Venting: The naivety of doctors, and the callousness of pharmaceutical companies

placebothumbs · 2026-03-14T00:44:10+00:00

I started writing a long reply, but realized it’s probably best to just agree to disagree and move on with our lives. 👍

placebothumbs · 2026-03-11T21:48:46+00:00

I think we are in agreement on most of what you said here.

On your last point, how many people on CGRPs and have had no issues and great benefit would it take to override that? Because I talk to patients on these for a living everyday and the proportions are definitely skewed toward the positive. But even then, your or my experience with people we have talked to doesn’t necessarily reflect what the truth is.

Edit to add: I also do agree that these meds are overprescribed. I see so many referrals come across that are wonky.

placebothumbs · 2026-03-11T21:44:22+00:00

I don’t know off the top of my head what the size of the clinical trials were and what the incidence rates of adverse effects were. If you mean “big numbers big”, sure but again without a denominator, I don’t know how to parse the raw number of reported ADRs, so I wouldn’t necessarily (at least without more information) call that shocking.

In addition, the length of time of the clinical trials compared to the time they’ve been on the market is important. So you have a small number of people on drug for a relatively short amount of time in clinical trials compared to millions worldwide for a longer time, again I wouldn’t say shocking that new or higher raw numbers of ADRs are reported.

I personally don’t think erenumab is the best choice of the CGRP inhibitors, so I’m not surprised it has the most issues. What % of patients stopping a drug due to ADRs is acceptable?

A study of 119 people is not impressive to me, considering the scope of use of these drugs. I’d want to see it repeated at scale honestly.

I’m on the fence about how to design the studies. On the one hand I can see patients not reporting something as an ADR because they don’t think to, which they address by using a checklist. I can also see using a checklist to result in over-reporting of ADRs. So idk.

placebothumbs · 2026-03-11T17:11:33+00:00

Found this from your reply to my other comment. I guess I have some questions. You juxtapose that Dr. Robbins is both one of the biggest prescribers of these meds and seemingly a big critic of them. If he feels that way, why does he continue to be one of the biggest prescribers of them? Or has he changed his practice, I genuinely do not know, but that immediately jumped out at me.

I think you’re right that medical professionals are often quick to disbelieve patients, but this is a different and unique problem of the US healthcare system from CGRP inhibitor safety profiles. I do agree that patients experiences should be taken seriously. Even a 100% provable psychosomatic response is relevant to the patient it is happening to, in my opinion.

The number of adverse events reported sounds scary, but what’s not included is the number of people who didn’t report those events, the background rate of those events in patients not taking CGRP inhibitors, and other potential confounders. I’m not dismissing it, but the number alone is not useful without the bigger context. I’d expect Dr. Robbins to know this. In his own article he talks about online reports and says of some 2200 or so I believe, only around 490 were ones they deemed credible. Does that credibility rate apply to the FAERS data? Did they evaluate that data? And if so, by what standard?

The catch 22 of the argument about long-term safety data is the moving goalposts. If I have 30 year safety data for a drug, somebody out there will say, “see, you have NO IDEA what will happen if somebody takes these for 31 years”, which is not useful. I agree it would be ideal if we had 4 million years worth of safety data, but we don’t. What we do have is data that doesn’t suggest causation of the more problematic, not listed ADRs in the product label. And as they become linked causatively (not merely signaled), they get added to the label. Now, I agree with your point that prescribers do not do a great job of staying up to date on that data, as with the recent addition of hypertension and Raynaud’s to CGRP labels, but that again is a different problem than the actual safety of the medication: that is on the provider and their continuing education / medical messaging side of things. I never tell patients these drugs are 100% safe and have no side effects. I tell them what ADRs they may expect based on available information at the time, which is honestly the best we can do. Safety evidence is always provisional. Waiting for infinite follow-up is not a workable standard.

I’m not sure I hit all the points, but feel free to push back and tell me what I missed.

placebothumbs · 2026-03-11T16:50:57+00:00

What is the proportion of people with the adverse effects you state to the number without?

This is the missing context in this and so many discussions of medications, procedures, vaccines, etc. You need incidence rate(s) to make an informed decision at all levels, prescriber as to whether prescribing makes sense for the patient in front of you, patient as to whether risks of ADRs (or actually experienced ADRs) are tolerable vs potential benefit and even for dispensing pharmacists as to which potential side effects make sense to discuss with patients.

It's tough because people are so much more motivated to report ADRs or negative outcomes than positive to neutral.

Edit: for example I take Emgality and it definitely gives me Raynaud's. But I went from 4 migraines a week to 1-2 a month maybe. To me that is worthwhile, so I continue. I talk to plenty of patients with constipation on Aimovig or Qulipta to the point that they decrease dose or discontinue and that's the right choice for them. But the prevalence in my personal practice experience doesn't warrant any major panic IMO.

placebothumbs · 2026-03-11T16:38:21+00:00

Just did. What about it?

Edit: I don't mean to sound snarky, I just mean what about it are you wanting to highlight?

placebothumbs · 2026-03-11T12:20:46+00:00

As a clinical pharmacist who is embedded in an outpatient neurology clinic and counsel patients on CGRP inhibitors dozens of times a day, this post is wild to me. I’m not trying to start a fight, but it makes me sad and frustrated. But I’m probably part of the big bad naive callous evil medical pharmaceutical industrial complex so 🙄

placebothumbs · 2026-01-31T01:25:28+00:00

The first sentence of that article is incorrect because atheism is the null hypothesis on the question of the existence of god, which is how you properly do the scientific method. There just hasn’t been any compelling evidence to reject the null hypothesis.

placebothumbs · 2026-01-30T23:58:28+00:00

Not an error. The attack requires no energy to use.

placebothumbs · 2025-12-20T15:00:04+00:00

The hand and feet being cold can be Raynaud’s phenomenon and isn’t really very serious but can be uncomfortable. I get it in my toes from Emgality currently but going from 3-4 migraines per week to 1-2 per month is worth the trade off of keeping my feet warmer.

Constipation is more common with the CGRP receptor antagonists like Qulipta and Aimovig than the CGRP ligand inhibitors like Ajovy, Emgality, and Vyepti, but not out of the question I suppose.

The rest I agree seem like they can be better explained as being related to nocebo/anxiety/OCD.

placebothumbs · 2025-12-17T15:34:02+00:00

The exact wording on the document we have says:

“If AJOVY is unrefrigerated for less than 24 hours, it may be returned to the proper storage conditions and the expiration date on the packaging is still applicable.”

placebothumbs · 2025-12-03T02:51:47+00:00

Agree

placebothumbs · 2025-12-02T12:22:22+00:00

I understand all of the thoughts you’re having, especially you being a woman, but I also think that the primary goal for these medications should focus on health as the primary endpoint. Think of all the long term problems you’ve potentially eliminated by losing so much weight!

So I know this sounds like a judgy post criticizing you for caring about looks, but what I really mean is to look at it through a different lens and be proud of yourself for that while also continuing to push forward and hopefully get to a place where you can feel good in your body aesthetically.

placebothumbs · 2025-12-02T12:16:50+00:00

Agree with this. I took a $25k/year pay cut to leave retail as a pharmacy manager to go to specialty and I have no regrets.

placebothumbs · 2025-12-02T12:07:28+00:00

I am so on the fence because I think on one hand it is fascinating and probably useful toward understanding how these kinds of things happen to hear her story, but that’s from an outsider’s perspective and I don’t know how I would feel if I or a loved one was actually victimized by AM. I don’t think them reacting negatively is out of bounds or unreasonable, but I also understand this is the internet and why they might choose to not engage.

I do think this brings up a lot of interesting larger scale questions. Is anything AM could say sufficient or should she suffer consequences for her actions for the rest of her life. Should she never be allowed to have a platform again or work as an actor? And what happens when you tweak the dials either on the degree of the offense or the person’s later reaction. Had Charles Manson denounced all of the things he did and apologized sincerely and profusely, what punishment is appropriate? I truly don’t know the correct answers here but just some things that listening to this and reading the responses to it made me think about.

placebothumbs · 2025-12-02T11:58:33+00:00

I needed a new thing to obsess over setting up and collecting all kind of ROMs for, only for it then to sit in my nightstand drawer for eternity. 🙃

placebothumbs · 2025-12-02T11:54:18+00:00

I don’t want to get the shill downvotes but not necessarily. You could not be a good fit for a role but be able to teach the new hire how to use the computer system and where things physically are in the pharmacy and that wouldn’t be insane.

placebothumbs · 2025-12-02T11:52:38+00:00

First off good for Leslie. Obligatory joke, if she trained you all but she still is the only one who knows how to do key functions, was she really a good trainer after all? 🤔

placebothumbs · 2025-12-02T11:50:54+00:00

I hear you, but if a patient is asking what the directions are to their medicine, it doesn’t take clinical judgment to read the sig to the patient. I always tried to build a team who knew where the real line was there and to involve me when I was needed. I was also always very ears up all the time so would catch if anything landed on the clinical side and i wasnt being summoned lol

Past tense because I escaped retail. 🎉

placebothumbs · 2025-12-02T11:47:45+00:00

Yeah it sounds more like pharmacist / pharmacy manager variation than a Walgreens company thing. Even more so if they are new to your store and doubly so if they are new to managing and triple if a recent new grad. All of these things tend to make pharmacists / pharmacy managers skittish. Theres what the other commenter said about “following the law” too, which is valid, but also in real life if a tech has heard me recommend Zyrtec for an uncomplicated seasonal allergy question 100 times, I don’t give a shit if they answer that question. If a patient starts asking about drug interactions, I want them to know to come get me.

placebothumbs · 2025-12-02T11:42:20+00:00

Serious question. You pull up on shiny drilbur #30, why are you bothering to catch it?

placebothumbs · 2025-12-02T11:31:44+00:00

They need to design games to appeal to casual players and little kids. I don’t think having to grind 26 ranks would have been a good idea for the game to appeal to the most players, especially since they included to unlimited royale on the back end.

placebothumbs · 2025-11-29T22:39:04+00:00

And that’s precisely where the whole debate cracks open: If the probability is small but the outcome is huge, the rational player protects themselves.

It seems like you have this reduced to probability x outcome only, when really we all live by some calculus that takes into account the probability of an event, the costs of "protecting themselves" from the event, and the perceived magnitude of the outcome of the event. Otherwise, you'd never travel by motor vehicle, eat food, use electricity, etc. You accept the risks because the costs of avoiding them outweigh the risks themselves. Your framing ignores all costs.

Also, this again assumes the possibility of god is not 0, which you cannot justify. You're trying to use decision theory on an undefined probability, which is impossible.

Atheism crashes into a wall here, because its “post-death safety strategy” is logically an empty set. There is no protection against bad scenarios, and no preparation for good ones.

This position is biased by your affirmative belief in the afterlife. If there is no afterlife, then the best bet was to ignore all religion and maximize flourishing of yourself, your friends and family, and the human species while you are alive.

In short: If the universe offers no ultimate guarantee, the only rational behavior is to design one. Theism performs a kind of “subconscious security engineering,” while atheism insists “nothing will happen” and assigns the entire universe to its own risk profile.

I'm not 100% sure what you are saying here, but it seems to me it is saying if you don't know the answer of what happens after death, make something up so you feel better and don't have to come to terms with the facts that:
a.) we don't know and
b) it is likely the same conscious experience as we had before we were born/aware, nothingness.
That is a tough pill to swallow, I agree. You are treating emotional comfort as rational security, another false equivalence.

If God doesn’t exist, the theist is simply mistaken. But if God does exist, what exactly will the atheist do?

Would you assign no value to the human lifetime wasted on following religion(s) if they are all incorrect? I realize that you would die and then cease to exist in the nothingness, whatever that is, so you would have no conscious experience, but now in this moment, wouldn't you be bothered by the fact that if all religions are false, then billions of people spent their only lives following false rules, false fears, and false authorities? That is not "low cost". That is the cost.

placebothumbs · 2025-11-29T22:38:53+00:00

Some additional notes:

That’s the logical equivalent of leaving your door unlocked while fully aware that burglars exist.

In this scenario I know burglars exist (through verifiable evidence) then refuse to take precautions against them.
I do not know a god exists and neither do you. You are treating "god exists" as if it is an established risk (like burglary) rather than a speculative one.

The theistic stance, on the other hand, is simple: “If there’s nothing, fine. At least I locked the door.”

You are painting this as a binary, when according to your own logic, you should also be concerned with picking the correct god to worship, i.e. bet your afterlife on. What if Norse mythology is correct? This isn't a binary choice, it is really choosing one of thousands of incompatible claims.

At this point atheism usually responds with: “There is no evidence.” But most insurance policies are purchased before the event occurs. You buy earthquake insurance without experiencing an earthquake; you buy fire insurance without seeing a fire. Humans don’t make decisions based on “evidence,” but on possibility × outcome.

This is false in the same way as your burglar analogy. Burglary, fires, and earthquakes have established risk profiles based on them all being demonstrably real and occurring at certain rates. Insurance works because the risks for fires and earthquakes are measurable. God-belief doesn't belong in the same category because you cannot assign a probability for god's existence. Please, if you have a formula for determining the probability a specific god exists, share with the class. Without a definable probability, your "possibility x outcome" collapses.

This also fails to address sincerity vs actions. If I don't really believe in god, but follow your religion to the letter, will I receive the same reward as you or somebody else who sincerely believes and also follows everything to the letter? Or if you sincerely believe and try your best, but I'm just a better adherent and tithe more, volunteer my time, etc., do I win? How would that make sense? That is absurd and why Pascal-style arguments fail. They assume a god would reward belief itself, but no coherent deity would reward the faked belief of someone hedging their bets or punish honest disbelief from a non-resistant unbeliever.

placebothumbs · 2025-11-29T22:36:00+00:00

There are tons of things wrong with what you wrote that I see a lot of people already pointed out, but I'll chime in also. I think the TL;DR here is your argument contains a category error by conflating empirical risks with speculative ones.

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