A survey of over 300 synthetic publications published in Organic Process Research & Development over a 10-year period (2001−2010) provides a top-level overview of current synthetic strategies. It reaffirms the widely held view within the pharmaceutical industry that the synthesis of complex, multistage pharmaceuticals is untenable without the use of reactive, potentially mutagenic intermediates and that calls for "avoidance" reflect a lack of awareness of the challenges inherent in modern synthetic chemistry. On the basis of this survey, we can conclude that the average number of steps required to synthesize each active pharmaceutical ingredient (API) was 6 (5.9) and that the average number of reactive intermediates per synthetic route was 4 (4.1). It was also noted that there are four major classes of reactive intermediate that are commonly utilised in the later stages of API syntheses, (i.e., the last four stages): alkyl halides, acid chlorides, aromatic amines, and Michael acceptors. There was minimal usage of highly potent compounds from the "cohort of concern", which suggests that any additional focus on "cohort of concern" would be misplaced. Most of the cited publications gave several different alternative synthetic routes. In all cases there was no evidence to suggest that any of these alternative routes could produce the final API (of typical complexity) without the need to use reactive intermediates at some stage of the synthesis. In addition, the number of reactive intermediates remained broadly similar irrespective of which route was selected, strongly challenging the notion that avoidance was ever a viable option. This again underpins the argument that control, not avoidance or ALARP, is the most appropriate strategy in the overwhelming majority of cases.