When national drug manufacturers can't provide the right medicine, local doctors turn to Santa Ana pharmacist William Garvey. And he does what any neighborhood chemist could do at the turn of the century--he concocts his own.
"A lot of times, patients can't handle or don't like a type of medicine that comes from big industry," said the white-haired, soft-spoken Garvey as he mixed ingredients in a glass beaker and poured the resulting mint-green liquid into lozenge molds. "So physicians call me and I whip up something like this that works."
The end product of this recipe--palatable progesterone lozenges available in spearmint or peppermint for premenstrual syndrome sufferers--will replace injections or suppositories for hundreds of Orange County women, Garvey said.
The lozenges are one of many specialized compounds--like throat sprays, skin creams and time-release motion-sickness capsules--that Garvey has made at the request of 20 Orange County doctors with whom he works.
"Bill is really very special," said Santa Ana dermatologist Lawrence Sherwin. "It's unusual to find someone who will mix up interesting concoctions. And it's not only that pharmacists don't fill them, it's also that almost no physicians write those kind of prescriptions anymore."
Garvey, 48, is one of the few remaining pharmacists in the United States who compounds drugs into new formats, dosage levels or combinations. Instead of just stocking prepackaged goods, his small, crowded Santa Ana/Tustin Clinic Pharmacy has raw ingredients and packaging equipment--tubes, bottles, syringes, nozzles, molds, boxes and capsules--in every color of the rainbow.
Garvey said his interest in being an old-fashioned pharmacist stems from his childhood in Montana where he made house calls with his father, a country doctor who understood the importance of a good pharmacist.
For many years, pharmacists--then called chemists--made up medicine based on physicians' orders, Garvey said. "Their role was compounding and dispensing. Now it's mostly only counting and dispensing."
The change in pharmacy came after World War II, Garvey said, when the field was industrialized into a network of major drug companies that manufactured the medicines and distributed them to pharmacists. Chain drugstores sprang up and the role of the neighborhood pharmacist changed. "The bonds today are between physician and manufacturer instead of between physician and pharmacist," said Garvey, who has been a pharmacist for 25 years. "That works fine for the most part, but I think patients and all medicine lose something."
The advantages of the industrialization of pharmacy were that billions of dollars were poured into research and development of medicines and the Federal Drug Administration was formed to monitor the safety of the drugs, Garvey said. But the disadvantage was that mass production and distribution limited the physician to habitually prescribing only what was available commercially.
It also made the pharmacist's job ho-hum.
"The manufacturers became so efficient that it virtually eliminated the need for the pharmacist," said Mervyn Kalman, associate professor at the USC School of Pharmacy. Although it's "quite uncommon," he said, for a pharmacist to customize medicine, "I think it's wonderful. It's very difficult for an individual to spend the time."
"The pressure now is not to do your own compounding," said Garvey, who worked for years in large chain drugstores. "Before I came here, I was dispensing the same routine stuff put out by the manufacturer. But I realized patients' real needs were not being taken care of."
Patients often can't tolerate certain strengths or forms of existing medicines, Garvey said. Sometimes, it's a simple question of the taste. Other times, it's the method of delivery, such as a capsule rather than a tablet. Or in some cases, it's a simple case of not having the existing forms of drugs in stock.
Pharmacists are regulated by the government, and Garvey stressed that under the law, the request for compounding new formats must originate with a physician. "A pharmacist has a license to compound," said Garvey. "If a physician asks me to make up a product and we agree it is safe, I can compound it. If a pharmacist sells directly to the consumer who has a doctor's prescription, he or she is acting as a compounding pharmacist, not a manufacturer.
"I have a lot of terrific ideas of my own," he said. "But if I wanted to put drugs out commercially, I would have to spend 8 to 10 million to do the research and get it on the market as a new drug. Then I would be in the manufacturing business."
When Garvey was approached two years ago by Dr. Stanley Lubell, a Santa Ana gynecologist who needed a better method for treating PMS, the pharmacist saw it as an opportunity to be creative.
"My patients were using rectal progesterone suppositories and acceptance was minimal at best," said Lubell. "I wanted a palatable lozenge that could travel with patients." Garvey spent two years creating a product that was more acceptable to patients and more effective in treating PMS symptoms because of the improved rate of absorption, Lubell said. Ninety-five percent of the gynecologist's 300 patients who once used more expensive progesterone medicines now request the lozenges, which sell for $1 each.
"That's a price that manufacturers can't compete with because of their overhead and expense in getting products past the FDA," Garvey said. "I can't tell you how rewarding it all feels. The challenge is great."
In another case, a radiologist needed a throat spray with a certain ingredient that was not available commercially. Garvey researched the product, determined a safe concentration and made a spray that even tasted good.
"A key thing is palatability," he said. "Most medicines, even over-the-counter goods, taste awful." Although he trademarks some of his products, he can't corner the market with his concoctions; any pharmacist could make the same product if he wanted to. "But again, it goes back to economics," Garvey said. "It's easier and less time-consuming to sell pre-made drugs. It would not be feasible for me to have all of my business in compounding, but this really expands the physician's capability to prescribe." It also makes him feel more involved with patients.
"There's a vast amount of knowledge that pharmacists have," he said. "They know things such as why it's better to buy a more expensive thermometer (because it's aged and gives a more accurate reading), or what potential side effects medicines (have)." It's important for people to choose pharmacists well. "You have to take the time to explain things," he said. "I get a lot of patients calling me to ask questions. That's another area that is a lot more rewarding than counting and pouring pre-manufactured medicine."