The People's Perspective on Medicine

Do Pharmacists Like Pills More Than Prevention?

A pharmacist says, "I'm more interested in prevention than pills." Does that make him a pariah?

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 dmiller1952@aol.com.

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I would love to know more about the artichoke extract please. A friend has been told to take half a 5mg of a statin (which is difficult to cut as no scoring of the tablet), with a warning she is a candidate for a stroke. I thought statins increased sugars? She has type 2 diabetes and a higher BP, could lose maybe 20 lbs for better health and do more exercise.

I myself have been told my cholesterol is somewhat high, that I should try to avoid saturated fats (given up cheese) and to exercise more and will have a test again in 6 months. I’d like to try the artichoke extract too – much better in my mind than medication. We are so foolish not to take natural remedies but rely on a drug to allow us our bad choices. Hoorah for a pharmacist who is also aware of natural remedies. What a blessing. I hope I can still have an occasional ice cream though. Balance is the key.

As a board certified holistic health practitioner, I wholeheartedly agree with Dennis Miller’s comments. My own PCP asks my opinion and never offers a drug as a first option. With my patients, I always offer the possibility of natural approaches in lieu of drugs and that generally does what’s needed, especially combined with good diet, exercise and meditation.

That said, the pharmaceutical industry would not stand for pharmacists failing to peddle their products. Their interest is in their bottom line, not your health or mine.

My doctor has given up. She tried to encourage people to make lifestyle changes but hardly anyone even tried. I’ve lost 40 pounds but it’s taken 10 years to do it. I’ve really worked at walking and have one knee replaced, and now the other knee and a hip are acting up. It is so hard to change lifestyles. We need more studies done on what works in helping lifestyle changes. What works and is low cost.

I agree with the article and will be 77 years old next month. I am on no prescription drugs. I do senior stretch twice a week, yoga twice a week and Tai Chi once a week. I take CBD oil for joint pain and have no more joint pain. My goal has always been not to be on prescription drugs, and so far I have succeeded.
CH

Dr. Miller is right on. I have Gerd and hate the PPIs. I do not eat fried, spicy, tomato products, sleep on an adjustable bed. etc. I tell the Gastro Dr. that the medicine is doing a number on my bones, maybe brain, maybe heart. He says I am a worry wart. I am thinking “What you think is great is not.” Have been on it since 2006. He says to keep taking it. I quit it, and them symptoms come roaring back. Maybe not strict enough diet. Throat now has scar tissue, very scary.

This is an excellent article. As a retired public health professional, I agree with your comments. Health education taught in schools, practiced at home, and promoted by physicians, would do much to reduce our reliance on medications. After all, it’s always better to prevent a problem than to treat it.

I think this article hits the nail on the head. Patients have become too dependent on meds to treat diseases that could have prevented in the first place.

I agree with Dr Miller. I wish other medical doctors wouldnt be so quick to pull out their script pads to solve medical issues. I saw an orthopedic doctor the other day who wrote me a script for pain meds. He didn’t say a word about changing my eating patterns, becoming more physically active, using OTC supplements, perhaps seeing a chiropractic physician, etc. Big Pharma encourages use of prescription meds., as the Food Industry encourages eating foods not healthy for us.

I love the pharmacists I have in my area. So many times they have given me perfect information about a drug and what else I could try if I am concerned about side effects.

I wish the doctors I have gone to would be as honest about medications. Example: my bad cholesterol was way too high. I was concerned about statin side effects. The pharmacist suggested trying an artichoke extract for about 60 days to see if that helped. My bad LDL number dropped by 40 points.

My doctor was shocked to see the blood work results. I told her sometimes it is best to try something natural first. My doctor seemed almost annoyed that I would not be on a statins.

Thank goodness for great pharmacists, I tell mine how much I appreciate them.

My daughter has a friend who lives in Europe. She is amazed at the large number of medications that people in the US are accustomed to taking. Her family doctor favors early intervention such as diet, exercise and quitting smoking to prevent disease. He will prescribe pills only if that doesn’t work.

I think pharmacists are helpful if asked, but the angry and litigious nature of our society makes it hard to offer advice when not being asked. And the “metrics” pharmacists and their pharm techs have to meet has many running so fast, they don’t have time to think. Compound that with dealing with a public where there may be a language barrier, educational barrier, or just a lack of common manners, who has the time to overcome these things. In my opinion, it should be happening in the doctors office first.

Some diseases run in families, and I have the ones my parents had. Would it help with my blood pressure if I lost weight? Surprise, I am already on the low end of normal weight. And so it goes for the other medicines I need. I don’t see how my lifestyle is causing these problems: I seem to be doing all the right things, and that is not enough. So I am grateful to the medicines, including the doctors who prescribe them, the companies that make them, and the pharmacists who fill them. I just hope my pharmacist doesn’t feel bad about giving them to me.

I am quite surprised at the tone of this article. Doctors are the ones that should be stressing a different route for their patients. And patients should be more willing to adjust their lifestyles so that they can live longer without drugs. I would never imagine placing blame on a pharmacist for filling the prescriptions a doctor writes for a patient who won’t change their way of living. People want a quick fix without effort.
On the other hand, maybe some patients just cannot improve their circumstances even with dietary and lifestyle changes and must have drugs to assist.

Perhaps the measurements should be how well do the drugs perform over the long run. Do they keep people alive, improve their lives and make them healthier. Do they actually fix root causes of disease and sickness. Sorta like the pro QB who piles on the statistics during the season, but can’t win a playoff game. So one guy out prescribes another…it proves nothing and is meaningless.

Thanks so much for article!

I am not a pharmacist but did spend 2 decades in the healthcare industry as an administrator and consultant. It is no mystery to me that two things happen with regularity. Surgeons operate and internists medicate. That is how they are measured and rewarded. Imagine what would happen if both did not follow standard protocol. The medical industry would collapse.

I may be a bit more hardened than most but at 66 I’ve seen a lot and know that self-reflection and willingness to change are vital to a good and healthy life. How did we become so drugged. I place a great deal of blame on the individual. Imagine running ones life in the same manner as a healthcare interaction. For example you go to the doctor and he says take this statin drug. You dutifully go off to the pharmacy and begin the process of poisoning yourself. What other event in ones life would evoke such an unquestioning act and yet people do it.

I have done significant research to learn about options to keep myself as healthy as possible and limit if not eliminate pharmaceuticals from my life. When no other choice is available to solve a problem then it’s a different story. I got myself off BP meds and will not touch a statin. My average BP is now 122/76 with a resting pulse of 61. If I can do it others can do it.

The thoughts I have to share on this topic are even more radical than those of Mr. Miller. We have a veritable explosion of transgender children in western societies. Why? Have there always been large numbers of transgenders and they have simply kept it a secret or is something else at play? I know we have huge amounts of hormones in our food chain because producers feed hormones to their chickens, turkeys, cattle, pigs, etc. to promote size and growth rates. Has the existence of this hormone “bomb” in the food we feed ourselves, babies and children disrupted the gender procedure in our children? Have we once again interfered with a development process that has naturally developed over the eons.

This is and outstanding article!
The author, Dr miller, has put things in perspective .
I wish the other half of the medical profession ie,Doctors and specialists could read and follow his advice.

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