Part Two of Upselling Drugs

 I decided to approach one more official body, Otago & Southland District Health Boards. Here is the reply:

  

“The DHB has a contractual relationship with pharmacies and requires ethical standards to be upheld at all times. The DHB is not the correct or appropriate organisation to make judgement on a pharmacist's ethics or actions. I can however provide you my personal views as a pharmacist which hopefully you will find helpful. Your experience of being offered another product with your antibiotic prescription is common practice in New Zealand and around the world.  I ask you the question ... if it had been a different product such as a cough medicine or pain relief, then would your response have been the same?  The pharmacist was offering a product, which in their professional opinion, would have had benefit to the patient.  The product you would have been offered would have been some form of pro-biotic which does have a solid evidence basis for being beneficial when taken with antibiotics.  Ultimately you were provided advice and given a choice.”

In my view this argument still emphasised option above ethics. I remained unconvinced. However, with so much high-powered opposition my conviction was faltering. At this point the practice manager returned to work and restored my faith, at least in one corner of the medical field. 

      

The doctor given the task on behalf of the practice to take up my concerns wrote the following, “which reflect the position of the practice:”  

 

“Offering of probiotics suggests that everyone gets side effects from antibiotics, when this is clearly not the case.

 Offering of probiotics is at best confusing for patients and at worst undermines the credibility of the doctor, by suggesting that the prescribed medicine is somehow ‘bad’ for them.

There is an ethical conflict which arises from the fact that the pharmacy is making money out of selling the product being recommended.

There is a big difference between patients actively seeking pharmacist advice and being offered unsolicited advice.

There are tensions arising from the fact that pharmacists dispense both evidence based medicine and alternative treatments.”  (Though not concerned about pharmacists giving advice about alternative treatments per se, it is important that they make the distinction that it is not an evidence-based treatment).

 

The pharmacy manager’s response is summarised as follows: 

 “Providing advice to patients about the taking of medication is considered an integral part of the pharmacist’s role, including what possible side-effects to expect and in what circumstances they should go back and see their doctor.

Making recommendations about treatments with general health benefits is also part of the pharmacist’s role. This is not intended to be ‘hard sell’ and it is the patient’s decision whether they follow the advice or not.

It is never intended to undermine the advice or treatment made by prescribers.”

Nevertheless, the manager noted that she would be working with the pharmacist involved to address his understanding of how advice should be communicated to customers.

This division of opinion between front-line doctors and patients on one side and everyone else on the other side is surprising and a bit of a worry. Particularly when poor, inarticulate people front up to pharmacists with a prescription for themselves or their children. The “decision” the patient has to make is to waste money on drugs they don’t need or feel guilty for being confused and stingy.  There are clinical and ethical views here, and the real worry is that they may in time be swamped by the clout of a billion dollar industry.

    

Christopher Horan

 

UPSELLING DRUGS. PART ONE.

I caught a virus and a touch of pneumonia. Nothing serious. Nothing to worry about. My doctor prescribed antibiotics and off I went to the pharmacist feeling confident I was being well cared for. After the usual wait the pharmacist gave me a little bottle of antibiotics for $3.00. But at the same time he produced another bottle of pills called Probiotcs, saying, “I always advise patients to take these too because antibiotics kill the good as well as the bad bacteria.” These pills were over $30.00  

I was lost for words for a moment. I didn’t have extra money on me. But that was not my major concern. Whenever I have sought advice from pharmacists I have found them unfailingly helpful, but this was a first; unsolicited advice inconsistent with advice given by my doctor. I found the experience disturbing. How would a person who is hard-up as well as sick respond to this dilemma? The feeling of unease stayed with me.  How much was this a commercial intrusion into the world of medicine? I set out to find out.

First stop: The practice manager of the medical centre I attend. I sent the  following (abbreviated) email entitled "Ethical Issue."

“1. I  did not go to the pharmacist for advice. 
2. The advice he gave me made me question the value of the advice given by the doctor.
3. I have never experienced this kind of unsolicited advice from a chemist before when asked simply to provide prescribed  medicine.
4. I think this indicates that the chemist is abusing the special relationship with your practice for commercial gain. I found the man friendly. Perhaps he was unaware of the ethical issue here. You may not agree. I would appreciate your opinion.” Back came the reply:

“You are correct in pointing out that the situation you experienced raises a number of issues which need to be clarified.”  

So, the matter was now between the pharmacy owner and the practice manager.  But getting a response from the owner of the pharmacy proved difficult partly because the practice manager went on leave and there was some miscommunication. Weeks dragged on until I decided to phone the pharmacy.

I raised my concerns with the manager. She repeated what the pharmacist had said: Antibiotics attack good and bad bacteria and it was common practice to sell Probiotic. "We sell a lot." She was polite but could not see my point of view about the practice being unethical. And so I wrote to the Pharmacy Council of New Zealand. They  replied: 

“The product that you were offered when collecting your prescription for an antibiotic is a service offered by many pharmacists to counter harmful side effects of antibiotics.  The pharmacist is within his/her rights to offer or recommend such a product as long as the patient is given the choice to decline the purchase.”

I wrote to Pharmac and got this reply: “It sounds like your pharmacist was offering you some probiotics.  These are an optional extra to, as your pharmacist explained, keep up the healthy flora in your stomach to reduce the likelihood of stomach upsets as a result of the antibiotics.”

“You can either consider this to be 'upselling' or the pharmacist 'doing his best for his patient' by offering you this option, albeit unsubsidised. Either way, it is allowed for your pharmacist to offer you additional products if they feel they may help your situation.  And you have the right to decline them if you wish.”

 All this was  fine  but  none of it  answered the issue (or the word) I was concerned about. I had asked for a judgement on ethical practice and I was still looking for an answer.

 

 

 

UNDRESSING THE BULLIES.

Given that New Zealand respects civil rights, Wanganui’s banning of gang patches was bound to bring on a protest. But is the argument about the erosion of civil liberties or anarchy versus democracy?

The gangs have clearly not been denied free speech. Their ability to engage in the political, religious and social life enjoyed by other citizens has not been curtailed. In other words, all those democratic rights that we hold dear, rights that are virtually unquestioned in our society, are available to members of gangs.

Gangs are criminal organizations that have set themselves against society and created their own rules. Their customs include grooming ‘prospects’ to commit crimes to earn membership. And the cultural and moral relativity that educated apologists talk about includes gang rape.

But the most disquieting news I gleaned the day after the banning was a 'Morning Report’ item on National Radio. Apparently a handful of mayors had been canvassed for their views. One of them insisted his identity be kept confidential. That, in a nutshell, is why gang patches and democracy are at odds.

WHEN IT SUITS.

I value democracy above most things. For all its faults it seems to be the only system of government that places individual rights above the rights of the police, courts, the church, politicians and other powerful groups. I could argue about the relative merits of social democracy and liberal democracy but not today. What is on my mind today is democracy's failures, and my own double standards when I rejoice in those failures.
For instance, the introduction of MMP. It came in after successive Labour and National governments got carried away with unbridled power. I was delighted with my enhanced ability to participate in the process of democracy, by using my vote to curb these two swaggering old foes. But at the back of my mind was the niggling thought that this victory was threatened by the promised review of MMP. Promise or not, it never happened. Possibly because The House of Representatives began to look genuinely representative, the notion of seriously re examining it was quietly put away.
More recently the ‘smacking referendum,’ which I wanted to fail, proved embarrassingly successful. Again I found myself on the side of expedient politicians who ignored democracy’s call. We may argue about the place of leadership in guiding democracy, and we do, anything to make us feel better. But our words leave a lasting taste of vinegar.
Then we have super-sized Auckland, a project which had little concern for the views of its citizens. It was the views of appointed super citizens that came down like Moses with the blueprint. This august body wanted Maori representation on the super council regardless of the fact that Maori voters don’t seem to care one way or the other. The government said no, leaving the super citizens to ponder the feeling of citizen powerlessness.
I grit my teeth in admitting that I agree with the government yet again on this issue. But I’m left with the feeling that someone’s been shafted.

Good and Faithful.

What follows is for the eyes of blokes only. Women dare not allow themselves to understand this strange male obsession I am about to describe. For to understand would be to threaten the foundations of the economy devoted to women’s clothing. To be precise, I am not talking about all blokes either, only those of a certain age who have for some decades been out of the hunt for women. Blokes who, even if they were still in the hunt would not stand a chance of pulling a woman, any woman. In other words, blokes who are past it.
I want to talk about my brown, woollen jersey that has, with considerable regret, just been laid to rest. If I sit down and think hard, I can just remember all those years back when it was new. Of course, while its newness was a handicap as far as I was concerned, it impressed the hell out of the woman in my family, which is, I concede, the chief function of men’s clothing. I felt uncomfortable wearing my new jersey. So bright and so, well, new. Spotless. I couldn’t drink a cup of tea for fear of that first drip, that inevitable brown stain I would make worse by surreptitiously rubbing with my finger.
“Where’s your new jersey?” I was asked when I tried to glide around the place invisibly in my old jersey. Women notice these things immediately. Hairs growing out of your nose and ears. Eyebrows that are just beginning to enjoy a wild independence. Shirt collars that could, with understanding, go another day or two at least. But most of all, comfortable old jerseys that have, according to the oppressive discrimination of women, become fugitive overstayers.
So, as men do, I lost the battle and wore the new jersey more and more, and after a year or two when it was suitably stained and baggy with a little hole here and there, and no longer exposed to the searing examination of the beady female gaze, it began to feel comfortable. Years passed until my new jersey, it’s fibres pulled by poking nails, wool bleached by countless suns, aroma brewed to perfection by slaking rains, finally felt as though it had grown on me. Even after it had been dragged off my back to be washed from time to time, it was a joy to put on in the morning.
But sadly, the time came when even I found it difficult to distinguish the holes from the neck. That’s when I had to take a deep breath and say farewell to my good and faithful brown jersey. I gave it a decent burial, of course. But still, only the blokes out there will understand my grief.

BOOT CAMP DELUSIONS.

The term ‘boot camp’ is American and does not sit well in the New Zealand context, except that it is tailor-made for deceitful politicians. Boot camps are regimented places of enforced residence designed to change the hearts, minds and behaviour of young people who are out of control. These camps tend to be short-term and usually emphasise self-reliance training. The idea is not new.
Juvenile delinquency is an old problem. John A Lee, who became a writer and member of Michael Joseph Savage’s government, famously escaped from Burnham Industrial School. That institution was opened 1869. Later we had equally large Social Welfare institutions, short and long-term. We had borstals, which were basically youth prisons. We had, and still have, at least one proper youth prison, now masquerading as a ‘corrections facility,’ another strange Americanism. We also have a couple of small Child Youth & Family institutions with razor-wire fences.
In the 1970s on the site of an old TB sanatorium in Central Otago, there was an institution for the “cream of the Justice Department’s young offenders.” Those who were seen as mildly delinquent and capable of change. Alongside these initiatives there were small community homes and foster homes, some still in existence.
In the 1990s Social Welfare tried separating child and youth offenders according to ‘care and protection’ and ‘youth justice’ needs. This too had been tried over a hundred years earlier. And for the second time the boundary between wilful misbehaviour and emotional turmoil crying out for care and protection remained too hard to define.
Until fairly recently we had the ‘short, sharp shock’ treatment of Boot-camp-like Corrective Training. Young offenders 17 years and over were sent to these institutions for three months by District Court judges. When released they were on parole, reporting to a probation officer. Corrective Training was terminated because the recidivism rate was 96%. Conclusion: Short sharp shocks don’t work. Yet this bleak figure should not have been surprising. Short? From anyone’s point of view, three months in a residence away from home is a long time. From an adolescent view of the world it is a lifetime. Shock? Shock tends to fade giving way to familiarity after a couple of weeks. So there was never anything short sharp or shocking. To put the cap on this regime’s failure, most of the young men sent for Corrective Training were old hands. Offending had been part of their lifestyle for years. They were past being shocked by a little regimentation. Furthermore, it is difficult to imagine anything less likely foster rehabilitation than incarcerating like-minded delinquents under the same roof for three months.
Rehabilitation is what everyone is after. No one questions anymore if it is realistic. A S Neil, a talented educationalist in the 1930s and founder of the famous Summerhill School in England emphasised personal freedom, self direction, and happiness. It worked very well with many difficult children who were given their head in his private residential establishment. Newcomers swore, smoked, refused to attend classes, broke windows, were verbally abusive and violent, sometimes for months. But Neil was exceptional. When new students behaved badly, he had the patience and personality to ride it out, knowing boredom would set in and eventually the young wrecker would look for something interesting and constructive to do. Bearing in mind many of his disruptive students were highly intelligent.
Predictably, many who tried to emulate Neil failed. And the lesson for those who fasten onto occasional reports of successful boot camp type experimental schemes is that exceptional charismatic qualities are rarely handed out with management positions.
Boot camps don’t work any more than prison works. But what do we mean by work? When people say ‘it doesn’t work,’ they mean the offender’s beliefs and attitudes are not miraculously changed by the experience. They mean the behaviour of those young men with a predisposition to offend is unchanged by Boot camp or imprisonment. The astonishing thing is that so many people believe in miracles.
So what does work? Growing up works for most people. Adolescents who commit one or two criminal offences are not necessarily destined for a criminal lifestyle; they are simply young men. They usually grow out of it. For the rest, the hard-core, occasionally there are minor miracles that turn them around. Good parents help, or an aunt or uncle or grandparent that takes an interest. Being locked in a cell for a few days, seeing no one but adults with keys, can make a young man think. But the benefit of that thought is lost if he is then returned to his offending peers.
What often works for those at a turning point in their young lives is the Army’s Limited Service Volunteer Scheme at Burnham Military Camp near Christchurch. (In conjunction with Work & Income NZ) A six-week course restricted to young people aged between 17 and 25. Trainees wear military uniform. They have a structure of section, platoon, company. Busy, busy, days from 5.30 am to 10.30 pm. 70% of trainees find employment after this course or go on to further training. That’s success. The catch? The course is voluntary. Trainees are a mixed bag rather than being from a predominantly criminal culture. Obviously the positive tone of the course owes much to this selection mix. Politicians note: It works because it is not compulsory and because there are many ‘good kids’ in the mix.
Poor upbringing has a part to play in creating a considerable number of young offenders. It would take outstanding strength of character for many neglected and abused children to avoid the path that leads to prison. Obviously it is at that level that this issue needs most resources; getting community workers in the houses when the children are toddlers.
But to continue with the fact of youth offending: What, apart from growing up, stops young people offending? 1. The age-old advice to keep good company helps. Good examples from adults and peers can help a youth conform to responsible rather than criminal behaviour, and feel good about 2. Occasionally rehabilitation works. Something ‘clicks’ in a young person’s mind when exposed to a good rehabilitation programme, but only if that person has the potential to change. And that is the key, the inconvenient truth that is rarely acknowledged.
3. The fact is that some young people, and a considerable number of adult prisoners, don’t want to change. They have chosen a criminal lifestyle that gives them a ‘buzz.’ A buzz that leaves ordinary responsible bread-winning in the dust. To these people, gang members included, ordinary life is insufferably boring. They are not going to change. It is the buzz of excitement that makes the blood course through their veins. They will take what society has to offer but they are not going to contribute. They resent a ‘straight’ view of the world being imposed on them. So it makes no sense to waste scarce resources on people determined to reject them. If this one factor about youth and adult offending was acknowledged, rehabilitation resources could be targeted realistically, to people who want to change.

Mid year resolution

Time to get serious and post something at least weekly. Watch this space.