Pharmacy Medication Optimization

Reflections on the Future of Pharmacy

Calvin Knowlton, BScPharm, MDiv, PhD, ScD (Hon) | October 16, 2025

Earlier this month, I was deeply honored to receive the University of Florida College of Pharmacy’s Distinguished Service to the Pharmacy Profession Award. My sincere thanks to Dean Peter Swann and all those involved in the selection process. What follows are my reflections on where our profession has been and where it must go next.

From Adherence to Optimization

Nearly 30 years ago, when I was President of the American Pharmacists Association, many of us embraced patient counseling and encouraged adherence. But soon we realized something critical:

Adherence to a non-optimized regimen often leads to medication misadventures—namely, predictable and preventable adverse drug events (ADEs), which remain the third leading cause of death in the U.S. today.

And it’s more than mortality, it’s also morbidity. ADE-related falls, cognitive decline, and even suicidal ideation seriously affect quality of life and drive significant financial waste.

That realization pivoted my purpose from adherence to optimization of medication regimens, based on science. For the past two decades, I have worked to transform a 75-year-old paradigm of preference-based, “trial and error” prescribing into science-based medication regimens.

Why This Matters

Adverse drug events are not just common; they are a pandemic. According to the Lown Institute:

40%

of older adults take 5+ Rxs (polypharmacy)

20%

of older adults take 10+ Rxs (hyperpolypharmacy)

750

older adults are hospitalized daily for side effects from polypharmacy

400

older adults die daily from predictable, preventable ADEs

Why is this? It wasn’t that way 25 years ago. Why do we have a mindset of a pill for every ill — and sometimes even an invented ill? At least three reasons:

Fragment prescribing: Specialists prescribe appropriately within their own discipline. When multiple specialists are involved, the combined regimens often unknowingly conflict.
Direct-to-Consumer marketing: The U.S. and New Zealand are the only countries that allow direct-to-consumer drug advertising. (In 2022 alone, drug companies spent $7 billion on these ads.)
Misaligned incentives: Pharma continues to be incentivized for volume rather than outcomes. Compounding the issue, the FDA still mostly approves drugs based on whether they outperform a placebo—not whether they’re better than existing treatments.

Even with this “pill-for-every-ill” momentum, since the 1970s, electronic health records and pharmacy systems have been limited to analyzing one drug against one drug—not entire regimens simultaneously using modern science.

It’s time to move on to multi-drug, prospective, simultaneous analytics and mitigation.

A Science-based Action Plan

No one is talking about the current pandemic caused by unoptimized medication regimens. The prevailing strategy remains: just add another pill. It’s time to change that through three science-based action points.

1. Apply the full pharmacotherapy sciences

To truly optimize medication use, we must apply the complete scope of pharmacotherapy sciences, including:

Pharmacodynamics — what the drug does to the body, such as causing sedation or anticholinergic side effects
Pharmacokinetics — what the body does to the drug, primarily working to metabolize and eliminate it as a foreign substance
Pharmacogenomics — how an individual’s genetic makeup influences their response to medications

Together, these layers form an incremental cascade that moves us from preference to personalized, to precision, and ultimately predictive medication regimens. The result? Improved outcomes, fewer adverse outcomes, less waste, and lower costs.

2. Leverage the unique role of pharmacists

Pharmacy is the only profession whose curriculum fully covers pharmacotherapy sciences.

Care teams should leverage the unique role of pharmacists, incentivizing them to effectuate optimized medication regimens with measured outcomes. Collaborative practice protocols—now permitted in every state—empower pharmacists to apply this knowledge prospectively, before the next pill is swallowed.

3. Embrace technological and clinical innovation

Follow the science, and harness innovation from both directions:

Bottom-up: Simultaneous multi-drug, drug–disease, and drug–gene analytics are replacing outdated one-to-one interaction systems—the foundation of our own technology.
Top-down: As generative AI advances, data-driven care will increasingly connect outcomes across complex, comorbid regimens—enhancing the precision and insight of today’s bottom-up models.

The Future of Pharmacy

Pharmacists are the only profession uniquely positioned to identify, mitigate, and reverse the worldwide harms of polypharmacy: predictable and preventable falls, ER visits, hospitalizations, premature mortality, and the enormous waste of financial resources. We must lead the movement to ensure that pharmacotherapy science replaces today’s trial-and-error prescribing.

We are the only profession that fully understands drug disposition sciences, and can apply them through collaborative practice with care teams, and deliver this unique, value-based care across the globe.

We are the only profession that can perform simultaneous, multi-drug and drug-disease analytics—through our current bottom-up approaches, and increasingly, through top-down innovation as AI evolves.

I am thankful for the opportunity to continue this purposeful journey together, working with PACE and hospice care teams across the U.S.