WASHINGTON – Each month, the government sends World War II veteran Basil Irby refills for his five daily medications.
But when his cholesterol-lowering medicine arrived by mail one month, Irby and his wife, Jean, realized each pill was twice the dosage he usually takes.
“If we hadn’t read the instruction on the bottom, we wouldn’t have known,” the Baltimore resident said. “They sent me the pills and I’m to take half a pill. But they didn’t tell me about a pill cutter. Fortunately I had a pill cutter.”
Now Irby cuts the small, round tablets of Zocor in half, taking half a pill one day, and the other half the next.
In an effort to save money, the Department of Veterans Affairs in August 1999 began administering eight medications in double dosage, to be split by recipients. But Rep. Ben Cardin, D-Baltimore, said he has heard complaints from some veterans who say the VA sends pills that need to be split in half with no prior instruction to do so.
“There’s nothing wrong with splitting pills, if they can do it,” said Bill Dozier, national field representative for the VFW. “Our complaint is if they give it to the patient through the mail without education.”
Drug companies often base their prices on number of pills, rather than dosage. So the VA realized it could save money by purchasing fewer tablets at higher dosages.
“This year we expect to save $325,000 from these eight medications,” said Louis Cabuzzi, chief of pharmacy services at the VA Maryland Health Care System in Baltimore.
Most Maryland vets receive their medications from the VA in Baltimore, while some go to centers in Washington, D.C., or Martinsburg, W.Va.
With a 14 percent increase in Maryland VA patients this year, and 15 percent last year, the 10,000 veterans who split their own pills, save the VA center some money, Cabuzzi said.
At each veteran’s initial patient consultation, he is taught how to take each medication, what it is for and any adverse effects it may have. If a patient is considered capable of tablet splitting, he and his spouse will be taught how to split the pills.
Dozier said each veteran who is put on a pill-splitting regime must first be instructed on how to split the pill properly and then observed to make sure he can do it.
For most people this is not a problem, he said. But an older veteran, such as a World War II vet, or someone with arthritis or Parkinson’s disease, might not be able to split the pills properly.
Dozier said he has received very few complaints about tablet splitting. One man called the VFW and said he was getting pills that were twice his normal dosage in the mail, but did not know he was supposed to split them. So he went into the VA Center and was taught how to split the pills with a tablet-splitter and had no more complaints.
“He realized he was saving money for the VA, so we can treat more patients,” Dozier said.
As to sending out double-dose pills with no prior instruction to cut them in half or how to do so, Dozier said any such action would be a mistake and would hopefully be realized by the patient or the spouse. But, he said, veterans tend not to read instructions on their prescriptions.
“Nine out of 10 times the spouse is the one providing health care at home,” Dozier said. “The wife usually reads everything.”
The VA only approved eight medications for double-dosage dispensing because they are relatively expensive and they would not have adverse affects if a full pill were taken, Cabuzzi said.
While tablet splitting has become a common cost-saving measure for prescription drug providers, the American Pharmaceutical Association said there can be risks.
“What we recommend, if folks use tablet splitting, that the decision to split a medication should be made by the physician, the pharmacy and the patient,” said Susan Winckler, director of policy and advocacy at the association.
Winckler said she has received various complaints about tablet splitting from consumers. Often people have difficulty splitting the pills, or don’t understand that they are supposed to, or don’t understand the directions on the label.
She said some people read the slash in “1/2 tablet a day” as a dash, interpreting it as “one to two tablets a day.” For patients taking seven or eight medications a day, having one medication on a split-tablet regimen “proposes another challenge to regulating all those medications,” Winckler said. The patient then has to remember which pill needs to be split, and then split the pill correctly.
And not all pills split well. A recent report in the Journal of the American Pharmaceutical Association said eight of 11 pills studied were found to split inaccurately. Two of the eight medications offered by the VA’s pill- splitting initiative — Viagra and Lipitor — did not split correctly.
Irby said he has not had any trouble splitting his Zocor — but luckily he had his own tablet splitter. He received a tablet splitter from the VA six months after his double-dose pills started arriving.
“I got the pill cutter in the mail with the medication and no description. But fortunately, I knew what it was,” he said.