One of the most important health stories of the year disappeared almost without a trace within days of making headlines at the Chicago Tribune (Dec. 15, 2016). This newspaper sent investigative reporters to 255 pharmacies in consultation with a renowned drug-interaction expert. What they discovered is shocking: over half of the pharmacies visited dispensed dangerous or even deadly drug combinations.
What They Did:
Dr. John Horn is a Professor of Pharmacy and Associate Director of the University of Washington Medicine Pharmacy Services. He is an expert on dangerous drug interactions. With his colleague, Dan Malone, RPh, PhD, Dr. Horn advised the Chicago Tribune which drug pairs represented either a serious problem or a potentially deadly combination. Reporters then took legitimate prescriptions for two different drugs to pharmacies in and around Chicago to see how pharmacists would respond to these inappropriate dual prescriptions.
The Drug Pairs:
The antibiotic clarithromycin plus the migraine medicine ergotamine:
This combination could be lethal. Together the drugs could constrict blood vessels leading to poor blood flow or even a stroke.
The cholesterol-lowering drug simvastatin plus the antibiotic clarithromycin:
This combination could lead to excessively high levels of statin in the body. This could cause a potentially life-threatening muscle breakdown called rhabdomyolysis and trigger kidney failure.
The gout drug colchicine plus the blood pressure medication verapamil:
This combination could also lead to rhabdomyolysis and life-threatening complications.
The muscle relaxant tizanidine plus the antibiotic ciprofloxacin:
This combination could increase levels of tizanidine leading to low blood pressure, slow heart rate and fainting.
The birth control pill norgestimate and ethinyl estradiol plus the anti-fungal medication griseofulvin.
The anti-fungal medicine could reduce the effectiveness of the oral contraceptive, leading to an unplanned pregnancy.
Dispensing Deadly Drug Combinations:
The results of this experiment were dismal. In an ideal world, no pharmacy would have dispensed any of these drug pairs, period! At the very least, the pharmacist should have checked with the prescriber to verify that this is what was intended and let the prescriber know this was a potential drug disaster.
Finally, the secret patients (in this case, the investigative reporters) should have been warned that the combination was risky if not downright life threatening.
Sadly, 72% of the independent pharmacies failed the test. The combos were sold without hesitation or any warning. CVS also faired poorly, with a 63% failure-to-warn rate. Target, Kmart and Costco were hardly any better, failing the test between 60% to 62% of the time. When all the chain drugstores were combined, they failed to follow appropriate dispensing practices with regard to drug interaction warnings about half the time (49%).
Overall, 52% of the 255 pharmacies tested failed the test. The Chicago Tribune noted:
“They failed to catch combinations that could trigger a stroke, result in kidney failure, deprive the body of oxygen or lead to unexpected pregnancy with a risk of birth defects.”
That’s unacceptable. Imagine if half the airplanes in America had a major failure on any given day. There would be hell to pay.
What This Means to You:
Tens of millions of Americans take a handful of medications every day. Check out your pill bottles. Is there a blood pressure pill, something to control blood sugar, and perhaps a cholesterol-lowering medication? How about something for the aches and pain of arthritis? What about depression or insomnia? It is estimated that 10% of Americans take five or more different drugs every day and that does not include OTC meds or supplements.
You might think that doctors would catch dangerous or deadly drug interactions before they reached the pharmacy. The medical literature suggests that prescribers frequently override drug interaction alerts that pop up on their smart phones or computers.
The safety net is supposed to be the pharmacist. These health professionals get a warning on their computers every time deadly drug combinations appear in patients’ records.
In the Chicago Tribune test described above, we can assure you that there was not a pharmacist who did not get some sort of computerized warning that the drugs about to be dispensed posed a problem. And yet over half the time the interaction alert was ignored. How could that be?
Pharmacies Have Changed:
Pharmacies have become a bit like fast food emporiums. Spend any time in a busy pharmacy and you will discover that the pharmacist is working furiously to fill an extraordinary number of prescriptions. There is no time for lunch or bathroom breaks. The pharmacy technicians do not have the training to interpret drug interaction warnings. They are working as fast as they can to get the prescriptions out the door.
Once the newspaper released the results of its secret shopper study, some chain drugstores promised to improve. They stated that patient safety was a high priority. And yet the volume of prescriptions is so daunting that it will be hard for chains to change their business practices. They would need to hire more pharmacists and slow down the pace at which they fill prescriptions, something that would be bad for the bottom line.
The Cry-Wolf Computer Challenge:
The computer programs that alert pharmacists (and physicians) to dangerous interactions or deadly drug combinations are not very sophisticated. So many warnings are issued each day that there is now a name for what happens: “alert fatigue.”
It is a little like the boy who cried wolf. You remember the story. The little boy cried wolf so many times that the people in his village began to ignore him. When the real wolf came, he was ignored. If the computer is constantly warning about interaction problems, pharmacists and technicians tend to tune it out. They override the warnings and hope for the best. If patients are hurt or die, the likelihood is that no one will realize deadly drug combinations were the cause of death.
How to Protect Yourself:
In our book, Top Screwups Doctors Make and How to Avoid Them, we have chapters on:
The Top 10 Screwups Doctors Make When Prescribing
Drug Interactions Can Be Deadly
The Top 10 Screwups Pharmacists Make
In each chapter we provide practical tips about how to avoid dangerous or deadly drug interactions. Anyone who takes more than one medication a day should check out Top Screwups. If you have a friend or family member who takes multiple medicines you might want to order a copy. It’s too late for Christmas, but you just might save a life in 2017. Here’s a link to more information.