What do you know about the side effects of the pills you take? We often urge readers to consult their pharmacists, who may be more knowledgeable than other health care professionals. Dennis Miller, RPh, is a retired pharmacist living in Delray Beach, FL. He has written this article for his colleagues. We think many consumers would also be interested.
If someone were to come to our country from another planet, this visitor might conclude that one of the most remarkable things about the health care system in the USA is that the primary approach to sickness is to prescribe synthetic substances (drugs) most of which are accompanied by a long list of potential adverse effects. This extraterrestrial visitor might conclude that the state of America’s health care system regarding drugs is not very advanced. Surely an advanced health care system would use drugs that have a risk vs. benefit ratio that is much more strongly tilted toward benefits. Surely most drugs would be far more effective than placebos.
The fact is that many drugs approved by the FDA demonstrate only marginal benefits over placebos. Lobbyists from Big Pharma pressure Congress to get the FDA to speed up the approval of drugs that certainly do not fit the layman’s definition of “safe and effective.”
How Safe and Effective Are Our Drugs?
Of course, many drugs are absolutely essential and even lifesaving. Insulin and antibiotics come to mind immediately, but there are many others. On the other hand, pharmaceuticals are often double-edged swords. They have the power to help, but unfortunately they also have the power to harm. In some distant utopia, all drugs will be fabulously safe and effective. Every pharmacist knows we are not there yet, or even close.
If all drugs were unquestionably safe and effective, our jobs as pharmacists would be a lot easier and a lot less controversial. Many pharmacists are not comfortable discussing side effects because such conversations demonstrate that the drugs we dispense are not unequivocally beneficial.
Direct to Consumer Advertising:
Only the USA and New Zealand allow direct-to-consumer advertising of prescription drugs. Sociologists and psychologists should conduct studies about these advertisements as a social phenomenon. What does it mean when products are widely advertised even though they are accompanied by a long list of potential adverse effects that, with other products, would scare consumers from using those products? Do viewers ignore these side effects and assume that they are surely very rare?
People viewing these advertisements often comment something like, “Yeah, the side effect occurs in one person in a million so the company is required to list it.” On the other hand, I’ve heard friends and family members react by wondering why people are so eager to take prescribed medications.
Pharmacists and Cognitive Dissonance:
In psychology, cognitive dissonance is the mental stress or discomfort experienced by an individual who holds two or more contradictory beliefs at the same time.
Cognitive dissonance theory is founded on the assumption that individuals seek consistency between their expectations and their reality. An individual who experiences inconsistency (dissonance) tends to become psychologically uncomfortable. Since it is impossible for a thinking person to hold two mutually exclusive beliefs simultaneously, anxiety is usually the result.
Cognitive dissonance is inevitable in every pharmacist’s life when the drug industry’s rosy view of pharmaceuticals collides with that brick wall known as reality. Cognitive dissonance is evident in:
- The contradictions between the glowing picture of drugs painted by direct-to-consumer advertising on television and the reality of a long list of potential side effects
- The contradiction between the FDA’s seal of approval and the reality that many side effects don’t appear until after a drug is on the market
- The contradiction between the fact of a healthcare system based on drugs and the reality that prevention is safer and more effective than pills
Cognitive dissonance often arises when there is conflict between a pharmacist’s positive concept of himself/herself (The drugs that I dispense are safe and effective), and the reality (Some drugs do more harm than good).
How do pharmacists handle this disconnect? Do we react with hostility and denial toward customers who sometimes question the safety of the drugs we dispense? Or do we confront the possibility that there may be some truth in the fears customers express?
On the one hand, our instincts tell us that human health is primarily the result of basic factors such as good nutrition, healthy lifestyles, maintaining a healthy weight, avoiding a sedentary lifestyle, avoiding the use of tobacco and alcohol, etc.
On the other hand, our healthcare system is based on the manipulation of molecules and cells with powerful synthetic chemicals called pharmaceuticals.
How Can Pharmacists’ Attitudes Be Reconciled?
Why is modern medicine fixated on alpha blockers, beta blockers, calcium channel blockers, H2 antagonists, proton pump inhibitors, HMGCoA reductase inhibitors, etc.? Has modern medicine miraculously discovered errors in tens of thousands of years’ worth of human evolution?
Why is modern medicine obsessed with attacking and overwhelming delicate biological processes with synthetic chemicals foreign to human evolution?
Why is our healthcare system (and so much of pharmacy education) fixated on chemistry rather than on nutrition and lifestyles?
In order to lessen the inner turmoil caused by the attempt to hold diametrically opposed views simultaneously, pharmacists have to adapt to big contradictions. Being a pharmacist requires juggling absurdly contradictory perspectives.
Here is an anonymous comment posted on the Drug Topics website beneath my commentary titled “Pharmacists and Cognitive Dissonance:”
“I can’t believe you can read my mind so perfectly! The cognitive dissonance you speak of is as familiar to me as getting out of bed in the morning, and much less palatable. How DO you reconcile what you know to be true with what you must tolerate to survive. For many years, I have felt “two-faced” or phony in my practice of pharmacy. What I really want to do is tell my customers to flush the medication and start taking care of their bodies. What I have to tell them is how the medication will “help” them, and how they should take it faithfully. I’ve played the part as long as I can. I’m getting out. I can’t in good conscience keep shoveling this stuff out. Keep up the good work!”—Tired Pharmacist
How often do customers call you from home after reading their patient leaflet and tell you they’re not eager to take the prescribed drug after seeing the potential adverse effects? Do you feel that it is your job to reassure customers about the safety and effectiveness of all the drugs you dispense? Does your job required that we be cheerleaders for every drug we dispense?
How Do Pharmacists’ Attitudes Shape Their Behavior?
Do pharmacists have a duty to tell customers about the most dangerous side effects, or just the most common ones? Most pharmacists would probably say that there is not enough staffing to allow us to have thoughtful conversations with our customers regarding side effects, nor do our employers, physicians, and Big Pharma want us to have these conversations.
When I entered pharmacy school, one of the biggest shocks for me was learning about the common occurrence of adverse effects with prescribed drugs. Before entering pharmacy school, I assumed that pharmaceuticals are highly refined substances that directly target specific pathological processes which are well understood. I was shocked to see that so many drugs are crude synthetic substances (never before seen in the long course of human evolution) that overwhelm delicate biological processes.
So many drugs are like a shotgun approach to illness rather than a surgical strike. In contrast, ophthalmologists directly attack the pathology when they remove a cataract. Orthopedic surgeons directly address the pathology when they fix a broken bone. Dentists directly attack pathology when they remove tooth decay or treat an abscessed tooth.
In contrast, when physicians prescribe pills, these pills are distributed widely to every corner of the human body. Drugs for depression, cancer, arthritis, blood pressure, elevated cholesterol, type 2 diabetes, etc. are taken orally and then travel in the blood stream throughout the body, often adversely affecting multiple organs and biological processes.
Sometimes customers ask the pharmacist, “Is this drug safe?” I have concluded that customers want a simple “yes” or “no” answer. They don’t want nuanced answers with an in-depth discussion of the pros and cons.
Do Pharmacists Take More Pills?
Which of the following do you believe is more likely to be true? 1) Pharmacists take more pharmaceuticals than the general public because we know what’s on the market? Or 2) Pharmacists take fewer pills than the general public because we know about potential adverse effects.
I’m 66 years old and I’ve taken very few prescription drugs during my life. When I had an abscessed tooth, my dentist prescribed clindamycin without even asking whether I was allergic to penicillin. Knowing about pseudomembranous colitis and overgrowth of C. diff, I asked him to prescribe amoxicillin instead. I believe that I experienced ZERO adverse effects from amoxicillin, a great drug!
On the other hand, I was once prescribed erythromycin, a drug that caused such major stomach discomfort and otherwise made me feel so terrible that I was unable to take more than 5 or 6 tablets.
I’m now retired but during my many years in North Carolina, I worked for a chain that employed two floater pharmacists who were married to each other. I got to know both of them pretty well over the years. The husband was known to eagerly work 60 hours a week because he enjoyed receiving a fat paycheck. One day I worked with his wife who commented that her husband “won’t take anything himself, not even an aspirin.” Yet he eagerly worked long hours dispensing drugs that he was not eager to take himself.
What Do You Think?
Does the possibility of muscle weakness cause pharmacists to double down on dietary/nutritional and lifestyle changes so that they can avoid statins?
Does the long list of possible side effects from proton pump inhibitors including pneumonia, C. diff. overgrowth, osteoporosis, kidney disease, stomach cancer, and liver disease
cause pharmacists to avoid these acid suppressors?
Does the risk of tendon damage from fluoroquinolones cause pharmacists to avoid this class of antibiotics?
How do pharmacists and their customers react to the long lists of potential adverse effects listed in direct-to-consumer drug advertisements on television? Do you suppose the images of happy families having fun on sunny days with the family pet are meant to distract viewers from all the potential adverse effects?
Clearly these drug advertisements on television are hugely successful. Otherwise the drug companies would not spend gargantuan sums to advertise these drugs.
When a customer asks you “What side effects are possible with this drug?” how do you react to that question? Obviously with dangerously low levels of staffing in pharmacies, you don’t have the time to answer this question thoroughly. Do you grab the patient leaflet and mention a few of the most common or mildest potential adverse effects? Do you mention some of the most serious? Do you have an ethical obligation to mention the most serious even though they may not happen frequently?
Fluoroquinolone antibiotics have been in the news a lot recently because of new FDA warnings about the safety of this class of drugs. Yet many of the adverse effects highlighted in these FDA announcements (like tendon damage) have been known for decades. I save my old copies of The Physicians’ Desk Reference. The oldest one I have is the 1994 edition.
The official prescribing information for Cipro (1994 PDR) includes this in the WARNINGS section:
“The oral administration of ciprofloxacin caused lameness in immature dogs. Histopathological examination of the weight-bearing joints of these dogs revealed permanent lesions of the cartilage. Related quinolone-class drugs also produce erosions of cartilage of weight-bearing joints and other signs of arthropathy in immature animals of various species.” (1994 PDR, page 1571)
I suggest you spend a few hours on YouTube watching the many testimonials from patients about serious damage they’ve suffered from quinolones.
Do you think that the incidence of tendon damage from quinolones is greater than is commonly perceived? Do you think the incidence of muscle pain and weakness from statins is greater than commonly acknowledged? Do you think that dentists prescribe clindamycin too readily, given the potentially serious colitis?
How Should Pharmacists Counsel Their Customers?
Do pharmacists have an obligation to tell customers something like, “The fewer drugs one takes, the better?” Do you feel that the common occurrence of side effects should prompt the public to do everything they can to avoid having to take drugs? Do you believe that “An ounce of prevention is worth a pound of cure”?
There are obviously many drugs that are essential or even life saving. On the other hand, dietary/nutritional and lifestyle factors can greatly decrease the need for drugs. The fruits and vegetables at your farmer’s market don’t come with leaflets describing possible adverse effects. That’s because, unlike medications, they aren’t likely to cause any.