As a teenager, Shah Afshar was a runner — an errand boy — at an Iranian pharmacy. He’d watch men in white jackets mixing powdered or liquid medicine and talking patiently to customers, who would take the medicines home and get better.
Later he emigrated to the United States, moved to Idaho for college and pharmacy school, and stayed.
Today, Afshar owns one of a half-dozen pharmacies in the Treasure Valley that specialize in custom-making medicines for physicians and their patients. The so-called “compounding” of medicines has been around since Hippocrates. Ancient physicians steeped herbs and ground foods into natural medicinal recipes. Modern-day compounding pharmacies have come into vogue as an answer to pharmaceutical manufacturers that ship bulk products in one-size-fits-most packages.
People who have never heard of compounding pharmacies received an unfortunate introduction this fall after contaminated batches of an epidural steroid from a Massachusetts compounding company produced an outbreak of fungal meningitis. Fifteen people had died by Oct. 14, and at least 214 people — including an eastern Idaho man — had been diagnosed with the disease. To relieve back or neck pain, the contaminated steroid was injected into four patients at Walter Knox Memorial Hospital in Emmett and 35 patients at Pain Specialists of Idaho in Idaho Falls.
In the right hands, the age-old process of compounding is safe, effective and necessary. Compounding at small pharmacies has grown as some previously made drugs have been discontinued. “I have watched as manufacturers abandon products,” Afshar says.
Afshar declines to disclose revenues at his pharmacy, Customedica, at 145 W. State St. in Eagle. He owned several traditional pharmacies after he graduated from Idaho State’s pharmacy program in 1980. It’s not unusual — in fact, it’s encouraged — for Customedica customers to watch as pharmacists and technicians work in a glass-enclosed lab filled with a thousand chemicals, medicines, creams, powders, preservatives and flavors. They make hormone-replacement creams, injectable hormones and liquid medicines that can be measured into any dose for children or people (and animals) who can’t ingest pills.
Compounded products are also useful for people with allergies to certain dyes, oils and gluten products found in manufactured medicines.
Customedica receives about 45 prescriptions a day. Techs and pharmacists spend their days mixing, measuring, blending and polishing medications. A typical compounding pharmacy like Customedica has one room for making nonsterile products and a “clean” room for making sterile ones like eye drops, IV antibiotics and natural vitamin B12 injections.
Idaho’s compounding pharmacies are tightly regulated, says Elaine Ladd, a pharmacist and co-owner with her husband of Ladd Family Pharmacy at 1109 S. Broadway Ave. in Boise. The clean rooms are required to avoid the types of contamination found at the New England Compounding Center.
The first and most important regulatory layer is the State Board of Pharmacy, whose compliance officers can show up without warning and inspect any area. They usually inspect once or twice a year. The U.S. Food and Drug Administration also has the right to inspect. So does the U.S. Drug Enforcement Agency.
Compounding pharmacies also police themselves. They send samples of their lots to independent labs for analysis to ensure that the medications are safe and their potencies correct. Every six months, pharmacies with clean rooms bring in inspectors to certify that the rooms and their equipment are free of environmental toxins.
“Compounding is very rewarding,” says Matthew Murray, a Customedica pharmacist. He began as a technician in 2005. Like Afshar, he saw compounding as a calling and went on to pharmacy school, graduating in 2010.
Murray and Ladd say compounding pharmacists see themselves as part of a triad in relationship with physicians and patients.
Gary Wilburn agrees. Wilburn, who went to pharmacy school with Afshar, bought Lemp’s Apothecary in 1989. Lemp’s opened its doors in Boise a half-century earlier, in 1939, when making medicines by scratch was standard procedure. Lemp’s is on the main level of a medical building in the Anderson Plaza on 2nd Street, near St. Luke’s Regional Medical Center in Downtown Boise.
Wilburn says half of all independent pharmacies do some kind of compounding — the garden-variety mixing of a bulk medicine into a liquid solution. Lemp’s, Customedica, Ladd and Medicap Pharmacy in Meridian are among the smaller number that do more-advanced compounding.
Wilburn, who declines to disclose revenues, says more than 90 percent of his business comes from compounding medicines. A chemistry lab is stocked with computers and bar-coded equipment that ensures that the ingredients and doses are correct. The pharmacist makes the final call on the product before it is handed on to the patient. Wilburn employs one part-time pharmacist and two compounding techs.
Their compounding space also houses a clean room, with high-efficiency particulate filters and a sterile-preparation hood. The sterile environment begins with an anteroom that leads to the clean room. Each room is at least 10 times as clean as the previous one.
Local compounding pharmacists have been fielding calls from concerned physicians and patients since the meningitis outbreak first made headlines. They note that their pharmacies cater to individual patients with prescriptions, unlike the Massachusetts company, which was sending bulk products to pain centers and clinics throughout the country.
“If patients have any questions about the medicines they are taking, they should talk to their pharmacist and ask them how they make their medicines,” Wilburn says. “Our first concern is for our patients, and we always know who our patients are.”
Jamie Talan: email@example.com