Central to the nature of social meanings afforded to medications is the ascription of their relative risk and toxicity. This is a key aspect of Barber’s pharmaceutical gaze whereby pharmacists are able ‘to see’ into the properties of medicines and predict their potential effects. Barber’s conceptualisation does not, however, place an emphasis on the specificities of the individual patient body through which, and within which, these potential effects occur. Although he notes that pharmacokinetics historically enabled hospital pharmacists to control risk, he suggests that pharmacy practice ‘is not based on parts of the body…manipulating, cutting or caring for the body’ (Barber, 2005). Ryan et al. (2004) argue in contrast that an analysis of the body in pharmacy is needed and the data presented here suggest that the potential (adverse) effects of drugs cannot be so easily separated from the biological patient body upon which they are acting. Hence, through the process of making medicines meaningful, pharmacists also make the patient body pharmacologically meaningful by constructing them, and in so doing gazing at them, as at-risk medications users. This co-construction of medications and patient bodies creates a need for medications and at-risk medications users to be expertly managed by the pharmacist through the employment of a discourse of toxicity.
This discourse of toxicity is centred on the way in which potential drug toxicity is communicated to patients and managed through the characteristics of pharmacy practice. The data suggest that there are two key ways in which this discourse of toxicity is manifested in routine pharmacy practice; through the timing and location of drug dispensing and administration.
The timing of medicinal interventions is central to pharmacy’s management of toxicity and ensuring drug effectiveness. This timing is practised in a sequential and cyclical model whereby medications administration is located at a specific point within a sequence of clinical interventions in order to offer maximum effectiveness, as Hospital Pharmacist 9 (an Oncology pharmacist) says:
166
“Because there is a risk of anaphylaxis with it and the risk is reduced over time so if patients are okay after the first three cycles or whatever then they should be reasonably okay after that” (HP9- Oncology)
In communicating the importance of drug timing to patients through the discourse of toxicity, pharmacists ascribe sociality to medications by locating them within the patient’s ‘lifeworld’. In doing so, medicines become meaningful through the management of the risks associated with them by becoming a part of the patient’s wider social and cultural practices, such as being re-configured as part of meals or an evening regime. Through this reconfiguration as social objects, it is thought that increased adherence to medications regimes can be achieved. Adherence to medications regimes has been highlighted elsewhere as being a particular challenge for pharmacists and other healthcare professionals (Farmer, 2010). Farmer (2010) notes that a lack of adherence with medications can be due to a medication regime being understood by patients as sitting outside of their normal lifeworld. This is central to the discursive shift towards medicines optimisation where patient involvement in medications decisions is centralised as a way in which the use and management of medicines can be optimised through increased patient engagement (Cutler, 2011; Stephens, 2011). Given this, by mobilising practices which counsel patients extensively and locate therapy regimes within a patient’s normal routine, pharmacists are able to contribute to the improvement of adherence and, subsequently, patient outcomes, as Hospital Pharmacist 1 highlights:
“They’ve divided up into time periods to help them take their medicines at the right time” (HP 1- Chief Pharmacist)
This management of medicines timing is particularly important and highly centralised in the discourse of toxicity where the risk of ADRs is particularly high. Here, the dispensing of Oncology drugs is accompanied by relatively extensive counselling practices, as Hospital Pharmacist 3 (an Oncology pharmacist) notes:
167
“So the pharmacy staff, when they’re handing over prescriptions, will be doing a certain amount of patient counselling about how many tablets to take, how to take them, should they be taking them with food, after food” (HP 3- Oncology)
Hospital Pharmacist 3’s comment here, and much of the focus on timing in the discourse of toxicity, is located around discharge practices. Hence, much of the focus is on the effective timing of taking hospital drugs in community settings. The data also show that the location in which drugs are dispensed and administered is central to their ontological status. Here, the discourse of toxicity creates a distinction between primary and secondary care drugs vis-a-vis their potential toxicity and the expertise necessary to manage this toxicity.
In this distinction, primary care drugs, and the healthcare practitioners that routinely practise with them, become associated with what are perceived to be simple, common ailments that can be effectively managed with minimal risk of toxicity. Secondary care drugs, on the other hand, are ontologically associated with complex diseases and polypharmacy regimes which mobilise comparably toxic medicinal interventions.
Such toxicity of secondary care drugs is managed in the hospital setting by being contained within the physical boundaries of the hospital and the co-location of different practices within it. This is in contrast to the primary care setting where such toxicity cannot be easily contained within one environment as practitioners (most notably GPs and pharmacists) are geographically dispersed and do not practice as bioclinical collectives as do those in hospital-base settings.
Given this ontological and discursive binary between primary and secondary care drugs, healthcare practitioners working within each sector cultivate a particular set of expertise around the diseases and medications that they routinely encounter. In this way, boundaries are drawn between the knowledge and work of GPs and hospital doctors and community and hospital pharmacists, as the quotes below demonstrate.
168
“Community pharmacists don’t even deal very much with cancer drugs. That’s still secondary care” (CP 8)
“GPs are not happy about sharing responsibility for prescribing and monitoring these patients. They want to stick with what they know - diabetes, hypertension. They don’t want to see patients, generally I’m talking and there will be the occasional GP who might be happy but by and large they perceive oncology as being high-tech, complex, complicated” (HP 9-Oncology)
“There is quite a big gap at the moment but we shouldn’t forget that these patients are not only treated for the condition that they get all singing all dancing medicines for they’ve also got general medical conditions… And they will be getting treated by their GP and getting their medicines from the community pharmacy for a whole wide range of things as well as specialist care” (HP 6- Director of Pharmacy)
This discursive binary between hospital and community medical and pharmacy practices around the notion of complexity (both disease and drug) is, arguably, increasingly blurred as more patients are managed through shared care arrangements and hospital drugs are increasingly administered in community settings. One particular example here is the breast cancer drug Herceptin14 which is increasingly prescribed in hospitals but administered in patient’s homes in the community. Nevertheless, Herceptin is prescribed for a relatively complex disease and, due to it often being used as an adjunct therapy with traditional chemotherapy, reflects this complexity in regard to its potential toxicity and managing adverse effects. Given this, timing remains integral to the management of toxicity that surrounds this therapy, as Hospital Pharmacist 9 (an Oncology pharmacist) highlights below.
14 This drug is described by Hedgecoe (2004) as the first example of a pharmacogenetic drug in
routine clinical practice. In the present discussion, however, the pharmacogenetic status of Herceptin is purely coincidental and not related to the argument at hand.
169
“Those drugs [Herceptin] were then made up by the third party supplier and then they were transported by the nurse to the patient’s home at a predetermined time, predetermined date” (HP 9-Oncology)
Moreover, this quote demonstrates that although the binary between hospital and community medicine is somewhat blurred, there is still a degree of boundary work being carried out around the management of Herceptin’s toxicity. As such, only practitioners with expertise in this area (in this case a specialist oncology nurse) are able to interact with this medication and the patient as a user of it. Such expertise moves beyond the confines of the hospital into the wider community setting, accompanying and enabling the movement of the drug. This suggests that the hospital regime for toxicity management is embedded within the drug itself. As a result, when the drug moves to the community setting, it carries the medicines management regime of the hospital with it, which brings secondary care drug ontology and primary care cultural practices together into the patient experience of drug taking.
These anxieties, grounded in discourses of complexity, and the boundary work they necessitate provide a useful framework for analysing the potential implementation of PGx technologies. As Community Pharmacist 6 highlights, at present there is an alignment between PGx principles and practices with highly specialised hospital-based fields which are routinely utilising relatively complex medications:
“I think there’s an assumption that it’s [pharmacogenetic medicine] very much secondary care led therefore you wouldn’t necessarily see that in the community and an assumption that it’s very specialist” (CP 6).
The role of disease and drug complexity in affecting the implementation of pharmacogenetics in hospital and community pharmacy practice is discussed in more detail Chapter Eight.
170