The People's Perspective on Medicine

Is Your Pharmacist Dispensing Deadly Drug Combinations?

Deadly drug combinations should never be dispensed. A new study reports that happens far too often. Patients were not warned of dangerous drug interactions.

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.

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About the Author
Joe Graedon is a pharmacologist who has dedicated his career to making drug information understandable to consumers. His best-selling book, The People’s Pharmacy, was published in 1976 and led to a syndicated newspaper column, syndicated public radio show and web site. In 2006, Long Island University awarded him an honorary doctorate as “one of the country's leading drug experts for the consumer.” .
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I currently work for a major chain pharmacy as a pharmacy technician. There IS software in place that blocks the sale of a prescription if there is an interaction of any medications or allergies on file. The pharmacist must address the issue with the patient before manually removing the block. The pharmacist counsels with some of these same patients on a monthly basis, for the same interactions, and you would be surprised at how inconvenienced and offended the patient feels because we want to make sure they are aware, even if they have been taking the medicine long term.

Many patients don’t want to be bothered with speaking with the pharmacist. They want their medicine and be out the door, like a fast food restaurant. If a patient also gets prescriptions from a different pharmacy chain, our computer systems are not interactive, so we don’t have access to this information and rely on the patient to inform us, so we can add it to their file. Each and every prescription must be double checked, some flagged for counseling and approved by the pharmacist before leaving the pharmacy.

I would recommend that all patients be more proactive in making sure their pharmacy has all updated information on medications and allergies on file. I have never seen a pharmacist refuse to consult with a patient. So ask questions if you’re not 100% sure about what you’re taking.

I think you have to be in charge of your own health; what you put in your body as to drugs, food,etc. No one else has any vested interest in your well being as much as you should. If I am ever given a prescription for anything, I do all the research on it I can find before I put it into my body. Plus, my personal belief is that naturopaths or functional medical doctors are much better to figure out what is causing the problem you are having as well as a solution without prescribing
dangerous drugs. They do nothing to heal your problem; just mask the symptom so you THINK it is being healed. The problem is still going on in your body. Get educated and help yourself to better health.

I am suffering from the after effects of being on a low dose of prednisone for 6 months, 5mg. When I got what they call moon face from it I called the RA guy who gave it to me and he said, of course, stop taking it. I asked if I needed to taper off and he said no because it was a low dose. Wrong. I have had so many things happen from taking prednisone I don’t even want to start listing them. My primary care Dr. Said he never gives it for more than 5 to 7 days. I should never have been on it for 6 months. I was taking it for a very mild case of RA, I am 77. The original meds he gave me weren’t working so he added the predisone on to that. I was not in bad physical health until then. Now 6 months later I have one thing after another happen. My family Dr says most are from prednisone. Should I have been allerted by the pharmacy? Maybe, but I think my Primary care Dr should have said something. He said he wasn’t notified that I was going to this RA Dr. They are all in the same health care system. Something is amiss with the whole health care situation. I know Drs and Pharmacies are busy but this has cost me my health.

Isn’t it more to the point that ALMOST ALL prescription drugs these days are dangerous? And, it’s the doctor that prescribes these deadly combinations. I refuse to take any of the newer drugs because of their horrible side effects and will continue to do so until they stop making the dangerous drugs. Why does the FDA okay these drugs when they have been proven to be so dangerous? Money is most likely the reason. I’m appalled by the drug reactions/side effects from these drugs. They scare me to death.

Thanks for the warning. I thought drug store computers would have an alert of dangerous drug interactions and then I would be informed of the issue.

That said, the Doctor is most responsible for the problem. Doctors should look at patients prescription list before adding any new drug. One of the good things about using patient portals is if you check to box to allow it then the medication list is available for all your doctors to access, easily and quickly.

As pts, we need to be proactive and ASK questions anytime a drug is recommended. People need to know that although we are aware of some of the most dangerous drug interactions, any time people take drugs( including OTC) then what you have is a soup pot of medications, no one knows how the body will react to this bombardment of chemicals.

Protect yourself and your family, look up a drug before you buy it and many websites have easy to use drug interaction information. There has never been a easier time to stay informed.

Only 50%? errors? Not surprised at all. My late wife filled and refilled prescriptions for Ultram (Tramidol) and anti-seizure medication several times without ever saying a word. Eight doctors missed it, too. When I finally discovered that Ultram was causing the seizures (black box warning) in 1996 by using our brand-new broadband internet and took the pharmacist to task, he stated that it wasn’t his job to review medications.

The eight doctors? They just shook their heads and mumbled “Sorry.” One had to be coerced to file with the FDA.

It was only a year of her life lost.

Why do you write these stories then charge for the information? Most people have a hard enough time paying for their meds, then you scare people with this info. Same old thing, let’s make money by scaring as many people as we can.

A few class action lawsuits of patients who have died and were taking potential lethal combinations of drugs would quickly bring change, particularly if pharmacy chains are identified.

I’m a retired chain store pharmacist. In my opinion, the Chicago Tribune investigation is a huge public relations disaster for the major chains. One would hope that the dismal results of this investigation would shame the chains into making major changes. But I predict that will NOT happen.

In my opinion, the root cause of pharmacy mistakes (including overriding significant drug interactions) is understaffing. Understaffing forces employees to work at maximum output for their entire shift. That increases the productivity of pharmacists and techs but it also causes a huge increase in pharmacy mistakes.

The Chicago Tribune had a follow-up article with responses to the investigation from four of the major chains. Most of the chains said that they would increase training in drug interactions and update their Policy and Procedure manuals to state that pharmacists must call the prescriber in cases of serious drug interactions.

None of the chains said they would address the heart of the problem by increasing staffing in the pharmacy. Increased staffing would hurt the chains’ bottom lines.

In my opinion, the big chains have made the cold calculation that it is more profitable to have pharmacists sling out pills at lightning speed, and then compensate any customers harmed by mistakes, rather than have adequate staffing for the safe filling of prescriptions.

About 20 years ago, US News & World Report did a cover story investigation that was quite similar to the Chicago Tribune’s investigation. The USN&WR cover story was titled “Danger At The Drugstore.” That cover story was embarrassing when it was published but, predictably, it had no lasting effect.

In my opinion, pharmacy mistakes (dispensing the wrong drug, the wrong dose, the wrong directions, and dispensing drugs that interact) will continue unabated until state boards of pharmacy get the backbone to stand up to the massive legal and political clout of the mighty drug chains.

The state boards of pharmacy need to fulfill their duty to protect the public safety by mandating adequate staffing levels in drugstores. Unfortunately, the huge drug chains lobby state legislatures to prevent state boards of pharmacy from requiring safe pharmacy staffing.

Understaffing is the root cause of the problem. The big chains have chosen understaffing as their business model for profitability.

Chain management has disdain for pharmacists who obsess over potential drug interactions or who spend too much time speaking with customers (“counseling”).

The main thing that the chains care about is how fast prescriptions are filled. Quantity is far more important than quality.

The big chains will update their Policies and Procedures manual to state that pharmacists must contact the prescriber in cases of “serious” drug interactions.

The chains hope that updating the Policies and Procedures manual will–to some extent–help protect them when some customer is harmed by a serious drug interaction. The chains will try to shift all the blame onto the pharmacist for not following the “Policies and Procedures” manual and calling the prescriber.

The chain spokesmen keep repeating the BIG LIE: “Patient safety is their number one priority.” Wrong! Profitability is, by far, their number one priority.

The chains received a black eye with the Chicago Tribune investigation. But I predict there will be no lasting effect because the chains absolutely do not want to hurt their bottom line by providing adequate staffing for the safe filling of prescriptions.

The public should demand safe staffing levels in pharmacies but I don’t see that happening any time soon. The public has a hard time believing that things are as bad as pharmacists know they are. Pharmacies must be adequately staffed to protect the public from serious pharmacy mistakes.

That is why I wrote the book What’s In Your Genes? Human Threads Linking Genetics and Genealogy.

Now that the FDA in 2017 will require clinical trials to use biomarkers, this will enhance what we are both trying to do.

Perhaps the blame should first go to the doctors who are prescribing the medications in the first place.

This is unbelievable. Since my wife starting taking so many drugs, I asked my pharmacist how they could keep track of all the interactions, and he said that the computer did that for them. I assume all software is available to all stores, so how did this happen? Just not buying the software? Maybe it should be legally mandatory.

My pharmacy has on record my allergy to penicillin. An Endodontist called in a Rx for an antibiotic prior to a root canal procedure 2 yrs ago. I took the antibiotic as prescribed and had a massive allergic reaction (hives) that sent me to Urgent Care.

The doctor at Urgent Care said the antibiotic the pharmacy dispensed was a form of penicillin. At Urgent Care, I was given prednisone IM and sent home with a prescription for prednisone tablets. Having taken prednisone in the past for poison ivy with no adverse side effects, I thought prednisone was safe for me. Within 12 hours of the prednisone shot and first oral dose, I had such a flush that it looked like a 2nd degree sunburn on my face/neck/chest.

The Urgent Care doctor told me to stop the prednisone immediately and “…never take it again.” Prednisone allergy alert has gone into my medical records and has been reported to the pharmacy. I wonder if I can trust any pharmacy to pay attention to these allergy alerts? In conversation with my gynecologist this year, I mentioned being allergic to prednisone.

The doctor expressed disbelief. She said she had never heard of anyone having a reaction to prednisone. She asked me what I would do in the future for steroid treatment if needed? What, indeed. No idea…….but I’ll have to trust in doctors. And….. pharmacists?

Re: Is Your Pharmacist Dispensing Deadly Drug Combinations?
This doesn’t even begin to consider drug-nutrient interactions. It was difficult to obtain this information during my career as R.D. Now, I see nothing at all about the possibility of meds interfering with nutrition and potential health impacts.

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