pharmacy mistakes, pharmacy checkout, pharmacists' attitudes, prior authorization

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 Reactions:

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.

By Dennis Miller, RPh, a retired pharmacist living in Delray Beach, FL.

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  1. karen

    I don’t usually take drugs. Once I was prescribed a drug for a chronic ailment, and it was the pharmacist (of a big box store, no less) who asked me if I had heard of the horrible side effects. Luckily for me, I was able to find an alternative.

  2. Sharon

    My former daughter-in-law is a pharmacist. She graduated at the top of her class. When she graduated she was given a head pharmasist position for a major grocery chain. She did not believe that Fluoroquinolones cause the horrific delayed adverse effects because she was not taught in Pharmacy School that they did so.

  3. Sara
    North Carolina

    Did you know that eons ago, pharmaceutical salespersons were known as “detail men”?
    What a joke!

  4. Sue

    I hope people read this. I make it a habit to read about side effects and be aware of them, and at least stop taking the meds, and let my Dr. know I have stopped. I have had them tell me to quit reading about the side effects and that I read too much. I think Doctors should read the drug label of every medication they prescribe.

  5. Sarah

    I learned the doctor- pharmacist role the hard way. I always assumed, like most people, that the pharmacist was there to protect you, they had the drug knowledge. Unfortunately, I was never made aware that the prescription of Levofloxin (generic antibiotic) and Prednisone were contraindicated. I had no idea of the lengthy 30 year history of lawsuits Johnson & Johnson had with Levaquin (the name brand antibiotic) and the massive amounts of people it had severely and permanently injured or killed.

    My last 4.5 years have been a hell I would not wish on my worst enemy, my life is full or pain and depression from what this drug has done to my life, love, and career. It has taken away most of it all, including my savings. I recently found out that the pharmacist does not override what the doctor has ordered. I was completely shocked. How can any doctor know what these drugs really do to you, their main job is seeing patients.

    This is a critical flaw in our system. NO ONE is looking out for the patient and you are on your own. Millions will suffer from this lack of knowledge, many will die or kill themselves from the side effects. What a sad, sad state of affairs.

  6. Helen

    I have a friend who is leary of every medication prescribed for her and she goes to the dr. repeatedly and doesn’t take most of what that doctor prescribes. Some of her ailments just don’t get better, and she has many. The pharmacist knows her well enough, and I believe, has learned to tell her what she wants to hear…that yes she will likely have a bad reaction to whatever the drug is. He simply discourages her more, and encourages her to avoid the risk of any reaction.

    I think he should fill the prescription and keep his mouth shut. There is enough information out there on the computer that one can research and figure out whether they want to take a drug or not and have the conversation with the doctor if they don’t. If you have a bad reaction to something you know what to avoid …it’s fluoroquinolones for me after a harrowing experience with Cipro. I get really irritated that if I am in the hospital for a simple procedure and they ask the usual…are you allergic to any drugs etc etc. that they insist on knowing WHY I don’t take quinolones. They have been a problem for so many people for years and the medical profession should have figured out the why by now. I copy information about them from your column and just hand it over to the nurse to avoid the why discussion.

  7. Nancy
    Richmond, VA

    I trust my pharmacist over my doctor on drug information. My doctor is educated about drugs from the pharmaceutical salesperson. My pharmacist’s education was extensive on the reactions of substances in the human body. That’s a huge difference in education.

  8. Marilyn

    I think it is terrible that doctors do not know the side effects of drugs. They are not taught that in medical school. People should not blindly take medicines without knowing what the side effects can be. I was fortunate to have a good pharmacist tell me not to fill a prescription for a steroid drug that was prescribed by a doctor. The pharmacist told me that steroid drugs can be very dangerous. When I read about all the side effects they can produce I was very thankful for the pharmacist. Please people, do not trust your doctors , trust the pharmacists that know how bad so many drugs are.

    • Sara
      North Carolina

      I have had to take steroid meds three times a day for three days each time after three consecutive days of Chemotherapy for three sessions. I only have one more session, and, thankfully, will soon be steroid free. So far have had no side effects. Will they come later?

  9. Janice

    Great article. I am reminded of the study where teachers were told a group of students were A and B students and the other groups C and D students. The grades given the students reflected the teacher’s belief that the student was either A and B or C and D even though the groups had been reversed. Many doctors I have worked with over the years expect their patients will not initiate lifestyle changes and write the prescription. As a dietitian and diabetes educator I am always inspired by the patients who do what the doctor does not expect and embrace lifestyle changes to lose weight, control blood glucose and cholesterol. Maybe we should all expect our patients/ clients to be A and B students.

  10. Gary

    Research several doctors on the internet: T Colin Cambell, Neal Barnard, Joel Fuhrman, John McDougall and other doctors as well. Learn about the short term and long term benefits of a plant based diet. As you change to a plant based diet you will find, from personal experience that you will be able to reduce and possibly eliminate the medications. Research the above people and then make up your mind from the evidence and from the experiences of many who changed to a plant based diet.

    Their are doctors,(you have to find them), that will work with you and not insist that you take the medications, if by diet symptoms are reduced and in many cases totally eliminated. “Food is your best medicine.” I mean here food,(dead animals are not food), as it is grown and NOT processed or packaged:

  11. jon
    los angeles,ca

    from jon: A very good and informative bit of info, long over due. I can only add that people like myself who are health conscious and 70 plus years in age find that vitimins and supplements tend to be so pricey that we can’t afford the out of pocket cost to maintain our health naturally. it’s not cheap trying to stay well and above ground. Thanks again for your insight.

  12. Dick

    When I mentioned the problem I thought I was having with Atoravastatin to my cardiologist he told me to quit taking it for 2 to 3 weeks and see if there was any improvement. It was difficult to tell if the muscle pain and lethargy was reduced as I have been taking it for long time. My doctor seemed amused at my concern when I first mentioned it however I’ve noticed that several people have complained about it if one can believe the blogs. Some people have stopped taking it, no longer being able to tolerate the side effects. This is the second statin that I have taken as Simvastatin, my first prescription was causing excessive coughing. Hopefully a better solution can be found to do the same thing that the statin drugs do wihtout the negative side effects..

  13. Retired RN

    On a lighter note, When Vioxx and other anti inflammatory meds were on the market, my 7 year old son saw an ad with an Olympic skater. He said, ” I want the pill that teaches me to ice skate.” Shows what advertising does to kids.

  14. Kim

    I’m an RN. Those are my thoughts, also. I’m allergic to 2 antibiotics and refuse to take Cipro or Clindamycin. I choose diet and lifestyle over statins and fosamax. Drives my doctor crazy.

  15. Dennis

    When you Rx, think about this article.

  16. Harvey

    When you pop a pill, think about this.

  17. Nancy H

    something you should consider

  18. Madeleine
    Sarasota, FL

    What an interesting article! It got us behind the drug counter and into the thoughts of pharmacists. Thank you for the exposure.

  19. ray

    The owner of my local pharmacy owns 12 stores in surrounding small towns. most older workers had been with rite aid so i knew them. their prices are competitive with large chains. in store or over the phone if i have any question time is no limit to how well they discuss my med,side effects,or interaction,or suggestion of a drug that would work better,or a cheaper one that works just as well. large chains seem short handed,basic hand your med and send you own your way. the dr had gave me 4 diff meds for heart.

    The pharmist said it wasnt good to take 40mg of one and 10 mg of another.the one i was taking 10mg said it would increase the 40 mg to about 60 mg in effectiveness which was more than i needed. i confronted my dr, she did research and said she would reduce my 40 mg to 20 mg. so i am thankful both my pharmist and dr are open to looking at things like that.

  20. carol

    When foreign people come to our country they can’t get over our processed foods. American greed has taken over knowingly salt keeps a person drinking, sweets for continued cravens, and the out come is to take medication which is more money in their pockets. We must be the most medicated country in the world. Organic is only as good as the soil they grow in.

  21. Sally

    The good news concerning levaquin:

    “Janssen Pharmaceuticals, part of Johnson & Johnson, has stopped production of (brand-name) Levaquin, according to the article, “Drug maker stopped making popular antibiotic Levaquin amid concerns about mental health side effects” published on the Indianapolis ABC affiliate RTV6 The Indy Channel. Janssen/J&J stopped producing both oral and IV Levaquin in December, 2017.

    The bad news is that there is still plenty of levofloxacin (generic Levaquin, made by hundreds or thousands of generic pharmaceutical producers) on the market, and it is maiming (and killing) thousands of people each year. The fight against these drugs is far from over.
    Victims of pharmaceuticals can’t sue drug-makers for harming them, they can only sue for “failure to warn” of the dangers of the drugs. Millions of people have been seriously injured with no recourse.

    They don’t even have to directly warn patients, they only have to say that they warned your doctor, the “learned intermediary” of the dangers of the drugs (or, at least they have to in theory – it’s assumed that doctors actually know what’s on the warning labels for pharmaceuticals… but most don’t).

    The FDA says that only brand-name drug manufacturers can change drug warning labels, and since generic drug manufacturers can’t change the warning labels, they cannot be held responsible for what’s on the warning labels. This results in victims of generic drugs being unable to hold anyone responsible for the harm done to them by the drugs” ~

    There was a black box warning for tendon damage when my husband could not move his legs after taking only two of five tablets of levaquin prescribed for a mild case of bronchitis. The warning went unnoticed by both his doctor and pharmacist! Luckily, he sustained no permanent damage, but others have not been so lucky. The FDA should have taken this drug off the market years ago!

    Big box pharmacies are now cutting back on pharmacists to save on company expenses, so more than ever we need to be well informed advocates of our own health (read those drug package inserts and go further to

    Many thanks to The People’s Pharmacy for providing information to make us better advocates we would not receive anywhere else!

  22. Carol
    Madison, WI

    More important, physicians need to be more aware of side effects. I suffer from lymphedema in both legs after nodes were removed during a cancer surgery. The BP meds my doc prescribed listed “swelling in feet and legs” as the main side effect. I said “NO THANKS!” and called the pharmacy to not fill it, which they didn’t. But I know the doc will be upset with me next trip. We’ve had this go-around before, when the meds listed common side effects that were far worse than what we were treating. It’s MY call whether I want to take the risk or not. If I don’t look out for me, the doctors sure as heck won’t.

    • Nancy
      suburban Chicago

      I agree with Carol. I had to be hospitalized on 3 occasions due to serious reaction(s) to prescribed medicines. It’s in my medical record. Yet, when a doctor prescribes a new medicine, he/she never checks the record for allergies/interactions.

      Worse, if I tell the doctor that a given medication is problematic, they scoff at the thought and tell me they’ve prescribed the medicine “for years” and “nobody ever had a problem with it.” The so-called “conciltation” with the pharmacist is that the tech just reads portions of the medicine insert. If you question them they tell you to “ask your doctor.” Nobody takes responsibility for this information crisis.

  23. Susanne

    Excellent and compelling article…thank you!

    • gary
      Norwich, Ct

      Pharmacists have an ethical responsibility to protect their patients . They are the last bastien of defense against drugs mishaps and polypharmacy practices of multiple doctors. The Pharmacist is the last one to know what you are actually taking and the only way he/she can understand a client/patient issues is to speak to them routinely. simply dispensing the correct drug as written a monkey can be trained for. Know that what is being prescribed is inappropriate can only come from a Pharmacist knowing his patients. Unfortunately although this is what should be practiced, no chains want to pay for good clinical practice, that will keep their customers well. The chains only prosper by making it as easy to refill medications as they can and their system design is constructed for that with little to no contact with the patient, as that takes time and time cost them money and directly impacts their bottom line which is their primary concern. People are getting sicker and suffering through these drug misadventures and lack of contact with Professionals like the Pharmacist who are in the unique position to catch these problems but this is not the way the system as practiced is working…We’re all going to pay for this in the long run. An ounce of prevention is worth a pound of cure, an old cliché that has been forgotten by the medical industry. I too am a retired and dismayed Pharmacist

    • Betty
      Dallas, TX

      It sure is! We need pharmacists – and doctors with this knowledge and approach.

  24. Fred W.

    My wife and I make a practice of researching online whatever prescription drugs we are given, and in doing so discover a long list of side effects for virtually all of them.
    So, we now rely almost exclusively on homeopathic medications, such as NasalCrom, sleep aids such as ashwagandha, melatonin, and valerian, that work beautifully without any serious side effects.

    Life style changes, when undertaken in very small baby steps, also result in such wide-spread health benefits that make prescriptions unnecessary. But neither physicians nor pharmacists are well-informed about homeopathic medicines that are far more effective than prescription medicines without the serious side effects.

  25. Jill

    I don’t think it’s up to the pharmacist at all, even though I see the problem for them but their job is to fill prescription medicine that a Dr, wrote for that person. The Dr, and patient are the ones who know what’s going on with them more so than the pharmacist? I was always under the impression that the pharmacist counted pills. A bit more than that I know but I don’t pay a pharmacist. I pay to see my Dr.

  26. Paul

    Lets get down to basics. The Pharmacist’s number one job is to fill the physicians order, the prescription. We are not physicians. Several court opinions rendered in malpractice suits have upheld this. When it was seen that many times patients were not told of the side effects the government enacted laws requiring pharmacists to “counsel patients” As part of the counseling a brief discussion of side effect and contraindications was required. My experience was that most patients did not want to be counseled. They wanted their medicine and be gone. Now it is required that written information be given to the patient and its there if they take the time to read it.

    Back when there were small independent pharmacies the pharmacist could control the ordering of drugs from companies that he or she knew and trusted. Now a buyer at chain headquarters make that choice. Now that buyer is buying from wholesalers who offer products from India and China where the FDA has a hard time guaranteeing quality.

    The bottom line stay healthy and stay off drugs.

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