I’m more interested in prevention than pills. Does that statement make me Public Enemy Number One in the world of pharmacy, and persona non grata to my colleagues? Or are there in fact a large number of pharmacists who feel the same way but are afraid to verbalize their feelings?
Have pharmacists internalized production metrics as the most important gauge of our value to society? Is human health directly proportional to the per capita consumption of pharmaceuticals? Many pharmacists working in high-volume pharmacies feel superior to their colleagues working in slower stores. Rather than use metrics like the number of prescriptions filled per day or week, wouldn’t it be better if pharmacists were able to develop metrics related to disease prevention? Shouldn’t the concept of helping people learn to prevent disease and decrease their need for pharmaceuticals be viewed as a very laudable goal for our profession?
Pharmacists Weigh In:
As a result of one of my commentaries in the pharmacy journal Drug Topics, I received the following e-mails from pharmacists lamenting the lack of emphasis on prevention.
One pharmacist sent this comment:
“As a 55-year-old retail pharmacist, I think about this every day. In fact, I joked to my wife that I would prefer to practice ‘Farmacy’ instead of pharmacy. Our diet and lifestyle make so much of what we treat preventable. We (our US population) eat too much sugar and meat and not enough fruits and vegetables. We don’t exercise. Smoking is just a given as far as something that one can give up and instantly see improvement.”
“My typical encounter is an overweight customer in drive-through picking up their cholesterol, diabetes, blood pressure and pain pill. Often times a person picking up their asthma inhaler is smoking a cigarette. My thought is always ‘Why are we even playing this game?’ I hope it gets better but I doubt it. I am one of those who has gone vegetarian to avoid the same meds I dish out every day. Thanks again for the article and for listening to a pharmacist who struggles every day with the meaning of his job.”
Another pharmacist sent me this e-mail:
“Medications are important in ER, urgent care, chemotherapy, pain control, but we have become dependent on them for everything! It’s so sad and I’m disappointed in being a part of this. It’s not what I imagined as a pharmacy student.”
Pharmacists often hear their colleagues make comments to other pharmacists or pharmacy technicians like, “If our customers would just take better care of themselves, exercise, lose weight and eat better, they wouldn’t need so many pills.”
After filling 8 or 10 or 12 prescriptions for one patient, technicians often make comments to other pharmacy staff like “I wonder how he has any room left for food.”
I Am Not Anti-Drug:
Let me emphasize that I am not anti-drug. There are many drugs in the pharmacy that are essential and even life-saving. That includes drugs like insulin and antibiotics. People with type 1 diabetes would die without insulin. If I had pneumonia, I would be extremely grateful for the availability of antibiotics that can cure this disease. If I’m in a car accident and I’m rushed to the emergency room, please give me a strong pain killer if I’m in severe pain.
Antivirals have been miraculous in extending the lives of people with HIV. These drugs are changing infection with HIV from a death sentence into a chronic condition. Can you imagine working in a pharmacy without levothyroxine or oral contraceptives?
Both of my parents died from cancer. My father died from non-Hodgkin’s lymphoma and my mother died from colon cancer that spread to her liver. I was extremely grateful for the availability of morphine. Both of my parents would have been in excruciating pain at the ends of their lives if not for morphine.
I am strongly in favor of the use of pharmaceuticals when they are used to treat conditions that are not preventable. This includes conditions like type 1 diabetes. Insulin is truly a wonder drug in my view. I view pneumonia and the use of antibiotics similarly. Insulin and antibiotics are miraculous drugs.
But let’s take, for example, my mother’s colon cancer. I am only speculating, but I believe that there is a reasonable chance that my mother’s colon cancer was caused or at least exacerbated by her years of cigarette smoking. I believe that many pharmacists view colon cancer as a largely preventable disease. It is often a consequence of one’s diet and/or tobacco usage.
Or take my father’s non-Hodgkin’s lymphoma. Pesticides are often mentioned as a risk factor for NHL. For example, farmers are known to develop NHL in greater numbers than the general population. Farmers’ exposure to pesticides is often cited as a potential cause. (Search Google for non-Hodgkins lymphoma pesticides for many articles.)
A Prevention Approach to Cancer:
The Merck Manual (17th edition, pp. 2591-2592) essentially states that up to 90% of cancer is preventable:
“Environmental or nutritional factors probably account for up to 90% of human cancers. These factors include smoking; diet; and exposure to sunlight, chemicals, and drugs. Genetic, viral, and radiation factors may cause the rest.”
Most Cases of Hypertension and Type 2 Diabetes Are Preventable:
In addition, The Merck Manual (16th edition, p. 984) says that most cases of hypertension and type 2 diabetes are preventable:
“Thus weight reduction will lower the BP [blood pressure] of most hypertensives, often to normal levels, and will allow 75% of type 2 diabetics to discontinue medication.” Ninety percent of diabetics have diagnoses that fall under the heading of type 2.
I’m a huge fan of the use of pharmaceuticals when they’re used to treat conditions that cannot reasonably be prevented or when used to treat the effects of genetic disorders. For example, I view the use of analgesics to treat the pain of sickle cell disease as a highly admirable use of modern medicine.
But I believe that many pharmacists would agree with me when I say that it is less admirable to use pharmaceuticals to treat preventable conditions like elevated blood pressure, elevated cholesterol, and elevated blood sugar in type 2 diabetes. I believe that many pharmacists recognize that dietary/nutritional and lifestyle factors such as exercise and weight loss can be better ways to address these conditions.
Diseases of Modern Civilization:
In my experience, very few pharmacists seem to be interested in the observation that the most common diseases in advanced societies are a result of our departure from what our genes are programmed for. There is a major mismatch or discordance between our genes and life in modern society. Our genes are programmed for a caveman existence or, at best, an agrarian lifestyle. Our life in modern urbanized and industrialized societies is profoundly at odds with our genes. The resultant diseases of modern civilization are often referred to as Western diseases or diseases of affluence because they occur in societies that have adopted a Western lifestyle and diet.
I highly recommend two books with similar titles: 1) Western Diseases: Their Dietary Prevention and Reversibility by Norman J. Temple and Denis P. Burkitt (Humana Press, 1994) and 2) Western Diseases: An Evolutionary Perspective by Tessa M. Pollard (Cambridge University Press, 2008). Understanding the fact that the most common diseases in modern societies are largely preventable has caused me to be less enthusiastic about the drug treatment of these conditions. In my opinion the focus should be on prevention, not treatment.
See also “Diseases of Affluence” in Wikipedia: (https://en.wikipedia.org/wiki/Diseases_of_affluence)
Examples of diseases of affluence include mostly chronic non-communicable diseases (NCDs) and other physical health conditions for which personal lifestyles and societal conditions associated with economic development are believed to be an important risk factor — such as type 2 diabetes, asthma, coronary heart disease, cerebrovascular disease, peripheral vascular disease, obesity, hypertension, cancer, alcoholism, gout, and some types of allergy. They may also be considered to include depression and other mental health conditions associated with increased social isolation and lower levels of psychological well being observed in many developed countries.
Do Pharmacists View Discussions About Nutrition and Prevention as Beneath Our Scientific Training?
Pharmacy students endure monotonous semesters of inorganic chemistry, organic chemistry, biochemistry, and medicinal chemistry. A discussion of nutritious foods, exercise, and prevention seems oddly out of place in pharmacy school. After all, pharmacists are scientists, not dietitians. Pharmacists believe that an understanding of molecules and cells is necessary for an understanding of human health.
Mechanistic and Reductionist Medicine:
Pharmacists learn that human health is dependent on the prescribing of alpha blockers, beta blockers, calcium channel blockers, angiotensin receptor blockers, proton pump inhibitors, HMGCoA reductase inhibitors, ACE inhibitors, etc. These are drugs that block or inhibit delicate biological processes that have been fine-tuned during the long course of human evolution. It is as if Big Pharma has miraculously discovered a huge number of errors in the design of Homo sapiens. Dietary/nutritional and lifestyle factors are irrelevant in this mechanistic and reductionist view of human health.
Disloyal to the Profession?
As the rapidly expanding number of private (for profit) pharmacy schools floods the market with pharmacists, our profession faces the regrettable situation where an increasing number of pharmacists must compete for a fairly finite number of prescriptions. With a more reasonable number of drug stores in the USA, pharmacists could spend their time filling prescriptions for drugs that treat conditions that cannot reasonably be prevented. An oversupply of pharmacists causes a dog-eat-dog world in which discussions about disease prevention and overmedication are unfortunately seen as disloyal to the profession.
What do you think? Offer your perspective in the comment section below.
Dennis Miller, R.Ph. is a retired chain store pharmacist living in Delray Beach, Florida. He welcomes feedback at firstname.lastname@example.org.