Monthly Archives: February 2020

Finding a personal niche in pharmacy can be exciting. It can bring you out of the day-to-day rut you may or may not have realized you were in—to a career that provides a renewed purpose. Some are lucky enough to find it before they even graduate from pharmacy. Others take their time and experience all options until they find themselves drawn to the one activity they can do without any feeling of burnout.

For me, that niche is compounding. In my first week at the College of Pharmacy at Dalhousie I walked into a pharmacy run by Byron Sarson, a Canadian pharmacy giant (in more ways than one) and with a reference from another giant, J.Esmonde Cooke from my hometown of Sydney, N.S. I boldly asked for a job. It turned out to be a day that set me on a path that would not take hold for two decades.

Ironically, after this blog was written, word came to me that  Byron Sarson passed away after a lengthy illness. His contributions to Canadian Pharmacy are wide reaching and his influence on me personally has made me a better pharmacist.  Many times I reflect on how I managed an issue in the dispensary and realize I learned that skill from him.

Byron ran one of the few pharmacies at the time known as “compounding pharmacies.” I slowly started to see the value of this type of pharmacy. Often we would receive calls from other pharmacies looking for recipes for various compounds from a binder he paid $5,000 for. Of course compounding was done weekly in our lab at the College. After I graduated, I grew to dislike the rare compound that would come into a “regular” pharmacy. It took time away from regular things, things I grew to dislike, like third-party phone calls, prescription entering in the computer, checking final prescriptions and answering the phone.

It wasn’t until I purchased that independent store I had worked at that I began a compounding business. First it was vet compounding and some HRT recommendations. But then I found an area where compounding completely stood out—palliative care.

I relocated the dispensary in the store and put in a compounding lab to contain the modest amount of compounding I was doing. One day, the local palliative care doctor came in to visit and asked what “all that was” behind the glass at the back of the dispensary. I took him back there and explained what I was doing with compounding. He was an open-minded, down-to-earth doctor and jumped on board immediately.

Over the next 10 years we discovered a wide range of treatment modalities that allowed us to better the lives of hundreds if not thousands of patients in the last months, weeks or days of their lives. Palliative care showed me that what I could do to bring comfort for these patients was extended to their loved ones. In whatever way this could help, I wanted to be a part of it.

Nova Scotia is generous enough to cover many of the compounds needed by these patients. Being in a rural area in Cape Breton, it became a challenge to get these compounds to the patients in a timely manner. Those outside of our area and not in hospital often received their compounded prescriptions via Canada Post courier, which we were happy to absorb the cost of. We eventually settled into some common compounds for these patients.

1. Transdermal pain compounds: With over a dozen proven active pharmaceutical ingredients to draw from and numerous studies backing up effectiveness, transdermal compounds for pain relief became our staple for helping palliative patients, especially those with cancer. Being able to treat patients in the worst pain imaginable became a motivating factor in pursuing evidence-based treatment of pain that most patients would otherwise not have access to. Using ketamine, ketoprofen, clonidine, gabapentin, amitriptyline, lidocaine, baclofen, carbamazepine, and a dozen other ingredients shown to prevent pain transmission along nerves in transdermal bases proved themselves over and over.
2. Mucosal membrane pain relief. Cancer patients often have oral pain. Various types of cancer that involve rectal and vaginal tissues require special delivery systems to relieve discomfort. Specialized bases that adhere to mucosal tissue and active ingredients that not only deal with pain but also help to heal tissue damaged by radiation therapy improve quality of life immeasurably in cancer patients beyond the standard “magic mouthwashes.” Creating these products from scratch rather than mixing commercially available products that contain alcohol that can irritate the oral cavity made sense. Tetracaine lollipops and clotrimazole troches also come in handy in these patients.
3. Wound therapy. Tissue breakdown in bedridden patients can become as troublesome as the medical condition that put them there in the first place. Ingredients like nifedipine, phenytoin, and misoprostol can speed recovery by aiding tissue repair. Various bases are available to aid in this process. Polyox dressing is a powdered dressing that can not only carry active ingredients but absorb significant amounts of exudate as well as protect the wound. Some bases by their very nature help prevent infection and scarring. Development of such bases by compounding supply companies has helped immeasurably.
4. Dry Mouth. Pilocarpine lollipops are a great way to deliver a proven ingredient in a way that is not only palatable but stimulating for saliva. Dry mouth is a major cause of loss of quality of life in palliative care patients and although they can take a little longer to make, they are a great tool to have available for the patient and physician.

Palliative care offers a wide opportunity to help using evidence-based products in compounding. The nature of palliative care gives a wider spectrum of potential treatments. Physicians are often eager to ease discomfort and improve quality of life in ways that may seem less proven than the normal hypertension and diabetes therapies we stick by in daily practice. Medicine seems more accepting to exploring possibilities in these patients in order to give comfort to them, which in turn gives comfort to their loved ones. This has proven to be an amazing area to practice. Thanks Mr. Sarson for introducing me to it and to Esmonde Cooke for introducing me to him.

Graham MacKenzie

Stone’s PHARMASAVE, Baddeck, N.S.