Profile of practice: Don West, RPh, Lloyd Center Pharmacy, Portland, Oregon

Pharmaceutical Compounding

Twenty years ago, Don West, RPh, bought Lloyd Center Pharmacy. The next year, another pharmacy owner was retiring and wanted to sell his store, but only to a pharmacist who would compound with an emphasis on personalized service. West bought that store also, with the understanding that he would continue the former owner's tradition of compounding. He then combined the two pharmacies. Shortly thereafter, a local visiting nurses' association contacted West about compounding morphine suppositories for pain control, and several obstetrician-gynecologists asked whether he could formulate progesterone suppositories. "That," said Vest, "started the ball rolling." For many years, he was the only compounder in Oregon.

Design: Cater to Customers

Today Lloyd Center Pharmacy, which offers pharmaceuticals and nutritionals as well as compounding, occupies about 4000 sq. feet in a large retail mall in Portland. It's in its third location since West bought the store, and this store opened in October 1999. The design, created by Robert P. Potts & Associates and a local architect, is very modern.

"Our customers love it," West said. "The aisles are wide and wheelchair accessible. The pharmacy counter is a semicircle that dominates the space. In front of the pharmacy is the cash-wrap, a smaller version of the pharmacy counter."

The compounding area is directly behind a large natural-health-products section to the left of the counter. The compounding laboratory, about 20 feet by 25 feet, is equipped with two laminar airflow hoods, an ointment mill, four electronic balances (two of which are analytical), an electronic mortar and pestle, capsule-filling machines, a mixing tumbler, and all the gadgets essential to a compounding pharmacy.

Put Patients' Needs First

West has always put the needs of his patients first.

"Because of my work with hospice teams," he said, "I began to realize the importance of individualized dosages for patients who are debilitated and whose metabolic functions are not working well. They often require medications that are not commercially available in the dosages needed. We began to work with our hospice clients to compound pain-control medications, and then we began to develop formulations to control nausea and vomiting."

About that time, a major drug used to treat morning sickness was discontinued from the US market, and a local group of obstetricians and gynecologists asked West to compound that medication, for which there was a great need. For many years, that was one of the most frequently prescribed compounds that he and his staff prepared. Today they compound any and all types of prescriptions, but most of their compounding (about 60%) is hormone related. From 5% to 10% of their compounds are for veterinary patients, and the remaining medications are prepared for pediatric or hospice patients. They also perform a lot of aseptic compounding (especially pain-control preparations and compounded medications for physicians' offices.

The staff (three full-time pharmacists, four compounding technicians, and two counter technicians) provides unlimited patient education and counseling without charge.

"We're always given that information away," said West.

Patients who return to the pharmacy to refill a prescription are always asked whether they have questions about their treatment and how effective the medication has been.

"The person on the other side of the counter tells me how the preparation is working," West said. "It's a reliable index of efficacy that is validated every day."

Market to the MDs and NDs

West's dedication to excellence has brought him professional success and great personal satisfaction. His compounding pharmacists currently prepare an average of 60 to 70 compounds per day, and the pharmacy patient base numbers in the thousands. Many of West's patients are from the metropolitan Portland area, but Lloyd Center Pharmacy is wellknown in other cities in the state. About 25 % of the total volume of prescriptions is delivered to distant addresses by US mail, United Parcel Service, or FedEx.

"Most of our patients are referred to us by their physicians," West said. "I'm pretty confident that if you ask about a compounding pharmacy in the city of Portland or the northwest corner of the state, our name will be suggested. We do our best to keep the medical community aware of our name."

To do so, West personally contacts his prescribers (either by phone or via an office call). He has found that a substantial number of prescribers are referred to him by their colleagues. He attends some conventions but is not a major marketer, according to him. He sends out a newsletter to physicians, dentists and veterinarians and also markets to naturopathic physicians (NDs), who in Oregon are recognized as primary-care physicians. NDs don't perform invasive procedures or have hospital privileges, but they can give injections and perform minor surgical procedures in the office. Lloyd Center Pharmacy pharmacists work with the National College of Naturopathic Medicine and all local NDs. Two graduate resident naturopaths work in the pharmacy every Friday, and an ND provides counseling once a week on all health issues, especially those pertaining to hormone replacement therapy (HRT) and women's health. They have not yet charged for that service but may eventually do so.

Fourth-year PharmD students (this year there are seven) from Oregon State University also spend a 6-week rotation in the pharmacy.

"It's gratifying to see the effective integration of alternative medicine with allopathic medicine," said West.

As to which types of diseases are most effectively treated by compounds, West had a ready answer: "Almost all of them. I won't infringe on a commercial product," he said, "but if the physician and the patient are willing to work with us, we can usually develop a compound that will answer the needs of that patient." He described the effects of certain compounded medications on diseases refractory to treatment with commercially available drugs.

"One of the more dramatically effective preparations that we compound is used to treat a fulminating eye infection. Compounded ophthalmic preparations are like a `magic bullet' that provides extremely rapid relief from some very uncomfortable conditions. Treating nausea and vomiting in hospice patients with a tailor-made formulation is also very rewarding; the patient and his or her family are always so grateful! Compounded HRT provides major benefits for some patients; it changes their life immeasurably for the better. Often, people with a hormone deficiency don't realize how good they could feel. After their proper hormone levels have been restored, they have a new lease on life."

There is no lack of variety in the prescriptions compounded at Lloyd Center Pharmacy. West and his staff recently compounded three omeprazole suspensions for children. The patients were infants with severe gastrointestinal problems, and those preparations quickly relieved their suffering. "I don't know another field in pharmacy that offers as much personal satisfaction as compounding does," said West. "Our patients often thank us for intervening and improving their quality of life."

West has ultimate confidence in his staff, which is knowledgeable and always ready to research an unusual condition or a unique patient need. To support that interest, West has devoted a section of the pharmacy to a sizable research library that includes historic and current medical and pharmaceutical information; staff members use it extensively every day.

Plan for the Future

West has a plan for the future. He always wants to keep his hand in compounding and says he would only sell the pharmacy to someone who would preserve the compounding aspect of its service, because there's a vast need for it, a need that will only increase.

"After talking with salesmen from some of the major drug companies, I realized that there will soon be unique opportunities for compounding pharmacists to work with drug manufacturers in the development of individualized dosages of biologicals, antibiotics, and other novel drug agents," he said. "Some drug companies are beginning to realize that compounding pharmacists have a unique skill level and could be extremely helpful to the industry. Compounding pharmacy has a special niche to fill. It has been around for thousands of years, and it's not going to go away."

Go for It

As he reviewed his career, West had some advice for students contemplating pharmaceutical compounding as a profession.

"There's only one way to treat a client, and that's the right way," he said. "If one of our patients feels that something is wrong, we'll do whatever is necessary to make it right. Success is measured in many different ways, and personal satisfaction is my key to measuring it. If personal satisfaction is important to you, compounding is the first thing to consider. It provides the challenge of formulating individualized treatments, there's a great need for it, you can earn a good living as a

compounding pharmacist

For additional information, contact Don West, RPh, Lloyd Center Pharmacy, 1249 Lloyd Center, Portland, OR 97232.