clinics, the hospitals, and before you know it, we had 650 members and we had a meeting six months later. Over 200 pharmacists

attending, which was quite an accomplishment. So the first PowerPoint I tried to give was explaining to them how we pass a resolution, what a resolution is.

Whereas, whereas be it resolved that we're gonna do this, so whereas,it's tough behind the pharmacy counter, whereas you don't think it's safe, whereas you think you're violating the law, be it resolved that we ask our Board of pharmacy to go into behind the counters and see just how, what the compliance rate is.

With over 90 rules, with your rules go in with your gap analysis and your [00:20:00] checklist, and just, if you come out of the CVSs and Walgreens of the world and say, huh, looks like they're hitting it all, then fine. But if you go in and see that they're asking for the first initial last name and a birth date, and that's all the information they're getting.

and texts and they're blowing through drug utilization review warnings in two and a half seconds. It doesn't take a smart person to go through these computers and see how long a pharmacist is on a warning page. You can go through patient profiles and see whether or not doctors were called or any pertinent information to therapy was, go pick up the counseling log.

95% of patients are declining counseling. Well why, if they're personally being asked that a pharmacist wants to sit down and go over 20 things with them, how is it 95% of these people are declining and signing away their right to be counseled? 

So, 

Mike Koelzer, Host: why are they,

Ray Carlson, RPh: Well why are they, cuz they don't wanna bother the pharmacist.

They don't want to. Everybody's busy. 

Mike Koelzer, Host: They don't want to add tension to it. 

Ray Carlson, RPh: Right, right. It has slowly crept into what it is today. So who's gonna, who's gonna buck the system? Who's gonna admit now that the system is so broken that you need,you, you need some savior to come along and try to, well, the savior, I think eventually is gonna be the people.

And that's because of the cold shoulder I got from the associations. So to back up a little bit, after we passed our resolution, half of the, half of the officers of our locality didn't wanna sign the letter to the Board of Pharmacy. they feared retribution. And I wouldn't have signed it either, So I ended up circulating a petition, a public petition to get people to sign to say, what's been your experience? If you were informed of what a pharmacist was supposed to do according to law, do you believe it's being done? And I took that petition along with our resolution. And I drove it down to the Board of Pharmacy.

Mike Koelzer, Host: Why didn't you care about retribution?

Ray Carlson, RPh: I don't know because I'm my own boss, I

don't have to 

worry about any. 

Mike Koelzer, Host: why didn't you worry about it?

Ray Carlson, RPh: Well, when I was a chain pharmacist, you're asking,

Mike Koelzer, Host: when you got this going and had it signed and you brought

Ray Carlson, RPh: I absolutely was sensitive to the other office officers and their positions, and even the members who didn't wanna come to the microphone and speak, I was sensitive to that. 

Mike Koelzer, Host: But why did you feel it was okay to go to the board? Were you worried about your license or that they would take retribution on

Ray Carlson, RPh: I wasn't worried about my license until I filed the lawsuit. when they denied my petition, when they denied my resolution, when they denied doing any action on what I was asking them to look into was when I filed the lawsuit.

Mike Koelzer, Host: I'm not saying I agree or disagree, I understand why they would be afraid of retribution, but were you also, but , your drive to do this was so strong you didn't care? 

Ray Carlson, RPh: I think so, and Mike, I think I've been numbed a bit by agencies. I've been inspected by agencies a number of times, including the Food and Drug Administration. The Board of Pharmacy was familiar with me in that, for two years prior to the New England Compounding Tragedy.

I had gone to the Board of Pharmacy several times. and even to the Rules review committee to get them to look at changing a rule. the 5% rule. I was not allowed to compound anything more than 5% of my total sales without a patient prescription name and blah, blah, blah. And I said, I told him, I said, something's gonna happen.

We see Mickey Mouse and Donald Duck names on stuff. We do not have the ability to go and inspect their facilities, and they're bringing stuff from overstate. Well, unfortunately, they said, well, you cannot exceed 5%. You must, register as a repackager with the Food and Drug Administration. So, okay, I hired a consultant and they got my computer to link up with the FDA's and I filed as a repackager of Sterile Drug. Well, a few weeks after that, we're watching MITT Romney. with Obama, and it starts scrolling at the bottom of the screen that people were on their way to the hospital with meningitis and how many had died and blah, blah, blah. And I was hoping that my application had been lost somewhere,in the digital space, but it wasn't.

And sure enough, and comes the FDA with their badges. They were looking after that. They were looking for any opportunity to come in and see the sterile operations of a compounding pharmacy. So they were there for a week and the Board of Pharmacy came in with them. Surprisingly I found a lot of comfort in having my Board of pharmacy inspector coming in with the Food and Drug Administration.

If you can imagine how the food chain of agencies work, I was comforted in that because you really, you don't share anything in common with, they're dressed in uniforms. Back to your question. I'm, I've been numbed, I've been inspected, I don't know, six or seven times by the FDA and numerous times by the Board of Pharmacy.

What were they gonna do? Plus they knew I had been there the two years previous, the New England compounding, and I had kind of issued a warning. Well, I had been issuing a warning about working conditions behind the pharmacy for a number of years. I tried to start a National Association of Employee Pharmacists in 1996, and that's [00:25:00] part of my book.

I have my first and only mailing that I sent on. Now, back then it was snail mail, so it wasn't an easy thing to do. I lost my job because I couldn't find work because everybody thought I was trying to start a union when actually I was just looking at the essence of professional association and its beauty.

It's not a union. it really isn't. It's how change is supposed to come about a little bit at a time. You don't wait for things to get this bad and then try to figure out a way to dig yourself outta this. It happens a little bit at a time, and these chain pharmacists should have been joining.

Our state association and a P H A all along, instead of crying about what they're not or not are not doing for them when they're not there. They should have understood the importance of professional association and joined. They didn't have to attend meetings. Just give them, just let 'em have the money and know that your vote is there.

Mike Koelzer, Host: Ray, what became of your lawsuit?

Ray Carlson, RPh: Well, first you have to have standing. And in order to have standing, you have to prove to the judges before they even hear what you have to say. You have to show to them that you've been hurt somehow physically, or financially. And I wasn't able to prove either financially. The worse it gets out there in retail chain pharmacies, the busier I get, these patients want some care and they're not getting it in chains they call us.

And so financially I wasn't being hurt, but you know, interest. Interesting though I was considering, going, federal, law, that if I argued that environmental law was being violated, that the drugs actually represented a poison that was being dispensed because laws were not being upheld. I would've been granted automatic standing, but I ended up, there is an Ohio law that allows me to obtain standing, if it is what is called public standing.

So public standing requires that you prove. So it would no longer be Ray Carlson versus the Ohio Board of Pharmacy. It would be Ray Carlson, and the citizens of Ohio versus the Board of Pharmacy. So I joined the public in Ohio. If I could prove that it was an important issue, that the people cared about it, and that death, further death would occur if the judges didn't side with me, it elevates to an issue that is of such importance.

I would automatically be granted standing and the judges would hear what I had to say. And what I had to say really was the law says that if the ru, if the Board of Pharmacy has any reason to believe that rules are being violated, they must investigate. And we had all the evidence we needed to suggest that these pharmacists were not following over 90 and the rules that the board had, had in place to make sure that they were, you just cannot do it in 60 seconds.

Working conditions cannot be so poor with so many complaints on social media. And all of the national news on the investigation that they did in Chicago, going in and handing pharmacies obviously to interacting prescriptions and how it was, how, how little these are being caught and stuff like that.

The evidence is there. The board must have had some indication that OBRA 90 and dispensing rules were not being complied

with. And very simply, all I was asking them to do was go in and look. If, again, if they came out and said everything looks good, then fine. If not, really what they needed to do was exactly what happened when the New England compounding tragedy happened and compounding pharmacy was turned upside down.

We were a leaf in the stream. It was totally up to the government as to whether or not we would even be allowed to compound drugs anymore. It could have totally been taken away from us. For the atrocity of it all, what happened in the three years after the compounding tragedy happened is exactly what needs to happen in the chain, pharmacy and retail pharmacy world.

These agents need to go in, like they came into my compounding pharmacy, like they come into my outsourcing facility. They show their badges. they're coming in for a week, an entire week, 10 days, 11 days. This last inspection of mine lasted off and on for over 30. That needs to happen.

Behind the counter board of pharmacy Agents need to show their badges, go in with their gap analysis, look at patient profiles, look at the amount of information that's being received on the front end to get an estimation at how much time pharmacists are spending on drug utilization review. Go to the counseling book and see how many patients are being talked to and then say, I understand the law says you must make a reasonable attempt, and maybe this is where corporate America feels they can get around a reasonable attempt.

Do you consider five out of 15 bits of information to be reasonable? Do you believe 95% not being counseled is reasonable? These agents, like with arcs compounding pharmacies, all they do is say, I want this, and this fixed. [00:30:00] You've got five business days to respond to how you intend to fix 'em and we better like how you're gonna fix 'em or we're gonna issue a warning letter.

And a warning letter is just like a little bit more anxiety. I have received one warning letter, from all of my inspections because really it was my first FDA inspection. I didn't really know the process and I. I, I didn't have to respond anything because just the way we kind, you kind of get manhandled, you think, well, okay, this is my spanking enough and

sort of a thing.

But what happened in the compounding world needs to happen in retail pharmacy,

Mike Koelzer, Host: Ray, if you could pick one word, why is it not happening, what would that one word be?

Ray Carlson, RPh: obscurity.

 I think death is obscured. I think the death is spread out over a long period of time without being able to be traced back to a particular incident. Every now and then, yes, a patient can get home and see they've got the wrong pills in the bottle. That's very obvious. You can consume those pills and die, and yes, you've got a claim there and the board would keep track of those types of incidences, but because you are not seeing in retail pharmacy what you saw with the New England compounding tragedy at 70, some people die within a few short months, 700 and some got meningitis.

You're talking about a short time span. You are able to see the cause of that, and so you're able to go forward with that. How are you going to apply blame to whether or not five bits of information on the front end was necessary? Did you need nine? Should you have really made a good effort to get all 13 or 14?

Could this have been caught? Had you counseled more than 5% of people? But where's your evidence? What does anybody know to subpoena CVS or Walgreens as to what they're gonna ask for? I would know if anybody had got the wrong pills or felt that they were injured.

I could tell 'em exactly what to put in a letter and they would settle 

Mike Koelzer, Host: Ray Devil's advocate. The pharmacist says, well, this prescription came in the cycle was right. It lined up with what the doctor wrote. There's no overlap. How the hell do I know if this person really has a sprained ankle and needs this or has pancreatic cancer or whatever ?

Ray Carlson, RPh: the pharmacist is supposed to ask, why are you here? That's the purpose of the first section of the law. Why are you here with this prescription? Is it your ear or your eye? Do you have cancer or do you hurt your back? So disease states, what disease states do you have? The first portion of the law is to ensure that the pharmacist takes or somebody takes a little bit of time to get some information about this individual.

Yeah. if you think that a pharmacist's responsibilities is just to make sure the right pills are in the right bottle, as long as a doctor writes that, then okay, degrade the profession down to an individual that's all you're responsible

for. or if it's just a calendar 

you're right. don't call 'em doctors then, you, a technician could do that.

And that's what the chains want. The chains want our role to be minimized to where we could have a tech check, a tech, and as long as that happens, put the pharmacist in a cubicle and just see whether or not patients call. And have questions about anything.

If so, we'll send 'em down the hall to that pharmacist and if nobody has any questions for a while, okay, we're gonna cut your hours. But we've got a remote pharmacist somewhere with a camera looking at tech, checking techs. , if you wanna disregard dispensing laws enough, if these dispensing laws define our profession.

This is why we applauded over 90 when it was passed. It defined what it is we were to do and the role we were to play in society. Just because a PBM says it's only worth a dollar, you can't accept the fact that the value of it is only a dollar. And this gets back to, I wasn't really thinking, a nuisance, a public nuisance.

Would be successful in the lake and Trumbull County. Two of the counties of our local association, Lake and Trumbull Counties, were the ones that brought the Bellwether suit against CVS and Walgreens and, I think Rite Aid and Giant Eagle dropped out, but Walmart, Walgreens, and CVS stayed in it.

 650 million. That was huge, it was the first time somebody had brought this claim against a chain pharmacy saying, you're partly responsible because of your carelessness. Well, lake and Trumbull County, they're in our local association. I'd like to think that maybe we had a little bit behind instigating the idea that dispensing rules are being violated.

But here's where you look at the PBMs. Okay. You,a PBM goes to General [00:35:00] Motors or Goodyear Tire and they say, you know what? We're gonna oversee all these prescription benefits for your company. You don't gotta worry about any of this. We're only gonna contract with pharmacies who guarantee they're gonna uphold the state and federal law, what state and federal law over the nineties, what they're talking about dispensing laws.

They are gonna ensure that all of the employees of General Motors, when they walk in, to have a prescription filled, that the pharmacy that this PBM contracted with is going to follow the laws and ask 'em what the law says they're supposed to ask when they drop the script off to take time to do drug utilization review, and then counsel to make sure that they're gonna take the medication.

Right. And not only that, the pharmacist, it's not just about disseminating information when they counsel. It's also about a pharmacist looking somebody in the eye and deciding whether or not you're taking Oxycontin 63 times a day. And having some suspicion, it's that, that they're not. But anyhow, the PBM is contracting with these pharmacies.

And are they auditing whether or not the service side that they're providing is being complied with? Do they ever go in and say, let me look at some patient charts and see whether or not there's any notes in there that say even talk to anybody. Let me go over and look at your counseling logs.

Are you, is, are the PBMs doing any of that? No. They're going in and saying, you know what? You dispensed a 35 day supply and you transmitted it to him in 30 days, we're gonna take back 5% of everything we paid you. It's money. Then, so here, I tried to go to our county with this. I went to Mahoney County here.

I went to our prosecutor's office, and, I said, look, he got a, this is, this was before I even filed the lawsuit. I said, why don't you take a look at something? Why don't you look to see how much in premiums you've been paying? The county has been paying to our PBM for all the prescription benefits and asks 'em whether or not the pharmacies they're contracted with are actually following the law.

If they, if you suspect they're filling prescriptions every 60 seconds or the mail orders every six seconds, how are you complying with the law? Is it any wonder why we have so much drug misuse going on right now? People don't even know what they're taking half the time. They don't know the names of it.

So I told the county, prosecutors say, why don't you get a little bit of this money back? The problem is, the problem has a lot of players here and I don't know how you fix something that has so many active players, certainly academia. I've talked on campuses, I've had professors that have said Dispensing is dead.

 Meanwhile, I'm about to give a PowerPoint presentation on all the rules of dispensing. It is what defines what we're supposed to be doing. What do you mean it's dead? you want this clinical you, you're pushing clinical. You want these pharmacists to sit in a cubicle and have these names.

They've never dispensed any people they don't know in other states pop up cuz a computer says they're on 15 different medications When you're supposed to be doing that before the prescription is dispensed, as the law says. So you have associations, they wanna sell web. webcasts and webinars and sell their $900 seminars so that you too could be an expert in medication therapy management.

Before you know it, you have a whole industry of medication, therapy management. Growing up, these pharmacists are ducking out, they're leaving retail chain pharmacies and starting up their own businesses and doing mtm. it's a whole industry because nobody wanted to say, wait, why are you even needing so much MTM when drug utilization review before the prescription is dispensed, before the drug is consumed, is. Properly being done. And it's not, nobody wants to admit it. It's a large problem. And so perhaps this is the reason why I've not gotten the kind of love that I thought. Maybe I, I would've thought filing a lawsuit of what pharmacist do you know, has ever filed a lawsuit on these sorts of grounds against their Board of Pharmacy.

Do you know of any, did you think I even got one blurb from any of the organizations? Do you think there was any conversation about the merits of what I was even asking? Well, now the consideration is there. This was five years ago when I filed the lawsuit. It's the same, almost the same basis that Lake and Trumbull County won 650 million on.

Mike Koelzer, Host: were you ever able to

satisfy those? 

Ray Carlson, RPh: I didn't get standing. No.

Mike Koelzer, Host: Not only was the lawsuit not able to go forward because you didn't have standing, you also didn't get any press from it to see if you could move this idea along.

So you come out with this book and I've got it in my hand right here. and it's not a Kindle Electric thing. I mean, this is a solid book. It's, you know what, a few hundred, 300 

pages? 

What was your reception when that came out? Did that get any of the traction that you want at this stage?

Ray Carlson, RPh: no, I think it'll take time. It is frustrating. I don't have a big following on LinkedIn. I think maybe the [00:40:00] title, maybe a put off for some individuals in the pharmacy world. I think I wrote it more for the public. But the pharmacy world itself, they may be put off by the title because they think that I'm just gonna be bashing chain pharmacy and pharmacy in general, that I would be shedding bad light.

and that's understandable. This is perhaps why the associations didn't want to post anything or write anything. like with my lawsuit, you won't find it in the annals of any of, as far as history is concerned in the profession of pharmacy. You won't find it anywhere.

So that's why I wanted to put it in the book. But I realize that perhaps it may shed a bad light, but I don't, I really don't think it does. I think if it sheds a bad light on anything, it sheds a bad light on the chain. Pharmacist unwillingness to join an association. Much of what we're dealing with could have been avoided years ago.

Had, had these chain pharmacists been called out years

ago and, and, and.

Mike Koelzer, Host: Maybe with pharmacists it doesn't go over. I think it will, but the public doesn't wanna read a book that comes out that says, you know, here's a book on pediatricians or, or nurses, and it's great. I was gonna tell you how much people love us, so people want that controversy.

Do you feel like you are a target with this book? You're really putting yourself out there. Is that worth it for you?

Ray Carlson, RPh: I have in the past. I mean, I've, and I've mentioned that in my book, I've, I had an instance where a cameraman put his camera. And asked me if I was worried about anybody putting a bomb under my car.I had a little public forum that I sponsored. I had a reporter ask me the same thing, because, you know,PBMs are bad, CVS is bad.

they could squash me if they wanted the Board of Pharmacy. They could squash me if they want, butI believe the Board of Pharmacy understood my intent. They know, and I've been on several radio programs, that they had to have heard me talk they're understaffed, they're underfunded.

The board of pharmacies has too many problems. I know what pharmacies are sending their way as far as problems. Their plate is full so I hope they understand why I've done some of these things. I've been doing it since college and I can't explain to you why even then, I was the guy standing on the corner at the fraternity party not understanding why there was so much drunken, disorderly conduct and why nobody was coming to our student P H A meetings.

In my book, I talk about the, my fraternity had a trial to have me removed because,some of the things I was saying about the brotherhood, and it was just because the brotherhood was professional. It was k y a professional fraternity. you can't be spending so much time socializing and partying and not attending any of our student A P H A meetings.

We would've had only one or two functions at the show. Well, you know what? These individuals graduated into the culture that ended up finding themselves behind the counter. And they did not want to join associations. They did not want to attend meetings. They did not want to stand up to a microphone and say, is there anybody else experiencing this?

But I don't have enough time to fill a prescription today. Or not do it safely. They did not embrace the democratic process because of, I don't know, 

abundance, apathy. 

Mike Koelzer, Host: Ray, do you think people like you and do you care

Ray Carlson, RPh: I, I think they do. I have a lot of friends. Yeah. I think they do. I think once they get past maybe the fourth rightness of the message, I can be a little bit straightforward about things, but yeah, I think some things are obvious. I don't think it's being forward at all. Sometimes I ask myself, how is it that you're not seeing this

Mike Koelzer, Host: it's a federal law 

that nearly everybody's breaking.

Ray Carlson, RPh: You cannot make a connection between filling a prescription in 60 seconds no way you can comply. You cannot see the growth of medication therapy management and say to yourself, we've got a problem with doing drug utilization review before the prescriptions are dispensed.

I mean, you can't look at all these drop boxes that I think the United States took back, what? 56 tons of drugs that were never consumed, and now you're putting boxes up for people just to discard 'em because you dispense them when you never should have. I think these things are obvious.

I'm wondering what is motivating the individual not to want to talk about it? Am I the first guest you have had to talk about over 90?

How can that be? Why is nobody else looking at the working conditions behind pharmacy counters and making a connection with the dispensing laws that the people pass to put 'em safe?

Are they safe?

Mike Koelzer, Host: they're not. If you look across the board, I think the average pharmacist, at least the independent, knows the chains aren't doing it.

They wanna do a little bit more than the chains are doing. They probably don't think about that law a whole lot. They probably say, we've got so many damn laws from the board and all this stuff,and they don't correlate that it's really good for [00:45:00] people. It's like another, big government law. So I think it's kind of like everybody goes along with the flow, I'm not saying that's right. I'm just saying everybody compares themself to each other. It's kind of like going down the highway. We have some 75 mile an hour ones, and I'm going 80. It's because, well, it's as fast.

Feel comfortable at my old age, but I'm going 80 and if everybody else is going 70, I would, if they were going 90, I'd probably go 85. You're staying with the crowd. I'm not saying that's right, but I think that's where it happens.

Ray Carlson, RPh: It's a path of least resistance sometimes, and this is why we're getting so many new laws. I'm not much one for laws, I mean, new mandates. I don't think we need to mandate how many prescriptions an hour, whether or not you should take a break or be required to take a break. But you know, that's the easy way to go throw some lobbyist money at it and have lobbyists pass new laws and have dinner and have a good conversation about passing a new law.

It is very difficult to get in somebody's face and say, you know what? I'm accusing you of not following the laws that are already on the books.

If you had followed the laws that are on the books, we wouldn't need these new laws.

Mike Koelzer, Host: Make tougher laws. Everybody acts like they're doing something, but they're not even enforcing the first ones, and no one's following the first one. So it's all like, 

it's all like smoke 

Ray Carlson, RPh: It's like with MTM you had to have a law passed to make sure that insurance is paid for mtm. Well, you just opened up another Pandora's box of abuse of, I've talked to so many pharmacists who've abused Sometimes they get $25 if, even if the patient doesn't answer the phone, they're having metrics set up where they're trying to get 'em done on weekends and this and that.

Whereas drug utilization of you properly done on the front end before the prescription was filled was the law that needed to be adhered

1. Not 

this new law of

medication therapy 

management, but it's more opportunity for administrators to continue. Administrate within the associations instead of coming to the aid of these chain pharmacists and other pharmacists and realizing that they're having to fill prescriptions in 60 seconds, and that professionally is what has them in the dumps.

Mike Koelzer, Host: I was watching Bill Maher and I listened to him more. I never thought I liked him cuz I would probably come down a little bit Right. And he had more left. But now when I see the woke wisdom, it's kind of moved Maher more to the center for me. So I really enjoy his stuff now.

I listen to his podcast and things like that. Last night though, he was calling out all of the celebrities who are taking their jets everywhere, their private jets everywhere. And Mara was saying, well, these people say they have to, it's like, I don't have to do my standup tomorrow night inNebraska and this person doesn't have to do this or that.

So here's what I like talking to you about though, Ray, because you could sit here and bitch about this and then you could say, you know, I've gone to Washington. I want this and that, but you are living this. You've got a store, and I would hope to God that you're doing 

Ray Carlson, RPh: this 

correctly Mm-hmm. 

Mike Koelzer, Host: about this.

So what does that look like?

Ray Carlson, RPh: You cannot have an outsourcing facility that's overseen by the Food and Drug Administration to do it incorrectly.

Mike Koelzer, Host: Do you run a 

regular pharmacy 

now too? Or

Ray Carlson, RPh: a compounding pharmacy, and we dispense all medications. I actually believe that my, my pharmacy, is able to dispense more prescriptions than most any other,

Mike Koelzer, Host: The outsourcing one, that's, almost what you'd call a manufacturer.

yes. We're half, I guess we are. Yeah. We are more manufactured than anything. I wanna throw that to the side because they say, well, Ray's doing this manufacturing, it's gotta be different than the real world. But you still own a real world pharmacy. It's more compounding, but you do regular meds.

So I'm taking it you're putting your money where your mouth is on this.

Ray Carlson, RPh: Yes. My pharmacy, we specialize in the endocrine. . So we do a lot with hormones. We do a lot with thyroid. We do a lot with erectile dysfunction. at the compounding pharmacy I have,with myself included, there would be four pharmacists on staff there and probably a dozen technicians. We have had to expand of late because many compounding pharmacies have gotten out of doing compounding because of usP 800 guidelines.

So now you have to have a negative pressure room that has to be vented to the outside. All the policies and procedures that go into being able to provide this kind of service was a 

large, it was a large hurdle for people and they gave us their customers. They didn't wanna do it.

Mike Koelzer, Host: Is that new that even the non-sterile stuff has stricter rules 

Ray Carlson, RPh: That's correct. So we installed the rooms. We retrofitted all of our rooms To be able to vent to the outside, you have to have so many room changes per hour. Temperature, humidity have to be constant. Everything has to be monitored. and we also installed a [00:50:00] hazardous clean room, which is very unique.

There's very few hazardous clean rooms. So here you have a room that needs to be sterile while at the same time venting to the outside. It's just not a, it's not an easy thing to build in addition to our sterile clean room or our non-hazardous clean room. So we have hair, hazardous, sterile, hazardous, non-steroid, non-hazardous, sterile and non-hazardous, non-steroid.

Mike Koelzer, Host: Wow.

Ray Carlson, RPh: it's, it's putting. I wouldn't say pharmacies out of business, but it has made pharmacies rethink about whether or not they wanna provide this service. I believe in the service that we provide with respect to the drugs that we dispense. I can also dispense regular prescriptions, all cash. I don't take insurance.

I never have, really, I never have. I think early on when I first opened in 2006, 2007, did I link up and maybe a couple prescriptions. But,the type of prescriptions that I was doing compounding, it was too difficult to bill and I didn't, just, didn't want to deal with the insurances in the PBMs.

I'm cash only. the outsourcing facility is pretty much, I mean, there's no PBMs, no insurance with the outsourcing facility, but the compounding pharmacy RC compounding, that's cash only. And with respect to the law and dispensing rules, there's the rules that guide you as to what it is you are able to provide to society.

Mike Koelzer, Host: Take me into how you practice, what you preach on this in terms of your counseling and gimme an example of that.

Ray Carlson, RPh: Well, the office that we have, we have a dry erase board in there. So if, for example, a patient doesn't understand why he's getting up three or four times a night, let's go to the bathroom. We just draw a picture of the bladder and the prostate gland and the urethra and what's going on, we don't fill a whole lot of prescriptions, so that's important too. I mean, the volume really is what allows you to have interactions with the customers. But with regard to over 90, I mean, well, my staff know that's top priority as far as the percentages that we counsel you. You have to remember though, also, even with respect to myself, I'm gonna be the first to admit it, we are having to accommodate a business model that the chains have already set in place for us.

This came out in the Lake and Trumbull County lawsuit. When CVSs and Walgreens, they were saying, well, you're independent pharmacies. We're dispensing just as many, if not more controlled substances at, well, who was it that was setting the business models? Who was it? Those were the ones that were able to stay in? Most had closed in our area, but those that were able to stay in business were only reacting to this deception that the chains seemed to be putting in place. 

The independence that were busy, and maybe were able to form some sort of a collaborative effort with other independence in the area, whatever the case may be. It was volume that was determining the speed, how fast you need, how many scripts did you need to fill in a day in order to stay alive, and was being determined by chain pharmacy,

Now in our area, we had a number of independent pharmacies that ended up surviving because a number of controlled substances they were able to dispense. And we knew exactly which pharmacies those were, and we knew they were, we knew they dispensed garbage. We knew their businesses were based on garbage. We knew the owners of them. The owners were great people. They had been great people in the past. They were members of our association, but they were trying to accommodate a business model that had taken away all of their gravy prescriptions, all of their high blood prescriptions, all of their thyroid prescriptions, all of the maintenance medications that their customers had, come to fill at their pharmacies, or now needing to be mailed away to a Walgreens mail order, a CVS mail order.

They did not have those customers any longer, and if they wanted to feed their families, the word got around that maybe they may have been a little more accommodative towards controlled substances. I can't speak for the rest of the country. I don't know to what extent independent pharmacies played in this, but to me, it doesn't matter.

And why the independent pharmacies never went back on the chains and said, wait a second. How are you able to dispense 350 prescriptions in a 12 hour period? with just one pharmacist on staff and technicians. How are you possibly able to do that? Why did they never look at the number of prescriptions being dispensed by mail order and say, how are you complying with dispensing laws at that rate?

Again, if you're just talking about the product itself, then you're gonna be blinded to the service that is to be attached to that product. The product is not going to harm the patient as much as the product without the service, and that's why drugs are important. we're not talking about [00:55:00] bread here, we're talking about drugs.

So how is it that the independent never questioned the CVS down the road filling,3,700 prescriptions a week and not wondering, well, 

What's your business model? 

Mike Koelzer, Host: Alright So devil's advocate. If just one more person does it, now I sound like a defeatist. But if just one more person does it, all we have is another ray in some county doing it, it's just another person that gets inspected by the DEA and all that kind of stuff? Why didn't independents say this? Why didn't they go to the chains and do this 

Ray Carlson, RPh: they're probably doing it themselves. 

little by little they were doing it themselves.

So they were filling prescriptions just as fast as chains trying to keep up. They weren't talking and counseling anymore than the

chains were to try to keep 

Mike Koelzer, Host: But let's say they went to the chain to complain. They're gonna get a deaf ear just like you have.

Ray Carlson, RPh: Yeah. Well, you know that they had more standing than I would, I don't compete with them. But if I was an in, if I was an independent pharmacist, I'd have good standing. 

I could go to the courts and say, you know what? The Board of Pharmacy needs to go in that CVS on the 

corner. 

Mike Koelzer, Host: you're not running a similar

Ray Carlson, RPh: Exactly. I don't compete with them, so I'm not being hurt. 

you have to prove to be, you're being harmed.

And if you can prove that, then they can listen. So why doesn't the independent say, you know what? That damn CVS or Walgreens on the corner filling 4,000 prescriptions a week, how are they doing?

Mike Koelzer, Host: following the rules. You know why they're not doing that? Why are there not more of these sorts of claims being brought before the courts? I don't know. I mean, we're witnessing what happens when you fill a prescription every 60 seconds. When has medication misuse ever been this bad?

Ray, if you could sit down with one person and that.

discussion was going to be recorded, sent out tv, whatever. who would that person be? Would it be the president? Would it be some CEO,or would it be a famous doctor? Recorded for the world to see,

Ray Carlson, RPh: in order to pin my hopes on change happening,

Mike Koelzer, Host: Yeah. Yep.

Ray Carlson, RPh: I would like to have that conversation. I think with the director of, c m s, the Center for Medical Services, the payer, they are the ones who pay the bills. They are the ones that pay for the prescriptions. 

Mike Koelzer, Host: What would you say to her?

Ray Carlson, RPh: the same thing I'd send in a letter to her year ago and have not heard anything back.

And exactly what I outlined for you, that, over 90% was a law That was to ensure that pharmacists followed through on these three areas in order to stop the abuse and misuse of prescription drugs as well as save money. And you are not to receive federal dollars unless you complied. And I would suggest to her that she should look into whether or not there is compliance and has been compliance over these years, maybe to ask for some of our tax dollars back.

Mike Koelzer, Host: And then you would like people to watch that and say, yeah, I've got that question too.

Ray Carlson, RPh: Yeah. Otherwise Joe Rogan, because I'd like to drop the F bomb every now and then. 

Mike Koelzer, Host: You should have done it here. I 

Ray Carlson, RPh: What the 

Mike Koelzer, Host: I try not to cuss on here because I don't, I mean, cuss too much. I don't want my show to be explicit, but I can't imagine a family's like listening

to this, going to the beach or 

something. you wanna drop 

F bombs to 

Rogan? 

Ray Carlson, RPh: And I would say to the pharmacy profession in general, I just can't imagine you're not looking at over 90 and there's not more conversation about it. I think we're starting to sense, and I noticed it on LinkedIn and again, I've only really been on there for, I don't know, five or six months now but I have noticed that there is beginning to be some recognition that there is this dispensing law.

on the books that the people would expect that this law be adhered to, and that perhaps some of our problems, whether you're talking about PBMs and their growth, cvs and their growth. I think we're starting to see the pharmacy world, sitting up and noticing over 90 drug use reviews and seeing that it was intended to define what it is we're supposed to do.

And as far as academia goes, you wanna push cubicle practice, you want pharmacists to walk around with doctors in the hospital. Okay, well, how many are you talking, first of all, . Secondly, I've worked in chain pharmacies, I've worked retail, I've worked for big chains, little chains. I've worked at every CVS and Giant Eagle in the three county area here.

And if allowed to practice pharmacy the way that OBRA 90 lays it out for us, you will not find a more challenging, satisfying, or clinically challenging, aspect to pharmacy. I would put it up against anything that a hospital pharmacist would be doing. I mean, you're talking about people coming in off the street and you have to get past some of the conversations.

Otherwise they would want to have and try to dig out what it is they're taking this medication for and make sure when they walk out of there they have some sense of their problem, what they're taking and that sort of stuff. For academia not to see [01:00:00] dispensing, because PBMs have said it's only worth a dollar,to me is, that's what.

Mike Koelzer, Host: You're absolutely right.

If you really did what you were by law had to do, what an exciting conversations you'd had with people 

to challenge them to, do all this

Ray Carlson, RPh: Absolutely. Unfortunately, and I think I noticed this, when my first pharmacy failed. I was young and I think I hold the record for the shortest lived pharmacy in the United States. It lasted two months. I think it's been two months. I spent six months without a paycheck when I was 26 years old, gutting an old building down here in my hometown.

And, expecting the community to just grace my presence When I opened, it was clear after the third month, they were not either able to transfer their prescriptions to me. This was 30 years ago, or they wanted to be anonymous. It was a small town here who wanted to know what antidepressant and a birth control pill.

And unfortunately for me, I hired the biggest gossiper in the town to be my register worker and it, and it, and, you know, and it, and it killed me. So, unfortunately, I had been elected to the president of the Ohio Pharmacist Associa. at a young age. I think that's another record, a national record I may hold as the youngest.

So I was president at age 27. I was really active in college and thought, I can just transition out. We had a little, I talk about this in the book, it was a little scum scam going on with your How Pharmacist Association at the time. And I was a representative from a Honda Northern University to opa and the director was in hot water and the elections were coming up and he talked to me and convinced me to run.

I had just gotten my license in May and I ran for the presidency of the Hal Pharmacist Association because this executive director wanted this other person not to get it and thought that I was a safe alternative or something. Well, I ended up winning. Who would've thought 

Who would've thought I was too? I was too. I wish I could go back and do it again now, and I may entertain that idea. But at 27, I closed my store. I was close to bankruptcy. I worked 11 different pharmacy jobs my first 10 years, as a pharmacist because I was trying to get the National Association of Employee Pharmacists up and going and sounded like a Union.

I was actually the one place that I worked. I know they were gonna let me go anyhow, but I ended up resigning because of a drug error that I made. But I knew I was on my way out back in those days. I was bringing my typewriter to, to type all my letters and correspondences, bringing them to work and this and that.

Well, here I was going to all the different stores passing out propaganda, packets of, Hey, join and we can make things better and we can, so I didn't do real well the first 10 years out, although it did lay a good foundation for, Understanding 7 certain things. but I never lost the love for professional association, the potential that I think.

and in my book, I label that issue number one. It really has nothing to do with the chains,the pharmacy management themselves. I'm a believer in free markets. I really am. If you can sell something for less and you can use economies of scale to bring the public a better product for less, I think that's a beautiful thing.

I really do. As long as it's, you're doing it lawfully. so I'm really not even that hard on the CVSs and Walgreens of the world. And, it is the chain pharmacist's reluctance to get together with their colleagues in a room and come together without their supervisors overhearing what they have to say, that they can raise their. hand and anonymity and vote yay or nay. That's all they have 

to do. And once you have that mandate from them and their support, even if it's just simple membership, send your $300 to a P h A. Even if you don't ever wanna attend a meeting, let them count you as an individual because somebody is gonna get in that room and know what you want.

Hopefully pass a mandate or resolution, and then give it to the Tom Mens of the world. And then Tom Mengen goes to the senator and says, look, I have an association of 300,000 pharmacists and we all talk to a couple of hundred people every day. We make good money.

We're smart. We have been educated in so many different topics.

I don't care what topic it is. A pharmacist can walk in a room and go from group to group and join in on whatever they're talking about. Biology, law, physics. It's, we're, we are educated, we're intelligent. This is our group. There's 300,000 of us. We want you to do X, Y, and Z and they'll listen. Unions don't really have that kind of poll with legislators.

They don't often like professional association. So I think the baseline of the book is, chain pharmacists and their apathy, why they have over so many years, very few have ever wanted to join, say anything. they've [01:05:00] been bought off 60 bucks an hour. I got an $11 an hour raise one time when I left the hospital and went to a chain.

I got a $7 an hour raise when I left an independent and went to a chain. You could see how we got, we, I worked 11 different jobs in, in 10 years. Chain pharmacists have been content not to want to disrupt that 60, $65 an hour, pull that gate closed and hope they didn't, hope they didn't hurt anybody. And I think that's our number one.

Our number one issue right now is we have to figure out a way to get these chain pharmacists to get up off of their asses and say something collectively this blackened out face on the television. Your gurgled voice. We just had one here. Antonio Chacha is a good friend of mine and, yeah. and he always says that he'll hit him with the right and I'll hit him with the left. Cuz we come at two different angles. He's all about the costs 

and he's doing a beautiful job bringing the cost portion of what we do and the light. I try to look at the service part of it, or lack of it, and what the law says we're supposed to be doing versus what we're doing in the 62nd timeframe.

We have to do it, but I come with the service side of it. So, between the two, the individuals like Antonio, and Ernie Boyd, who recently retired, have been there at the Ohio Pharmacist Association and all the other state associations wondering where these chain pharmacists are.

And over the years we see more students attending. We see the legislative days, I see 'em all over LinkedIn, all the pictures of all the white coats on the steps. And you try to zoom in to see who actually looks like a pharmacist and who looks like a student. Where are all the pharmacists? Well, there aren't many independents left.

And the chain pharmacist, we're not really sure what their problem is. But it is my opinion, and I'm at the point now,have been for the past couple of years, I think it's time to embarrass him. You can offer 'em pizza, you can offer 'em continuing education and free blood pressure screenings and do free face painting.

you gotta coddle to 'em a little bit to get 'em to come to a damn meeting. I think it's time to embarrass 'em. And say, do you realize you're like in the top one percentile of income earners? You think you don't have some civic responsibility with respect to dispensing medications that maybe you should get in a room every now and then and see if there are some other problems.

Like not knowing a drug like Oxycontin, is addicting. Who should have been on the lookout for an addictive drug like that? If not pharmacists, How long have we known the whole morphine class of drugs is addicting? What? Hundred 50 years We've known that. Everybody understands that a long-acting drug is more addictive than a short-acting drug.

So here you have a long-acting morphine. We knew that as pharmacists. W why aren't you coming together in these meetings and having civil conversations about social needs and, why are you staying away? I know you're burned out. I talk about in my book, it's called the Kick the Cat syndrome.

You're all pissed off. You're gonna go home and yell at your wife, or your wife's gonna go home and yell at the husband. Husband yells at the kid for no reason. The kid ends up kicking the cat. And that's how you deal with the frustration. You don't wanna jot something down and know that we got a local association meeting coming up at the bar and pub down the road every second Tuesday of the month.

 You don't want to go to an OPA or an A P H meeting and say anything, so I think issue number one, the majority of pharmacists in this country do not join a professional association, and they do not have one of their own. There's no fighting off the wolves, as I say, and there hasn't been for a number of years.

Good. Things are just not gonna come from that disparity in representation when these individuals are not representing themselves. The wolves are coming out and they're gonna, they're gonna chew you up. And that's what's been happening. We haven't even noticed it over the years. It's been one drive through window.

One. Got any questions for the pharmacist as they slide something in front of you? One little tactic after another? give the free coupons if there's a mistake or that kind of stuff that there hasn't been any fighting back. and God bless Opa and a P h A. They haven't had the numbers.

I don't blame either 

one of them.

they didn't have anybody in the room telling them even what was going on,so I think that's kind of where. Where we're at with respect to this. My problem right now is I'm, I haven't decided whether I want to take this period of my life and enjoy it.

 I've liked retreating into solitude and getting dirty and fixing up an old building. I don't like fighting with the profession and having to say things that seem like so few other people. I want to say that it causes a lot of anxiety, it really does. So I need a lot of forest therapy as the Japanese call it, to try to, just rethink about whether or not what I'm saying is accurate.

Even , but I don't know how many more years I said to myself, what I'd spent this last year writing the book [01:10:00] sales aren't really good right now is I was number one in new releases for about 10 days, and then the past week it dropped. Nothing. that's a little bit frustrating. . but at this point in my life, I have the grandkids coming now, 

and it's pretty cool.

I've 

got cash, I've got stuff I have. The only thing I don't have is I don't have resolution to this issue that I've been working on for since the fraternity days, you know, this apathy so, you know, maybe it's just that you and I are just happened to be born into that generation where the whole abundance to apathy, apathy to dependence to bondage ends up happening within our, stay here.

 and really in the end, what can you do? I mean, it's frustrating and enough trying to get pharmacists themselves. We even know that the law exists to understand the

issue. How are you gonna get the general public? To understand what you're talking about , Facebook is even more frustrating than LinkedIn.

It really is. You can't get them to move away from what it is. It interests them, which is okay. really it is. They should be allowed to take pictures of their feet on the beach and assume that professionals like us are doing what the law says we're supposed to be doing. And, and when we're not, we just need a few of us every now and then to come along and, maybe do what we have to do to try to pull it back into place.

 We never really understand why 

social change happens to begin with. And, but I do think education,, you have to educate the public cannot be left thinking that there never was a. About dispensing. they cannot spend the majority of their time and ignorance because when things do happen, well, I always said they will take out their frustrations and they won't know who to vent to.

They will think there's this government entity that they need to throw bricks at and burn cars, and they toss things over because they don't know why. They don't know why. And certain individuals like us have to increase our vigilance in continuing to educate them so that they understand that it is them.

They are part of the machinery, they are the democracy. You understand that this law is being broken. You are the ones that need to either yourself file a suit or have another sort of acclaim. You have to keep the pressure on. You have to be civic minded enough to solve some of these problems. . I actually thought the over 90 dispensing, non-compliance, would be an easy problem to solve.

I never thought that it would,take what it is, but whatever it takes. and again, with respect to social media, if I just keep putting things out, I know in a little bit of way that you're educating more and more people, so who knows?

 I have nothing to gain, nothing at all.

I get no income from this. , my efforts have cost me,I, I shudder to think at how much money I have spent over the past 10 or 20 years. I don't even know. From lawsuits, to gatherings, to catering individuals like us, come along. Just maybe, perhaps just because we don't have any ulterior motive about us.

 I'm gonna give all my proceeds, every dime I make from it, it's gonna go to either OPA or a P h a. I don't care to make any money off it. Every now and then, I think some individuals come along that we just have this belief about, for whatever reason it is that we're seeing things as we are, that we wanna figure out a way that we can articulate it, I tried in my book as best I could.

I wanted to educate the public on the law. I wanted to speak to the chain pharmacist. I didn't necessarily want to blame anybody for the opioid epidemic cuz as they say, the house is on fire, you don't care who started it. It's gotta be put out so maybe the title probably could have been rethought.

but the purpose of the book was to try to articulate some of these things that I've tried to do over the past many years, up till now. Really, I don't know if it was successful or unsuccessful, but you know what, I do think I have moved certain things in a particular direction. the law firm that, you know, with the lake in Trumbull County, it was a three hour conference call.

I talked to them about over 90 a year before the suit was, the suit came. FDA coming in and seeing my operation at the time New England compounding happened. I'd like to think that what they saw at the time that they decided whether or not a pharmacist was even to be in control of an outsourcing facility, I don't think that I have totally failed I understand.

I'm not gonna be one of the 50 top influencers. I don't even know how many people even know that I exist and had a P h A and OPA maybe have said something about my lawsuit at the time that I filed it, or , the association that I gathered, or the forums that I've held or the things I've written to them.

I have offered a p h a let me have 30 minutes at your annual meeting. Let me go up to a podium so much of what I have to do is off the cuff. 

Let me sit down and try and [01:15:00] write in a way that I think I would want to, if you had a message about the beauty of a professional, said, no.

Same with opa. , even my university, I think after I filed the lawsuit, they didn't really want me back on campus to speak to the student, a p h A group. Maybe that'll change. Maybe that'll change now. But yeah, hopefully with your program,these sorts of things 'll get out to them. I do think it's a good read.

I don't think it's real bashing. I think it's got some funny aspects. To it that I, I think once you start reading it,I think you, you would find it enjoying, 

it's not as long as it looks because you can skim through much of

1. I have six pages of nothing but comments from Chain Pharmacist in a survey to the Board of Pharmacy. Their words, the five addendums. I reprinted the Ober law, so that takes up a certain number of pages. I reprinted all of the laws in Ohio.

a letter that I wrote to cms you could read. I think that is the action going forward. I think, independent pharmacy needs to read the letter in addendum five that I wrote to cms. I think it kind of lays out what I'm thinking , the claim that should be brought against PBMs, again, the Achilles tendon.

but that takes up several pages. My lawsuit takes up several pages you could kind of skim through. So the actual guts of the reading is really maybe only 230 pages. Well, Ray, I'm gonna read it now because. I want to hear what you really think about stuff. I felt like you kind of held back today,

well have me on again now that I know that I could drop an F bomb every now and then 

Mike Koelzer, Host: right. 

Ray Carlson, RPh: absolutely.

Mike Koelzer, Host: Ray, golly, I'm gonna put a link to your book. I encourage everybody to take a look at it. read it through.

Ray Carlson, RPh: I appreciate you having me on, and hopefully we can do it again sometime.

I've enjoyed the conversation very

much. 

Mike Koelzer, Host: You too, Anna. I 

Ray Carlson, RPh: I look forward 

Mike Koelzer, Host: in touch.

Ray Carlson, RPh: Absolutely. 

Mike Koelzer, Host: All right. Thanks, 

Ray.

Ray Carlson, RPh: Ray Uhhuh. Goodbye.