The No. 1 thing patients want to discuss with their pharmacist isn't whether to take their pills before a meal or if their painkillers might be risky. It's the cost of their prescriptions, according to a survey released Thursday by AARP.

And while relentlessly rising medication costs may be at the top of patients' minds, it's an issue pharmacists are least comfortable discussing, the group says.

Of the more than 500 pharmacists surveyed, 76 percent said that customers frequently come to them with questions about drug costs. That's compared with 63 percent who frequently ask about medication side effects and just 37 percent who inquire about appropriate use of prescriptions.

At the same time, 63 percent of pharmacists said they were very comfortable discussing cost with patients, vs. 77 percent to 86 percent who were prepared to talk about safety issues, the survey concludes.

The survey was conducted for AARP by the polling company Harris Interactive, Inc.

It's probably not that pharmacists want to hide price information from customers, experts say. It's that drug pricing is so complicated -- and even sometimes mysterious -- that pharmacists may not know the answers.

"Most pharmacists absolutely went to school to discuss the clinical values of drugs. Today they are increasingly financial analysts," says Gregory D. Wasson, a pharmacist and senior vice president of Walgreen's Co.

Read WebMD's "Drug Industry Pledges New Openness"

Unraveling the Complexity of Drug Pricing

Wasson and others point out that prescriptions almost never travel from the drug company factory straight to the pharmacist waiting to sell them. Today, there's a complex web of wholesalers, distributors, management companies, and other middle men, each with their own formulas for calculating how much to charge for drugs.

By the time a pill bottle reaches the pharmacy, it's probably passed through at least four sets of proverbial "hands" and been paid for at least as many times. On top of that, most pharmacies do business with multiple distributors and benefit managers, meaning that the same drug can easily carry a different price depending on which insurance company or patient is paying for it.

It's no surprise patients have a lot of questions about drug prices. Average wholesale prices for the 197 most frequently used drugs by seniors went up 35 percent between 2000 and 2004, according to AARP. Inflation during the same time period was 12 percent.

"We are seeing prices outrunning the ability to pay," says John Rother, the group's chief lobbyist.

One strategy to cut through the confusion is to promote the use of lower-cost generics. Pharmacists in the survey said that about 60 percent of the prescriptions they fill each day have generic alternatives.

But not all pharmacists support using generics, which according to FDA regulations are exact equivalents of their brand-name counterparts. Less than seven in 10 pharmacists say they support substituting generics in most cases, while a third say they support the practice in every case when a generic is available.

Read WebMD's "More Than 1 in 10 Lack Health Insurance"

By Todd Zwillich, reviewed by Michael W. Smith, MD

SOURCES: Pharmacists' Attitudes and Practices Regarding Generic Drugs, Harris Interactive, Inc., released by AARP, June 9, 2005. Gregory D. Wasson, president, Walgreen's Health Services. John Rother, director of policy and strategy, AARP.