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This book argues that primary care medicine in the United States is in crisis. Drawing on personal experience from the perspective of a solo practitioner of primary care, the book reflects on unfavorable trends in the field that are amenable to repair. It cites examples such as polypharmacy (doctors' propensity to overprescribe) and “poly-doctoring” (the excessive and expensive referral to multiple specialists), as well as the malaise of a malpractice suit facing health care professionals. It also discusses problems in the U.S. health care system, such as lack of access to health care, the staggering price tag of modern technologic medicine, and the growing number of old people. The book blames the sad state of primary care medicine on economists' tenets of maximized efficiency, profit, and productivity. It suggests that American patients deserve ready access to a compassionate, comprehensive, and sustained relationship with their primary care physicians, which this book argues is the backbone of good health care.

This chapter comments on doctors' propensity to overprescribe, a practice known as polypharmacy. Polypharmacy simply means “many drugs,” and may be quite appropriate in certain cases, such as an elderly patient with an end-stage failing heart and requires six or eight medications plus supplemental oxygen therapy. However, too many prescriptions can cause serious allergic reactions and other problems for the patient. The chapter discusses the pitfalls of polypharmacy as well as its implications for the proper usage of pharmacopoeia. It also considers drug therapy as a physician's uniquely tailored form of care for an individual patient, the problem of exorbitant drug prices, the debate over direct advertising by Big Pharma, and the relationship between doctors and “drug reps.” Finally, the chapter emphasizes the important roles of the Food and Drug Administration and primary care physicians in addressing the problems associated with polypharmacy.

In Chapters 3 and 4 the general principles of pharmacokinetics and pharmacodynamics were addressed. This chapter builds on these principles and looks at specific groups and situations. After reading this chapter you should be able to:… ● Identify groups of patients at extra risk of interactions, explain why, and relate this to nursing practice. ● Identify groups of patients at more risk of adverse events from medications, explain why, and relate this to nursing practice. ● Understand why some patients might be at higher risk and how this might be managed…. This chapter will look at a range of patients from the perspective of the nurse administering medicines. Whilst care must be taken when administering medication to any patient, there are groups of patients where the risk of problems occurring as a result of having to take medication are higher and it is therefore even more important to be vigilant. For some patients the treatment will have to be altered to reduce risk. While this is not the responsibility of the student nurse it is their responsibility to be vigilant to changes in the patient and to report this to trained staff. There are some circumstances in which the risk to patients is always higher because the treatment they are receiving carries more risk. For example, patients undergoing cancer chemotherapy are receiving drugs which tend to be highly toxic. While the risk of some degree of harm is high, this is justified by the great benefit that patients can derive. However, it is vital that every effort is made to reduce risk. Similarly there are features of care in acute settings such as operating theatres and intensive care units that could increase the risk to patients (Neale et al, 2001 ). Staff may be under acute pressure, so it becomes harder to follow all the steps in a routine.

This chapter examines the careless use of prescription drugs such as Accutane in what Steve Findlay called “medicine-chest roulette.” In his May 1988 article in the U.S. News and World Report, Findlay reported that an estimated six million Americans experienced adverse drug reactions each year. He argued that pharmaceutical companies could not be blamed for this situation because they met their legal obligation to disclose their products' known side effects to physicians and pharmacists. Instead, he attributed the problem to the failure of physicians and pharmacists to pass on this vital information to their patients. This chapter considers the consumer drug reforms of the 1960s that contributed to the dismantling of the drugstores' traditional market protections. It also discusses the advent of direct-to-consumer advertising; how the dismantling of long-standing limitations on where prescription drugs could be sold and how they could be advertised affected patients and doctors; and how the confluence of aggressive advertising of new drugs, the growing extent of polypharmacy, and regulatory loopholes exacerbated the dangers associated with medicine-chest roulette.

This chapter introduces the concepts of therapeutic polypharmacy and synergy, and their applications to herbal medicines. Chemists and pharmacologists working with cannabis have pioneered research on these concepts for over a century. Therapeutic synergy between phytocannabinoids, such as Δ‎⁹-THC and CBD, is detailed in Chapters 6 and 7. Less research has focused upon the therapeutic synergy generated by terpenoids, flavonoids, and other constituents of cannabis. The chapter reviews studies demonstrating how these constituents enhance the beneficial effects of THC and CBD, and reduce the side effects of THC. Non-phytocannabinoid constituents also impact upon the endocannabinoid system, which includes receptors, ligands, and ligand-metabolizing enzymes. These interactions are pharmacodynamic and pharmacokinetic, and in many cases the mechanism has not been identified.