A Pack of Trouble
For several years I have used PillPack.com as my pharmacy for everything except short-term prescriptions. It has not been a perfect service, and since Amazon took over the company in 2018 it has deteriorated. But now that Amazon has completed merged it with its Amazon Pharmacy, it looks like they are bent on destroying what made it useful.
My physicians have me taking what some might think of as a lot of pills, not to mention a weekly “injectable” and a monthly injection. Two of the meds count as “controlled” substances. (That sounds more exciting than it is: one is a decongestant, the sort of thing you don’t need a prescription for, but now have to sign for. The other keeps me from sleeping all day. Don’t think “uppers.” I don’t get a jolt; I just don’t want to take a series of naps as soon as I’ve finished my first cup of coffee.) Others, such as iron pills and vitamin D, do not require a prescription, though I take them on the doctors’ instructions. I am happy with how I feel on this treatment regime. The physicians are happy with the numbers on my lab tests. I don’t have any trouble taking the pills or giving myself the injections. I don’t have any side effects that bother me all that much. Yet, my meds eat up hours of my time and give me awful fits of anger and frustration. The problem is not the meds, which keep improving. It is getting the meds and keeping track of them.
Usually the source of the trouble is an insurance company or a “prescription benefits manager,” but that problem seems to be insoluble. Now and then a pharmacist makes a mistake or doesn't understand the rules. But much of the trouble stems from the difficulty of sorting 12 different pills, some of which I take once a day, some twice a day, some once a week. Some I take in one-pill doses, some in two-pill doses. I used to spend part of every Sunday opening pill bottles, putting pills into the right compartments of a twice-a-day seven-day pill box, and hoping that I would sort them correctly and not spill a bottle of pills (especially not the tiny white ones!)
Then I heard about a technology that would allow me to abandon that ritual. Using it, all a patient’s meds are pre-sorted into rolls of individual packets, each clearly marked with the date and time that set of meds is to be taken. This system is both more convenient and safer the old system. Juggling a lot of little orange bottles, one can easily skip a medication or take one twice. Moving pills from the bottles into a pill box with 14—or more—compartments is time consuming and again invites missed or doubled doses. (Need I mention that patients taking a number of different meds are often older people whose brains, eyes, and fingers may not be ideally suited to the task?) I asked about investing in the tech—no luck—and resolved to sign with any pharmacy that began offering it.
When PillPack.com worked as it was supposed to—and, sadly, it often didn’t, especially after Amazon acquired it—the technology lived up to its promise. Instead of lots of bottles or blister-packs of pills, I received a roll or two of packets, each marked with the date and time the meds were to be taken. If I just tore the next packet off the roll each time I was supposed to, I was taking my meds correctly—no sorting pills into a multi-dose box or shuffling bottles and hoping I hadn't missed one or used one twice.
Now Amazon has integrated PillPack completely into Amazon Pharmacy. Despite operating PillPack.com for more than six years and being able to draw on all the technology developed and all the experience gained in their other operations to improve it, Amazon seems instead bent on making it less useful than it was before.
My last roll of packs from PillPack.com included 12 different meds—everything I take that isn't injected or inhaled—in one roll of packets.Now I am on Amazon Pharmacy’s system. I now deal with a less bulky rolls of packets, three pill bottles, and box of blister packs. Why? The answer varies with which of Amazon’s reps I chat with. Amazon Pharmacy refuses to include even the lowest level of controlled substance, such as decongestants, in packs. Yet my experience with PillPack.com shows that they can. It will not include meds that are not taken daily, because, the agents say, their system is not programmed for it. Amazon has owned the code that allowed PillPack.com to do it for the last seven years. And they will not include “lifestyle medications” in packs, though whether that term applies to the Vitamin D2 or to the beta-blocker my cardiology prescribes is a matter that varies with the agent.
That Amazon has decided to ruin the PillPack service seems clear. It is another example of what Cory Doctorow calls enshitification. Amazon has replaced something that served the customer well with something that is worse in every way. I assume they see more money in doing it this way. They will eliminate the expense of putting weekly meds or controlled substances into packs, and, because there is meager competition in the field, people will go on using them even as the service deteriorates. (They first bought and then shut down what would have been the alternative to a pill pack service Amazon Pharmacy created from scratch for a reason, and the reason was clearly was not to learn how to provide patients with meds in the most convenient form.) Many of us go on using Amazon for other things even as the search results more and more often return something Amazon makes a bigger profit on before the thing we asked to see. And we do that because there doesn’t seem to be a site we can go to instead.
There are no high-profile alternatives to Amazon Pharmacy as a PillPack.com replacement. CVS recently stopped offering a pill pack service. Among the smaller operations I have not found one that will both put all my pills in packets and fill my other prescriptions. The one I find most promising is MedBox, which will put all the pills in packets, but they have warned me that they may not be able to supply an injectable drug. So, my doctors and I will be dealing with two pharmacies, instead of one.
The solution to problems like the deterioration of Amazon’s search results and its destruction of PillPack.com is completion. I should be able to transfer my prescriptions to a full-service pharmacy that will put all the pills in packets, just as should be able start searching for other products on a site that shows me what I ask it to show me. But competition to Amazon is vestigial. If the free market to work, we need more than one big player. It is time to make markets competitive, and that means making sure there are competitors. Companies should not be allowed to simply buy up their rivals, and wherever one corporation controls too much of a sector, such as eCommerce or online search, it should be broken up. The medication for this problem is tougher antitrust laws and the rigorous enforcement of them.
Final Commemcement
For the last 10 years, I have regularly visited a college campus not as a student, not as a professor, but as a trustee. Being a trustee of Fontbonne University has been a role I have taken seriously, so I have been on campus fairly often. There have been board meetings and committee meetings, parties and receptions, and, as Fontbonne was a Catholic university, Masses. I have also been there for lectures, plays, concerts, and tours of facilities of many sorts. And I have played my role at ceremonial occasions, attending all the commencements and convocations I could. And today, in what may have been my last visit to campus, I played a new role, receiving doctorate of humane letters, honoris causa, and serving at the speaker at Fontbonne’s final commencement.
While a recognition of loss is a natural part of a university’s final commencement, the mood was mostly one of celebration. We are proud of the achievements of the students who received their doctoral, master’s, or bachelor’s degrees today. We are proud of the faculty and staff who have remained at work to help those students complete their studies and join in this final ceremonial celebration of our common enterprise. And we are proud that we are closing only after having given every student a chance to complete his studies, if not on on campus, at a university that will recognize all the work he has already completed. Thanks to President Nancy Blattner and Provost Adam Weyhaupt, we can be as proud of the way in which Fontbonne has closed its doors as of anything in its history.
These final commencement exercises were held in Doerr Chapel, the heart of Ryan Hall. Ryan Hall is the oldest building on campus and its center. Its design, like those of so many main buildings at American universities, embodies a particular vision of what a college is. The main entrance is up a fight of stairs, for scholarship is an elevated enterprise. You then enter what is at once a hallway leading to rooms where people pursue their various disciplines and a common room where all may gather. If you do not linger in this space, you are at the entrance to chapel, for the worship of God is central to life of the college, not peripheral. The message embodied in the architecture has been obscured as colleges have grown too large to fit in a single building and the original structures have been taken over by administration. But from Nassau Hall at Princeton to Fontbonne’s Ryan Hall, that was the message built into the structure of the building at their founding.
The “Prayer Hall” at Nassau Hall has been renamed the “Faculty Room” and refitted to look like the British House of Commons. At other colleges the central chapel has been transformed into an auditorium. But at Fontbonne the chapel remained a chapel to the end. I am glad to say that its altars and sacred furnishing will find new homes in the chapels of a high school and a graduate school of theology. And I am glad our final commencement was held there, rather in a gym or even outside in the quadrangle (through our spring commencement there was lovely).
The video of the final commencement is not of the highest quality—our best videographer may have been working on a touching legacy video, which uses film from our penultimate commencement in May—but here is the film I have of the conferral of my degree and my remarks. (It will open in a new window and may take some time to load.)
Here is the link to my Remarks at Fontbonne University’s Final Commencement Exercises. (Those who watch the legacy video will see that my opinions on academic dress were not shared by all members of the university community.)