Scott Gavura – Dispensing Skepticism

This is point of inquiry from Monday, November 25th, 2011. 

Welcome to Point of Inquiry. I’m Karen Stollznow. Point of inquiry is the radio show and podcast of the Center for Inquiry, a think tank advancing reason, science and secular values in public affairs. And at the grassroots. My guest this week is Scott Chavira, a registered pharmacist in Ontario who has a personal and professional interest in improving the way we use medication. Scott started the science based pharmacy blog in 2009 to scrutinize pharmacy practices and to begin a discussion within the industry about its obligations as a health profession. Scott has a Bachelor of Science in Pharmacy Degree and a Masters of Business Administration degree from the University of Toronto. His professional background includes pharmacy work in community, hospital and government settings. Scott is also a contributor to the Skeptic North blog and the science based medicine blog. 

Scott, welcome to Point of Inquiry. Thanks for having me. So I’ve read that there’s a shortage of pharmacists right now, is that actually correct? 

I think that’s hard to give a general answer to that, Karen. I mean, I think that there’s national and there’s regional factors and then there’s kind of overall economic factors that are probably influencing demand. I mean, certainly there can be very big gaps between the regional needs and the supply. What’s really interesting is there’s a number of new roles that are emerging for pharmacists that aren’t aren’t based on the drugstore model that you may be most familiar with where you’ve seen pharmacies before. I think that the expectations for pharmacists are changing even within the pharmacy and pharmacists are gaining new roles. For example, some pharmacists are gaining the ability to provide vaccinations. So there’s some some exciting opportunities out there. The use of drugs is becoming probably more complicated, not easier. And I think that the need for drug specialists will probably continue to grow. 

And I guess this would change across countries as well. 

That’s right. I mean, there is some motility in the market for pharmacists where pharmacists can take their credentials and go to other countries and then seek to be licensed in different countries. And that’s certainly the case where where I am in Canada, where there’s international pharmacy graduates are quite common in pharmacy practice. And I think that’s been a means of addressing what’s been a kind of a prevalent and established shortage of pharmacists and certainly in this part of Canada. 

Okay, well, that clears up a bit for me. And I wanted to ask you about your blog. It’s titled Science Based Pharmacy. So what is science based pharmacy? 

Well, I can give you the short answer is that it’s named after the science based medicine blog, of which I’ve been a fan for a long time. But if I can give you a kind of the complete Air Canada contributor. 

Yes. 

And a contributor now. But to really answer that completely, I think we need to go back. If I can just go back to the pharmacy profession’s roots and pharmacy, actually, as a profession has been around since Roman times when King Frederick the second decided that pharmacy and medicine should be two separate professions, each with their own skills and responsibilities. And he issued an edict that drew a pretty clear distinction between the professions, outline professional responsibilities and the point that emerged at this time. And it is continued is that in exchange for the provision of products and services to patients, pharmacists were granted exclusivity to dispense medications to patients. So there’s some differences around the world. But in general, pharmacy in most countries is a self regulated health profession. 

So has that distinction. Sorry to interject, but has that distinction always been there since that time or not? Has it been some overlapping? 

Well, I mean, as I said, there are different. There are certainly differences that have evolved internationally and in the different countries in terms of how pharmacy is practiced. But in general, pharmacy is a profession unto itself. It’s a pretty clear focus related to the provision of pharmaceuticals. But the nature of the practice itself has has really changed dramatically, certainly probably in the last 50 years, where really from a very technical role, which was the pharmacists original role, was actually just manufacturing medications into one that’s really much more patient focused now, which is the pharmacists responsibility is now responsible for a patient’s drug related needs. So really identifying, preventing and solving drug related problems among the different health professions. It’s only pharmacy that’s really devoted up to the medicines themselves. So the blogger evolved over time as I emerged, as I observed, as have others, that, you know, community pharmacy are the drugstore in which increasingly becoming a place that was selling products that were not it’s not very science based and a little more questionable in terms of their their benefit. And the blog is really focused on the professional expectations of pharmacists and the sale of those products. And I think that the best way to change the pharmacy profession is to change it from within. So I started the blog really to have that discussion as I didn’t see it helping are occurring elsewhere. 

And you just mentioned catering to individuals with pharmacies. And I’m hearing more and more about these compounding pharmacies. So what are they? 

Yeah, like I said, not not too long ago, almost every prescription was custom manufactured or compounded and the pharmacists would take the raw chemicals and make it into a dosage form, like a capsule or a tablet or a liquid or a cream. And compounding allows the complete customization of a prescription, like a new strength of a capsule, you know, making a liquid form or a tablet or a cream that just isn’t available commercially. And with the with the proper equipment, even sterile injectable products can be made. Now, these days, commercial manufacturers supply most drug products and the need for in pharmacy compounding has really, really dwindled. And at the same time, there’s significant amount of regulatory oversight. So, you know, in the United States, it’s the FDA who monitors the manufacturing of drugs to make sure that they’re uniform, that they’re a standardized purity, potency, efficacy, and the safety standards are consistent. But any pharmacy is still capable of providing compounding prescriptions and some specialized calling themselves compounding pharmacy and more aggressively promote that service. So there’s a lot of there’s there’s many legitimate. Needs that exist for compounding. But there’s also the potential conflict of interest if a compounded pharmacy product is being offered without a clear reason, when there are no products that are available that are being manufactured commercially, that are also available. 

They sound very boutique to me in a sense, these compounding pharmacies. But I know that even recently my mother was getting a mixture, made some airdrops that were tailor made for her at the pharmacy. But with these compounding pharmacies, I’m hearing that some are offering some pseudo scientific services like chelation. So is that correct? 

Yeah. Yeah. Just by way of background, I mean, colation collation is the provision of a substance to increase the excretion of heavy metals. And in poisoning situations like LAT or aluminum, colation is medically necessary. It’s objectively effective because you can measure the effect of it and you and it’s approved for use. But the same term has a very different meaning and kind of the alternative medicine universe where proponents often well will support that heavy metal toxicity can be will be the cause of different conditions. And colation can undo microvascular inflammation. It can stop atherosclerosis. It could even reverse aging. 

Mm hmm. I’ve heard people say that it can treat autism and remove toxins in general. 

Yeah. Yeah. There’s there’s a belief among some that autism is simply a manifestation of heavy metal poisoning and that colation can can help. Now, providing colation to patients isn’t straightforward. It’s usually an intravenous infusion. But the products are available. They’re manufactured by pharmacists in pharmacies. And it’s a demand in the marketplace that pharmacies have stepped in to fill. Unfortunately, the objective evidence to suggest this practice is effective is lacking. 

Can it be dangerous? 

Yeah, there’s there’s absolutely dangers that are that are in place. And one of the things that I think is really important that, you know, my role as a pharmacist is is helping patients to weigh the benefits and risks of therapies. And in cases where you have a potential or treated potential treatment that doesn’t provide any objective benefit, then the risks that are related to providing injections certainly become a far, far more prevalent. You don’t have any benefit that’s known then. 

Then and often the weight of the risks becomes far more important because you’re you’re dealing in a situation where you don’t have objective benefits. 

And most cryptics know that pharmacies carry homeopathy and other products for which there’s no evidence that they’re efficacious at all. So what are some of the other questionable products that pharmacies carry today? 

Well, I think it’s important to clarify what we mean by questionable, and I like to look at it in the context of the claims that are made in the evidence base. So if you have a product and you want to sell it and you call it, you know what, they cranberry juice because we all drink cranberry juice and you want to sell cranberry juice, that’s fine. But if you’re going to tell me that your cranberry juice prevents or treat the urinary tract infections, then I think it’s fair to ask for the evidence in cases where there’s a testable claim, homoeopathy is probably an extreme example. And here we have a product with no demonstrated benefit. 

Another one that you see in some countries are your candles, which are sometimes stolen pharmacies which have the not only do they have no benefit, but they also have the added feature that they can cause harm through severe burns. I think when it comes to when you’re looking at whether the products are questionable or not at all. It’s also important distinguish between what’s behind the counter, the prescription products and what’s sold in front of the counter where there’s often very different standards in place. So in general, and I don’t want to generalize too much, but in most countries, the prescription drugs meet fairly strict standards for safety and efficacy, and they can generally only be sold after there’s been a review of clinical evidence as required by the FDA or Health Canada or some other regulator. Different requirements typically exist in most countries for products like supplements or in Canada. They’re called natural health products, which include items like homoeopathy. And anything in that category isn’t subject to the same efficacy and standards. So it really it really can vary, certainly based on what country you’re in and also what where you’re going to find a product. And I think as well, we’d say what was a question or not as well. 

What are the claims being made about it? 

Yeah, yeah, and in Australia, we have a system of registered or licensed products, so I’m not sure if you’re familiar with that, where the registered ones have to be proven to be efficacious and licensed ones. I think it’s just a a form of copyrighting in a sense. So I’m not sure if there’s anything like that in Canada or in the States. I believe there is in Europe because. 

Well, for for the U.S. market, certainly in Canada, we have natural health products, regulations, which emerged as a means of providing some sort of regulatory and licensing structure and products that clearly weren’t prescription drugs, but also were foods either. And so that’s it. AIMS aims to be really a regulatory middle ground where products are held to, above all, a lowered bar of safety and efficacy, but still some more standardization and some oversight beyond what was in place before the regulations, which is essentially no no regulatory oversight. And each country is dealing with it in a different way. 

So I guess the question is regarding pharmacies carrying homeopathy and other goods like that, why? Why is this done? Is it so that it’s consumer driven? What’s why is this actually happening? 

Well, I think if you’re talking about products like homoeopathy, it almost always is. It is a response to demand. And I think that that certainly is a pharmacist. I have a particular problem with that. And I I don’t always blame the pharmacist behind the counter because, you know, pharmacy ownership can change, too. And so the pharmacist who’s working behind the pharmacy counter, maybe an employee has no influence over what’s being sold in the front of the in front of the counter and on the shelves. And if you ask the pharmacist for their scientific opinion, I hope that they’ll give an evidence based one. But certainly I personally find it discomforting to see that homeopathy products are sold in pharmacies and put along on the shelves alongside products that actually have active ingredients. I don’t think that that speaks well for the profession. I think it’s putting you know, it’s putting patient patient autonomy and putting patient care secondary to retailing retailing issues. And I think that that’s that’s a particular issue. I think that pharmacy as a profession has a responsibility to advocate for the, you know, the patient interest and not need to take off its retailing hat and to put on its patient advocacy had in its health care hat. 

And that’s where I see the particular issue with homoeopathy in pharmacies. 

I absolutely agree. And it’s a shame that this tends to lend legitimacy to these products, I think, in the eyes of customers. 

Yeah, I agree. Exactly. 

I think that, as I pointed out, just from the beginning of pharmacy being created as a profession, a pharmacy has the right and responsibility to sell particular products as part of our healthcare system. Then I think it also has a responsibility to decide not to sell specific products when they don’t have any demonstrable benefit. 

And I wanted to ask you about integrative pharmacies as well, they seem to be gaining popularity. I used to live in California and there are a number of these pharmacies that were very popular. And so I’m wondering, what is an integrative pharmacist and what are these new pharmacies? 

Well, yes, we can. 

There’s a long historical trajectory for the integrative pharmacy or the integrative medicine as a practice, and I guess long, long ago, back in the patent medicine days, they used to call on scientific practices, quackery, I guess, and probably emerged at the time when it literally was being snake oil, snake oil that was being sold. But over time, the terminology terminology has changed and new new terms came out. So products gained an alternative label, that is, they were alternatives to medicine and practices. But even the alternative medicine label had problems and there were other terms like unorthodox or nonstandard. And the label became cam complementary and alternative medicine, you know, as a complement to medicine, not a not a replacement. And, you know, you can look at the National Center for Complementary and Alternative Medicine in the U.S. where you are is one example. It started its life as what was called the Office of Unconventional Medicine, and then it became the Office of Alternative Medicine before it took on its new name. So Cam has been the preferred term for several years, but the language continues to change and the new term seems to be integrative medicine or integrative pharmacy, implying that the practices are integrated. I think that when you read integrative, what it generally means is the nonscientific practices are being integrated within ones that are backed by evidence. And that’s really what it is. It’s a marketing term. There’s no specific practice standard that we can say for what makes something an integrative product or an integrative pharmacy. David Gorski’s blogged about this several times, that science based medicine really pointing out even that this really is just a marketing strategy rather than an actual practice. 

Okay. 

It sounds like the euphemism treadmill. It’s Steven Pinker talks about constantly changing names. 

Bakley. Yes. 

So do you ever personally have patients who come in and request folk remedies or complementary medicine and Steed deter them from that? 

I think I mean, I do. 

And I do speak with people who are often very quite quite passionate about these products. And I think in all cases, I think that I try to work with patients to understand their the rationale for the use of certain products and try to understand their motivations. I think at a minimum, I do want to ensure that the products that they’re taking, if I can identify them, are not likely to cause harm or if they’re taking other medications, are not likely to conflict or cause problems with the medications that they’re taking. 

At a minimum, I will try to verify that the safety of those products, at least if I will say, well, I there’s not there isn’t good evidence to suggest this works others. There’s good evidence to suggest this product doesn’t have any benefit when it’s been studied in clinical trials. At least I can provide some sort of assurance related to the safety if they do choose to continue to use it. 

And you’ve said on your blog previously that, paradoxically, the less evidence that exists to support the use of a treatment, the more passionate its supporters become. All seem to be. So have you seen this manifest? 

Well, when you’re speaking with a patient with, you know, HIV or diabetes or high blood pressure, you can objectively evaluate whether those therapies are working. I don’t need them to. They don’t need to want them to work. We can if we can measure the effects objectively. But when it comes to products for which there’s really no clear evidence of efficacy, it really rub people really rely on their own personal experience with products. And I think it’s really important to acknowledge those experiences. You know, I may try to describe kind of the natural history of conditions are nonspecific effects or placebo effects. And that correlation doesn’t doesn’t equal causation. But the personal experience can be very powerful. And I think it’s it’s problematic. It’s challenging to try to overcome that with with patients. I mean, I should point out that this isn’t unique to patients. I see exactly the same behavior at health professionals and pharmacists that will provide products that aren’t backed by good science and attribute their own observations as evidence of efficacy. I mean, I think certainly even my thinking on this has evolved over time as I realized it takes a long time. And I think it takes a real willingness to be very self-critical, to recognize the limitations of your own observations. I think that’s a skeptical rule in general and dealing, recognizing what personal experiences means and recognizing the limitations of our own observations, very, very challenging. And I think that when we’re when we’re talking with patients who who feel very passionately about their products, about their efficacy, then I think that it really I deal with it on kind of a case by case basis with patients in terms of helping them maximize their use and also in being being candid and providing a summary of what the best evidence, says Shaw. 

And over time, have you seen any patients change their opinion? 

I think some in time I believe that in some patients I’ve spoken to about homoeopathy have have believed it to be safe, for example, more like a vaccine. So they look at it as a very small, very small dose and providing some sort of response. But when I point out that the homoeopathy products, the vast majority of them have no active ingredients, it’s because they’ve been diluted far too much for there even to be an active ingredient. And that when I point out that homoeopathy products are. Can can be based around our base. They know fundamentally based on very unsound principles and be very implausible. You can get homoeopathy based on, you know, the color blue or you can get homoeopathy, you know, for mobile phones and you can get homoeopathy from for the light reflecting off of off of the planet Saturn. So, you know, all of these all of these, you know, you can get shipwreck is a homeopathic remedy when you explain it, when you go to these products and you describe them, you know, some people who are who really hadn’t thought too much about what homoeopathy was. They see it immediately for, you know, for for what it is. And other people are very, very passionate and feel very strongly that homeopathy is effective for them. And, you know, I think that’s my role to ensure that if, you know, if I’m asked to have the opportunity, I will provide a summary of what the evidence says about it. So, yeah, people people can change their mind. And I think it’s an ongoing issue of engagement and talking about, you know, motivations for treatment and expectations. I think that’s in all cases, it’s pharmacist responsibility, at least to be absolutely candid when it comes to what the evidence says. 

Sean, it seems like you’re putting a gradual dent into the industry. That’s very good. Well, I’m trying I think we all are in our own way. And speaking of of these alternative therapies, a lot of pharmacies carry supplements were in fact, I think most do. So what’s your position on taking supplements? Should this only be when their doctor prescribed, like, iron for anemia? Or what’s your stance on that? 

I think it depends on the rationale and why. 

Why would you why are we taking a particular supplement? I mean, we need to base each decision on the, you know, what’s the intent? So if you came in to me and said you wanted to take you know, you wanted a recommendation for vitamins. And I said, well, why do you want. Why do I want to take vitamins? You said, well, I’m feeling run down and I need a boost. But that’s your rationale for taking multi vitamins. I caution you that Valdek multivitamins don’t boost your energy. But if you told me that, you said, well, I’m thinking I might possibly become pregnant in the next year or two, I might have a different opinion. And I’d suggest that you would consider taking a prenatal prenatal vitamin simply because the fat benefits from folic acid in reducing the risk of neural tube defects is well documented. It’s important you have to really be taking the vitamin well in advance. I think in most cases, if you want to take a vitamin for insurance, which is a lot, you know, a lot of people just want to take it because they just believe that they may have dietary shortcomings. So I think it takes a short evaluation of dietary practices, but most people who eat a normal diet don’t have a big need for multivitamins. Think the science supporting routine supplementation with vitamin and otherwise healthy people is generally lacking. There’s no great evidence to show that they reduce the risk of heart disease or cancer. And the science supporting those big doses is even more questionable. There’s some signs that they may things that may cause harm as well. 

And you just mentioned folic acid. You’ve also written a lot about the fortification of foods, fortified foods, helping or hurting us? 

Well, I don’t know of any specific issues with food fortification, but it’s a question that’s kind of emerged from the literature on whether the does fortification cost benefits in one group and home to another. And I think it’s I think about it in the context of people who are seeking to supplement further in people with vitamins and folic acid is the example. You can also type of calcium as well. So we have like really good evidence to demonstrate that folic acid reduces the risk of neural tube defects. It’s a substantial effect. It’s it’s unquestioned from from the literature. And by fortifying the food supply, we’ve got good evidence to show that there’s a beneficial effect at the population level. But when it when it comes to other diseases, there’s a correlation, say, between, you know, diets, rates and diets that are rich in fruits and vegetables with with a lower risk of, you know, diseases like colorectal cancer. And based on the epidemiologic evidence, there’s been randomized trials that have been initiated looking at the effects of B vitamins, including folic acid on cancer risk. But the effects don’t seem to be as expected. The science is still unclear, but it’s certainly worrying that there could be increased risks from specific supplementation in some populations I think would be difficult to establish that fortification is causing harm. And in fact, I don’t believe that it necessarily is. But it really does factor into my advice to patients who are seeking advice on, say, supplements. So if there’s no clear evidence for benefits with folic acid supplements, say, in seniors’ or in males, then a cautious approach might be to say, well, you know, if you want to take a multimode vitamin, you know, maybe you don’t need to be taking one with a whole lot of folic acid. It’s fortified in our food supply and we don’t have great evidence to show that it actually is going to provide you with any benefit, nor is there any sign that there’s any clear deficiencies in males. So there’s probably not a lot of rationale for supplementing further. 

Okay. And I was also wondering, does it always make a difference? Was thinking in terms of vitamin D? I’ve read previously that sometimes the doses in fortified foods like milk are so low that they don’t really make any difference. 

Well, I don’t. I mean, I think vitamin D is an interesting, interesting case study. 

I mean, I think that there’s good evidence to demonstrate that most people particularism in, you know, in areas where they don’t get a lot of sun exposure and particularly seasonally probably would benefit from some vitamin D supplementation. I think that’s what we’re seeing where the evidence is going. I mean, I think that there’s there is vitamin D fortification. I think in, you know, with milk, for example, in the products. And so but in some cases, that may not be adequate. We may see that change over time. And I think we really need to have that informed by, you know, really by good evidence to suggest what the appropriate amounts should be. 

So anything helps, really? Yeah, something like that. Yes, certainly. 

In in general, is it always better to get off Ottomans from diet rather than supplementation? 

I think in most cases, yes. 

I mean, the data demonstrating really positive health outcomes are largely based on analyzing diets, not on supplements. And we don’t necessarily know that isolating and extracting specific ingredients into supplements, that we’re actually maybe eliminating the beneficial components. And, you know, many supplements are produced and sold based on this extrapolation. There’s been some interesting data linking that supplement consumption linked to worse dietary behavior as well. That is that people taking supplements may be more likely to make bad dietary decisions and that they they had they’re taking these supplements. So they they feel invincible, I guess. So, I mean, I think that based on you know, based on the overall evidence, I think that’s probably the best recommendation is to have a, you know, a good diet with lots of fruits and particularly vegetables, but should be able to provide most people with adequate amounts of vitamins. In most cases, there’s not really good evidence to support routine supplementation. I mean, I think that vitamin D supplementation, I mean, the best way to get it is probably if you need to take more as probably as a supplement compared to, you know, sun exposure, which has additional risks. And I think that when we supplement, we really need to consider the risks of the benefits and what’s the most effective way to do that. And I think specific supplementation really needs to be based on kind of individual clinical circumstances. 

I would agree with that, but I can see people taking a multivitamin every day and then the stadium with Donaldson and thinking they’re getting all of their vitamins. 

Yeah. And I think that that’s that’s that’s very, very common. And I think that I would try to emphasize with people that they really should. You know, if they’ve got the choice between tape buying a really expensive, expensive, multiple, multiple vitamin say that they’ve been recommended or spending on food, that they’re probably better off spending it on something like kale and eating that, where I think that the benefits are probably more likely than you would from any particular vitamin Fishell. 

And you’ve written about placebo prescriptions in the past, and I didn’t know those actually existed. So what is the case here? 

Yeah, it’s really quite interesting. I’ve been in pharmacy for almost 20 years and I’ve never seen an actual pure placebo and where, you know, the patient was actually actively being deceived by both the physician and the pharmacist. And I think it’s important to point out that there’s two different kinds of placebos that we can talk about as placebo prescription. So the first ones are the, you know, the pure placebos. Those are the ones that have no active ingredient. So those are the sugar pills salian injections. 

And you almost told me how homeopathy. There’s no active. 

Yeah, no. No active ingredient. Then I would say that we have impure placebos, which are products contain active ingredients, but they’re not effective for the condition being true. So that could be because of a low dose or the active ingredient doesn’t have any effect against the condition. So, you know, if you have a cold, a viral infection and you’re prescribed an antibiotic, that would have no effect on that or even the less dilute homeopathic products may have, you know, a small amount of an ingredient in it. But there wouldn’t be any effect because based on the way that we would know from the pharmacology and the effectiveness of that particular ingredient on the on the condition being treated. So, I mean, I think that that the prevalence numbers may are sometimes hard to tease out because we don’t know that an antibiotic prescription to necessarily beneficial or not at the time. So, you know, I blogged about this earlier this year and I certainly some pharmacists did comment that they had they had provided it. So it seems to be uncommon, but it’s definitely still happening, which did surprise me. And I was even surprised to see that there are some impressive looking, commercially manufactured placebos out there. 

Paul Fidalgo. Absolutely. Ask. I’ve seen lots. 

And I mean, I guess I guess a pharmacy could compound those. So I could take empty capsules and fill them with, you know, with talc or lactose and provide them. But interestingly, there’s been some surveys and I had reviewed a paper and David Goreski, science based medicine, reviewed some papers on surveys related to the prescription of placebos. And certainly that the the number of times that had occurred at least once was quite high, over 50 percent. And a lot of these groups, which really surprised me. But there’s definitely enough data to suggest a deliberate push. Placebo prescribing is taking place. And I think it’s with some probably with some ethical discomfort for a lot of prescribers. 

I would hope so, yeah. I’ve just got a few practical general questions about pharmacies and pharmaceuticals. I guess this is a big question. I had recently in a pharmacy myself on generic drugs, the same as brand name drugs. 

I think in most cases the answer is, is a clear yes. I mean, let’s consider how both these drug, how drugs are approved. So if we look at a brand name drug or a patented drug, the patented drug is tested in clinical trials and those clinical trials are evaluated. And there’s a decision made that Drug X is effective for condition Y and that drug is approved and allowed for sale. So the generic company comes along with the patent on that particular drug expires. What’s the manufacturer of that generic product needs to do is demonstrate that they have the same active ingredient. So if it say you’re Tylenol capsules, the acetaminophen inside, and then what the generic manufacturer needs to do is show that their products is just as pure. It’s the same active ingredient. It dissolves at the same rate. It’s absorbed in the same manner as the original product. And so those tests showing the absorption and the extent of exhaustion are evaluated by regulators. And that’s what the drug is approved based on. So a generic drug is based on a comparison to the brand name drug. And so in almost all cases, the generic drug should behave exactly the same way in the body as the brand name drug. There may be slight differences in kind of the formulation or the color of the tablet in the capital, but in effect, once that drug is dissolved and absorb should be indistinguishable from the brand name product in the body. 

OK. And I think you said on your blog that seven out of 10 prescriptions filled for generic drugs. 

Yes, it does vary, it varies based on the country. 

Certainly in most of Canada, what we have is most of the drug plans require what’s called mandatory generic substitution. That is, if there’s a generic drug that’s available and it’s deemed to be interchangeable or substitutable, then the generic drug is provided to the patient automatically. And a lot of insurance plans will pay for the brand name drug once the generic drug is approved. So most patients will be switched to the generic drug. The first prescription after the drug loses its patent protection. So it’s it’s the effects are dramatic and sustained. So the brand name drug market share drops dramatically in other countries. They’re made they may not have those rules for mandatory generic substitution. So it really does vary based on the rules around pharmacy practice. 

Great. Well, thank you for setting that straight to. And another question. Is it safe to use medication past its use by date? 

Well, I think we should talk a little bit about where these expatriates come from, the expiry date is really calculated based on testing by the manufacturer, and they will do accelerated tests of the product to look at the decay. So we’ll use heat, light, different conditions. So basically try to see how quickly the drug degrades in. In most cases, if a drug is slightly passed its expiry date, it may be less effective. I mean, I never recommend using a drug beyond its expiry date because I always assume, you know, that the drug may not have been stored under the optimal conditions. So you may hope patients may keep it in their bathroom where it could be exposed to humidity or they may keep it in some other place where the temperature controls are not as ideal. And so, you know, that expiry date on the packages is very conservative. But it’s also assuming you’re starring in it appropriately. In most cases, it’s very unlikely that it will that necessarily cause harm. And in some drugs actually decay or at least one tetracycline has been reported to cause to actually decay into an ingredient that’s more toxic. I think in most cases I would suggest that people would not use drugs that are expired. And also on emphasize that almost all pharmacies will take expired drugs so they can actually be disposed of properly. But don’t throw them into the water supply, please. 

Yeah, that was to be my next question. We flushed them down the toilet or not. 

No, please do not come out. 

Every pharmacy will accept expired drugs and they will that they are sent for incineration so that they do not end up in our water supply. 

And I wanted to mention the pharmacy museum in UOL Will. I’m not sure if you’ve ever been there before, but I’ve been there. 

I think it’s fascinating. 

Oh, it’s brilliant. I love it. And I went there recently during Psychon on the conference for CSI, and they had this big leach jar on display, which I found fascinating. And I understand that they used in modern medicine, again, in different ways for removing congested blood from wounds and things like that. But is there anything else old that’s new again in in pharmacy? 

I think that this is probably the most exciting area, certainly for me in pharmacy. 

And this is as we’re moving into an area of of truly personalized medicine. And I think that that’s where we’re seeing a lot of therapies that I think we thought in the past were not effective or we couldn’t use them safely and they’d been pulled off the market. They are emerging back as as potentially very promising therapies. And I think that the one that I think is most fascinating is the case of thalidomide, which most people are familiar with, which is developed as a as a sedative in the 50s and was taken off the market because of its horrible throughout agentic effects. But it’s actually been found to be quite effective for the treatment of cancers like multiple myeloma. So here’s a here’s a drug which has demonstrable harm. Absolutely horrific. And, you know, the case of thalidomide really resulted in really a complete overhaul in the way that, you know, that many countries review and approve drugs and resulted in, in many cases in safety standards that we have in place now. But it’s been found through ongoing experimentation that this particular product may have seemed to have a very important role. And there’s no drugs being developed that are based on the little amide that are also having a role in cancer. 

Right. I’m going to ask you if that’s thalidomide in in that current form or if it’s a component of it? 

Well, there it’s the Silin might in its current form, but there’s also another drug that’s used for cancer as well. That’s a that’s very structurally very similar to thalidomide as well. Another one that we could look at would be arsenic, which was used a long time ago for the treatment of syphilis. But it’s now used in the form of arsenic trioxide to treat certain kind of leukemia. So I think it’s pretty fascinating. We can also look at, you know, there’s there’s drugs that have there’s a drug that was on the market and in the past for treating lung cancer, which was, you know, removed from America because it was felt to be very effective and subsequently through actually identifying which patients do respond. There’s a, you know, a test, the tumor test. It’s been developed so that drug can actually be used and seems to be effective. And so it may be that there are drugs that we had concluded were ineffective. But if we can identify upfront which patients actually would respond, then we can give the dragging in patients who will respond and not give it to the patients who either won’t work or may cause harm. So I think that that’s actually really a really exciting aspect of kind of medicine and pharmacy practice and how it’s going as we’re going into the era of, you know, genetic sequencing and genomic medicine. 

I’ve just got one final question, and this is the most important of all of them, I think. How are you trained to read doctor’s handwriting? 

You need to know what you’re looking for. And I think that it is the only time I I think that a lot of prescriptions are still written in very in. 

In Latin abbreviations. And so in most cases, we can we can identify what it is. And if we don’t, we have to call the physician. I think that the era of the badly written prescription is slowly closing as we move into an era of using computer prescriptions and computer generated prescriptions and and instructions being written in plain English. 

I think that we will still see the Latin for some time, but it’s I guess it’s a learned skill. And I admit that I sometimes had a difficulty myself, and that’s what I have to contact the prescriber and ask what exactly as they were writing. 

I’ve always wondered about that. Well, Scott, thank you so much for joining me today. It’s been a pleasure to speak with you. 

I’ve enjoyed it. I’m a big fan of the show. 

Thank you for listening to this episode of Point of Inquiry, all views expressed by Scott Chavira. His personal views alone and do not represent the opinions of any current or former employers or any organizations that he may be affiliated with. All information is provided for discussion purposes only and should not be used as a replacement for consultation with a licensed and accredited health professional. Scott Caviars articles can be read at science based pharmacy, dot WordPress, dot com and science based medicine dot org to participate in the online conversation about this show. Please join our discussion forum at point of inquiry dot org. The views expressed on point of inquiry aren’t necessarily the views of the Center for Inquiry n affiliated organizations. Questions and comments on today’s show can be sent to feedback at point of inquiry. Dot org. 

Point of inquiry is produced by Adam Isaac in Amherst, New York. And our music is composed by Emmy Award winning Mike Whalen. Today’s show also featured contributions from Debbie Goddard. I’m your host, Karen Stollznow.