Why We Don’t Let Pharmacists Prescribe

the_mad_hatter_by_fayrenpickpocket

Pharmacy associations are not sending their best. They are sending people that have lots of problems with reasoning, and they are bringing those problems to us. They’re bringing drugs. And some, I assume, are good people.

But try to buy “real” Sudafed, or Panadol, or a Codiene containing product, as an adult, and one is presented with an experience that can only be described as “wanting”.

One is finally left to wonder how the pharmacy associations come up with their recommendations for drugs, and their sale, at all. Almost certainly by committee – that much seems clear.

But what one is not left wondering is why we do not let these people prescribe medications themselves.

To Protect You From Yourself

They are here to keep you safe. With no regard for personal efficacy, or criminal intent – no the “you” part is not required, in the world of the pharmacist. Patients are surplus to demand, at least the mind part is. The body part they want. The body part has the wallet. Yes; the pharmacy association wants your body. And only wants you for your body.

And not that anyone asked for this attention particularly. We did not dress hot to entice – we are febrile. No situation arose that called for their ever-so-expert “bad” touch. And yet here we are. Running a fever, running nose, and running a gauntlet of irrationality.

Codeine is dangerously addictive. Paracetamol virulently toxic. And a packet of 60mg Pseudoephidrine tablets is more sought after, on the criminal black market, than the very narcotics that the innocent looking brightly coloured boxes of breathing, are rumored to be turned into.

Or so you would be forgiven for discerning, from the way some of these “people” carry on. All the while trying to peddle products that, they themselves do not believe to work, in placei; drugs that may actually be dangerous, like phenelephrineii.

To the untrained eye it can seem all for the best, prima facie: except none of the fear mongering can be held as justifiably true. And law enforcement know it iii iv. And the AMAv knows it. And, quite frankly, most people on the street know it too.

In truth, none of these compounds are a major problem.

Drugs are Bad, Mmm…k?: Reflections Dancing with Some Data

Codeine is not dangerously addictive. We have advanced forensic tools for examining Codeine – in the living and the dead – and its transformation into Morphine in the bodyvi.

Not only is metabolism different in every patientvii, seeing the drug effectively metabolised to an active compound at a ratio of only ~10:1 in the best case: the idiosyncratic differences are such that, in as many 1 in 20 cases, Codeine is not metabolised into any desired compound at all (therefore having no effect on the patient whatsoever)viii. Hardly the dream.

As for paracetamol: no one is accidentally overdosing. Though, for the amount of alerts I get in my inbox monthly regarding this topic, one would be forgiven for thinking that people are having a single Panadol, and their heads are exploding.

So, regarding the great dangers of Panadol (Acetaminophen/Paracetamol) that fill up my in-box multiple times per week; to say they have been greatly exaggerated, would be less than a great exaggeration.

Panadol does not make the top list of deaths, or poisoning, pretty much at allix. In the poison specific portion of the ABS statistics, it ranks only among suicides and overdoses as (a likely reasonably non acute concern) single compound that was present among many – never as the cause. Though you have to read the fine print to really work that out (I know, reading *blurgh*)x. Alcohol is also never included, it is worthy of note.

So, you are looking at, at most, between 8-18 deaths (in real numbers) where Panadol was even present. No claims it was really involved, and antidepressants were still more commonly used even for suicidexi.

To put that all in perspective: even if we take those as “Panadol damage related death” (and pretend there are no suicides, and that no other drugs were involved); the actual death likelihood: ~1 in 23’000xii.

The death from radiation exposure risk is ~1 in ~12’000 xiii – not including cancers. Yet you do not see the SERT team xiv unloading clips into the sky during every electrical storm, nor shooting at the sun during the hot summer’s day, do you? And nor should you. But these pharmacy association recommendations make about as much sense.

In fact, arguably, quite a bit less sense.

However, these drugs are merely the runners up. As everyone knows; the real danger comes from the well organised, politically connected, and highly networked international criminal underworld… which also, as it happens, is entirely sustained on cold and flu medication bought by people on the way to work. I mean, obviously.

Pseudo Pseudo Ephidrine Scare Mongering

When it comes to street amphetamine, approximately 80% does not come from known sources of in-country pharmaceutical pseudoephidrine stocks, according the Federal Police xv xvi.

And of the estimated 20% amount remaining, the majority is actually thought to come from ingredients either smuggled in from fake orders to shell chemical companies, or from massive bulk raids of pharmaceutical factories xvii xviii.

Yes: somewhat surprisingly, it turns out drug syndicates do not get the bulk of their resources from elaborate chains of multi-state wide cold and flu sufferers compiling 60mg tablets at a time, edging towards a ton.

Who knew, eh?

Everyone but the Guild of Pharmacists, apparently.

If it is true that 9.5 kg of street Meth – a recorded bust from this month xix – is worth $3 million wholesale, but pseudoephedrine is worth $200k per kilo on the black market xx xxi; where is the incentive? Honestly.

That means that if you had a 15 man crew in your bike gang* (*and I am pretending you do not have to deal with other items, from bribing the pharmacist and/or security guard; to hiring a delivery driver; the cook chemist – plus we are also ignoring distribution and its costs. I mean you do have to sell the stuff, you can’t just take it into a bank… right? But pretending you could)…

Right, SO, again: If you had a 15 man crew, then that record haul would earn each of you less than the median wage for this country that year xxii. And no job stability.

You’d be far better off all going on the dole, paying a third of your payments each to have one member of your crew go to university, and open up your own legitimate pharmacy; that you all own shares in. That is where the smart money would be.

A never ending weekly supply of orders; deliveries to your door; sales representatives coming to you, and customers that can come out during the day! And not least of all: no breaking the law, and the associated problems.

The reason they do not do this, is because the vast majority of the source for the illicit drug supply simply does not come from citizens trying to alleviate the symptoms of allergies or the flu to get to work. It is not true.

And So That Is Why

So the next time it comes up that “pharmacists should prescribe”, because they have memorised our best guess at enzymatic pathways some 30 years ago. Say no.

And when they lament that even clinical and neuro psychologists get to prescribe before them, along with nurses and physician’s assistants; let it be known that this is why.

Yes, those drug sales numbers are likely inflated. But police forces have budgets and jobs to protect – what is the pharmacist’s excuse?

With the exception of hospital pharmacists, the average shampoo monger sees only relatively healthy patients anyway. They have nothing to add of value, certainly nothing that the same (identical) “medication clash alert” app, used by most physicians, does not already have covered. Thanks.

And, finally, the other fields believe in self efficacy. Personal responsibility. Patient autonomy. Criminal intent. Police and clinicians have some contact with reality.

Pharmacists do not. It may be questionable to even let some of them make recommendations, in certain cases. Perhaps the cases outlined above rank among them.

At the heart of the matter is the fact that pharmacists are, for the most part, entirely divorced from both clinical and forensic reality – and that is why we do not let them prescribe.

JJR

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*JJR is the psychiatry and research science investigator for the Chronicle LS.

[+++] Research Blog Marker

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JJR (2015).Why We Don’t Let Pharmacists Prescribe. JChronLettSc, 01518(9), Ed5.

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i Horak, F., Zieglmayer, P., Zieglmayer, R., Lemell, P., Yao, R., Staudinger, H., & Danzig, M. (2009). A placebo-controlled study of the nasal decongestant effect of phenylephrine and pseudoephedrine in the Vienna Challenge Chamber. Annals of Allergy, Asthma & Immunology, 102(2), 116–120. http://doi.org/10.1016/S1081-1206(10)60240-2

ii Meltzer, Eli O., Paul H. Ratner, and Thomas McGraw. ‘Oral Phenylephrine Hcl For Nasal Congestion In Seasonal Allergic Rhinitis: A Randomized, Open-Label, Placebo-Controlled Study’. The Journal of Allergy and Clinical Immunology: In Practice (2015): n. pag. Web.

iii Australian Federal Police, (AFP). ‘Amphetamines – Australian Federal Police’. Afp.gov.au. N.p., 2015. Web. 18 Sept. 2015.

iv Australian Federal Police, (AFP). ‘Australian Federal Police – Annual Report’. (AFP). N.p., 2013. Web. 18 Sept. 2015.

v Australian Medical Association (AMA). ‘Australian Medical Association’. Australian Medical Association. N.p., 2015. Web. 18 Sept. 2015.

vi Berg-Pedersen, R. M. et al. ‘Codeine To Morphine Concentration Ratios In Samples From Living Subjects And Autopsy Cases After Incubation’. Journal of Analytical Toxicology 38.2 (2013): 99-105. Web. 18 Sept. 2015.

vii Smith, Howard S. ‘Opioid Metabolism’. Mayo Clinic Proceedings 84.7 (2009): 613-624. Web. 18 Sept. 2015.

viii Smith, Howard S. ‘Opioid Metabolism’. Mayo Clinic Proceedings 84.7 (2009): 613-624. Web. 18 Sept. 2015.

ixABS,. ‘4102.0 – Australian Social Trends, 2001’. Abs.gov.au. N.p., 2015. Web. 18 Sept. 2015. http://tinyurl.com/oamucwc

x ABS, Poisoning. ‘4102.0 – Australian Social Trends, 2001’. Abs.gov.au. N.p., 2015. Web. 18 Sept. 2015.

xi ABS, Poisoning. ‘4102.0 – Australian Social Trends, 2001’. Abs.gov.au. N.p., 2015. Web. 18 Sept. 2015.

xiiABS,. ‘4102.0 – Australian Social Trends, 2001’. Abs.gov.au. N.p., 2015. Web. 18 Sept. 2015. http://tinyurl.com/oamucwc

xiii National Safety Council, (NSC). ‘National Safety Council – Death Hazard Ratio’. NSC. N.p., 2015. Web. 18 Sept. 2015.

xiv ‘Special Emergency Response Team (Queensland) | World Public Library – Ebooks | Read Ebooks Online’. Worldlibrary.org. N.p., 2015. Web. 18 Sept. 2015.

xv TheAustralian,. ‘Stolen Tablets Worth $10M To Speed Labs’. N.p., 2015. Web. 18 Sept. 2015.

xvi Australian Federal Police, (AFP). ‘Australian Federal Police – Annual Report’. (AFP). N.p., 2013. Web. 18 Sept. 2015.

xvii Crime Commission Joint Report (ACC) ‘4 Intelligence Operations | Australian Crime Commission’. N.p., 2015. Web. 18 Sept. 2015.

xviii TheAustralian,. ‘Stolen Tablets Worth $10M To Speed Labs’. N.p., 2015. Web. 18 Sept. 2015.

xix Australian Crime Commission. ‘Two Charged, 9.5Kg Of Meth Seized In Perth | Australian Crime Commission’. N.p., 2015. Web. 18 Sept. 2015. http://tinyurl.com/nby7zve

xx Federal Police, (AFP). ‘Amphetamines – Australian Federal Police’. Afp.gov.au. N.p., 2015. Web. 18 Sept. 2015. http://tinyurl.com/owostt3

xxi The Australian,. ‘Stolen Tablets Worth $10M To Speed Labs’. N.p., 2015. Web. 18 Sept. 2015.

xxii ABS- Earnings. ‘6302.0 – Average Weekly Earnings, Australia, May 2015’. N.p., 2015. Web. 18 Sept. 2015. http://tinyurl.com/64r3o4

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About J.Chron.Ltt.&Sci. [JRR]

~CogSc (Humour); NeuroPsych; Philosophy (Death/Identity); Methods (Research); Intelligence/Investigation (Forensic); Medical Error~
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One Response to Why We Don’t Let Pharmacists Prescribe

  1. Pingback: Cognitive Enhancing Drugs & Students | Journey Chronicle in Letters and Science

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