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dangerous drug combinations

Story at-a-glance -

  • Fifty-two percent of Chicago-area pharmacies investigated dispensed drug combinations that could result in stroke, kidney failure, oxygen deprivation, unintended pregnancy, birth defects and other health risks
  • Among the individual pharmacy chains tested, CVS fared the worst, with 63 percent dispensing dangerous drug combinations with no warning to patients
  • Pharmacies are pushing fast service and tracking pharmacists’ speed in filling prescriptions, likely causing them to cut corners on patient safety reviews
 

Pharmacies Miss Half of Dangerous Drug Combos

February 21, 2017 | 28,096 views

By Dr. Mercola

The average American adult took nearly 13 prescription drugs in 2015, according to Kaiser Family Foundation statistics. Seniors (aged 65 and over) took even more; the annual per capita prescription drugs filled at pharmacies was 27 among seniors in 2015, while even U.S. children took an average of four prescriptions each.1

The numbers are alarming not only because of the chronic and acute conditions driving such massive prescription drug usage but also because of the risks of the drugs themselves, particularly when taken in combination. In the U.S., 1 in 5 adults take three or more drugs and 1 in 10 takes five or more.2

Many people depend on their doctors and pharmacies to not prescribe or dispense potentially contraindicated drugs, but doctors are not always aware of all the medications their patients are taking (or their potentially dangerous interactions), and any fail-safes in place at pharmacies are also not measuring up.

In a recent Chicago Tribune investigation of 255 U.S. pharmacies, it turned out that dangerous drug combinations are putting millions of Americans at risk, representing an "industry-wide failure."3

More Than Half of U.S. Pharmacies Sold Dangerous Drug Combinations With No Warning

Chicago Tribune reporters Sam Roe, Ray Long and Karisa King investigated just how often potentially dangerous drug combinations are dispensed at Chicago-area pharmacies without warning to patients.

Fifty-two percent of the pharmacies investigated did just that, handing out drug combinations that could result in stroke, kidney failure, oxygen deprivation, unintended pregnancy, birth defects and other health risks.4

Among the individual pharmacy chains tested, CVS fared the worst, with 63 percent dispensing dangerous drug combinations with no warning to patients. Walgreens ranked the best, but at a 30 percent failure rate still had much room for improvement.5

Others, including Kmart and Costco pharmacies, had a 60 percent failure rate while Walmart failed to warn patients of dangerous drug interactions 43 percent of the time.

Pharmacists Should Have Spotted the 'No Brainer' Dangers

Perhaps worst of all, the dangerous drug combinations presented were "no-brainers," according to pharmacy professor John Horn of the University of Washington, who helped select the drug pairs to test.

The drugs were not new to their market and their ability to cause serious health issues if taken together should have been common knowledge to pharmacists. The prescriptions were presented to pharmacists either together or a couple of days apart, and included dangerous drug combinations such as:6

  • Simvastatin (a cholesterol-lowering drug) and clarithromycin (an antibiotic), which can cause severe breakdown in muscle tissue, kidney failure and potentially death when taken together
  • Tizanidine (a muscle relaxant) and ciprofloxacin (an antibiotic), which can cause heavy sedation, lower blood pressure and loss of consciousness
  • An oral contraceptive and griseofulvin (an anti-fungal), which can lead to unplanned pregnancy as well as cause birth defects
  • Clarithromycin and ergotamine (a migraine drug), which can cause potentially fatal gangrene or stroke
  • Colchicine (a gout medication) and verapamil (for high blood pressure), which can lead to a potentially fatal breakdown of muscle tissue, loss of red and white blood cells and multiple organ failure

The Illinois Department of Financial and Professional Regulation (IDFPR) requires pharmacists to alert the prescribing doctor if a serious interaction risk is detected, to determine if the prescription is correct and whether an alternative is available.

Pharmacists were considered to have "passed" the test if they either contacted the prescribing doctor or warned the reporter about the drug interactions, but in most cases this wasn't done.

Simply stapling an informational sheet to the prescription was not deemed to provide sufficient warning, as many people simply throw the pamphlets away without reading them.7

Are Pharmacists Working Too Fast for Safety?

Pharmacies are increasingly touting fast service, including drive-through windows, to customers, putting pressure on pharmacists to work fast, perhaps faster than can be safely done. It's not unusual for pharmacists to fill hundreds of prescriptions in every shift. In some cases, they may be filling one prescription every two minutes.

In Illinois, drug safety reviews are required in which pharmacists are supposed to check the medication's dosage and whether it could interact with other drugs the patient is taking. But the investigation found many pharmacists were too rushed to complete the review.

It's an issue that likely stretches beyond Illinois borders. The New Hampshire Board of Pharmacy previously found, for instance, that pharmacists spend about 80 seconds per prescription on safety checks.

President Bob Stout told the Tribune, "They're cutting corners where they think they can cut … What happens, I found on the board, is people stop doing [safety] reviews. They're not going in looking at patient records."8

Pharmacies also use computer software designed to flag potential interactions, but the alerts may occur so often that pharmacists start to glaze over them and may miss some of the most important warnings, the Tribune reported.

'Every Prescription Is Timed'

Adding to pharmacists' pressures to move fast are company-wide "scorecards" that track pharmacists' performance based on filling prescriptions on time, responsiveness to voicemails and other tasks.

Many pharmacies also guarantee short wait times and quick service, which is alluring but potentially dangerous to customers. Forty percent of pharmacists working at such stores said they'd made medication errors because they were rushing to fill prescriptions on time.

Further, the Tribune reported on a national survey conducted by the nonprofit Institute for Safe Medication Practices (ISMP), which found two-thirds of pharmacists work at stores that track how long it takes them to fill prescriptions.9

Deepak Chande, a former head pharmacist at an Illinois CVS told the Tribune, "Every prescription is timed, and this is the worst of the pharmacist's nightmares."

He also described a color-coded alert that would pop up on computer screens if pharmacists fell behind on prescriptions. "It's an unreal pressure," he continued. "Your mind is kind of frantically trying to obey it."10

Even at independent pharmacies, problems persisted, not so much via time pressures but due to pressures to stay afloat and compete with larger chains.

Drug Interaction Leads to Stevens-Johnson Syndrome: 1 Woman's Story

The Tribune also covered the story of Becki Conway, who developed Stevens-Johnson Syndrome (SJS) after being prescribed two medications, Lamictal and Depakote, despite a black box warning alerting doctors of the known risk.

In SJS, the patient's immune system attacks their skin and mucous membranes. It begins with flu-like symptoms that progress into a painful purple or red rash that blisters and causes the top layer of your skin to slough off.

This can lead to serious infections, blindness, damage to internal organs, permanent skin damage and even death. Conway was left legally blind and struggles with pain and a constant cough caused by lung injuries.

Her case illustrated how fundamentally broken the system is, as she was failed at multiple points along the way, starting with the prescribing doctor and continuing with the pharmacist who dispensed the drugs and the multiple doctors and nurses who didn't connect her symptoms to the two medications she was taking.

"It starts with a hospital or physician error, then there's a pharmacy error and diagnostic errors, and that becomes the perfect storm," Conway's attorney Andrea Dalton told the Tribune. "At the end of this is someone who has to live with it for the rest of their life."11

Will the Investigation Trigger Pharmacies to Clean Up Their Acts?

In response to the Tribune investigation, CVS, Walgreens and Wal-Mart pharmacies announced they'd be taking steps to improve patient safety at their stores, including streamlining computer alerts so pharmacists see the most important warnings. The companies are also looking into changing the pharmacist's "offer to counsel," which is a legal requirement that some pharmacists meet simply by asking the patient if they have any questions during checkout.

The National Association of Boards of Pharmacy (NABP), an association of pharmacy regulators, is calling on states to require more robust counseling from pharmacists, in addition to public disclosure of pharmacy medication errors. They also proposed setting minimum staffing levels to help ease pharmacists' workloads.12

Addressing the poor health of Americans leading to excessive medication use is an issue all its own. But if you're already on prescription drugs, drug safety needs to become a priority, not an afterthought, especially since the 21st Century Cures Act relaxes FDA standards and makes it easier for experimental drugs and vaccines to come to market without being adequately tested for safety.

Doctors need better methods to prevent prescribing dangerous drug combinations, and pharmacies need stricter monitoring programs to prevent dangerous combinations from being distributed.

Apps like Epocrates, which physicians can use to check for drug interactions, contraindications, black box warnings and more, should help to streamline the process and protect patients, but unfortunately, most dangerous drug interactions are discovered by accident and entirely too late — or are not discovered at all because people may not equate their symptoms to their medications. In some cases, deaths caused by drug interactions may be incorrectly attributed to old age or other underlying health conditions.

Protecting Yourself From Dangerous Medication Errors

Every time you take a medication, ask your doctor and your pharmacist about the side effects and whether it's safe to take with any other medications or supplements you're currently taking.

Many common medications, including antibiotics, antidepressants and cholesterol and high blood pressure meds, can be dangerous if taken in the wrong combinations, so don't simply assume any combination of drugs is safe because your doctor or pharmacist prescribed and dispensed it.

Make a point of asking if the drugs you're prescribed are safe when taken together, and remind both your doctor and the pharmacist about your other medications (including over-the-counter drugs). Ask, and then ask again, and if you experience any unusual symptoms after taking a new combination of drugs, ask your health care providers if the drug combination could be to blame.

Ultimately, however, reducing your reliance on prescription and over-the-counter drugs is your best protection against drug interactions, and this is done foundationally, by leading a healthy lifestyle and taking control of your health.

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