Why Pharmacists Should Drop Products That Aren't Backed By Evidence

If you look at the shelves of most Australian community pharmacies or browse the pages of local internet pharmacies, you'll see numerous examples of products making claims that can't be supported by scientific evidence.

Pharmacy picture from Shutterstock

These include an increasing proliferation of homeopathic medicines, weight-loss products with names such SensaSlim, Undoit and Fat Blaster Reducta, products to enhance sexual prowess such as Horny Goat Weed (for both him and her) and numerous vitamin and mineral combinations.

But why do pharmacies stock, promote and sell these products when pharmacists are trained scientists? The short answer is that they are profitable. Some pharmacists have told me:

The products are heavily promoted, consequently people want them and if we didn't stock them customers would simply go elsewhere. In addition, we can provide advice if asked.

Others point out that the decision to stock is often made by the pharmacy owner or group buying chain and has nothing to do with the in-store pharmacist who dispenses scripts and gives advice. Such policies can extend to protocols aimed at up-selling complementary medicines of dubious value to customers getting certain prescriptions filled.

A Pharmacy Guild – Blackmores partnership along these lines was short lived but the practice still appears common. Recent research has shown that pharmacies that recommend the most complementary medicines to customers provide companion sale protocols to their staff.

As one respondent to this research said:

It's all written down in the [pharmacy group] protocols, so if you work for [pharmacy group] you're expected to follow this.

Other pharmacies, particularly large discount chains with an internet presence, point out that they stock thousands of, often short-lived, products and they cannot, and should not, be expected to research which ones are evidence-based and which are not. They have said to me:

Sorting out evidence-based products should be the job of the Therapeutic Goods Administration (TGA).

But the listing process of the TGA does not assess the efficacy complementary medicines. In addition, the Therapeutic Goods Advertising Complaint Resolution Panel (CRP) has clearly said that information on retailer websites is the responsibility of the website publisher.

There is clearly a conflict between the need for pharmacists to maintain a profitable business and their ethical obligations to the community.

In 2003 the Pharmacy Board of NSW said:

The community holds pharmacists in especially high regard and places its trust in pharmacists' professional judgment, and relies on pharmacists' professional advice.

Because a recommendation by a pharmacist for any medicine gives that medicine special credibility, it's essential that the recommendation is based on sound scientific evidence. Indeed, the trust in pharmacists and pharmacies is such that, simply because a medicine is available in a pharmacy, consumers will infer that it carries the pharmacist's endorsement and recommendation.

So pharmacists must be personally persuaded of the safety and effectiveness of the medicines (and other therapeutic goods) available in their pharmacies.

These principles have been reiterated by the new Pharmacy Board of Australia. Its Code of Conduct for Registered Health Practitioners states that providing good care includes:

Practising in accordance with the current and accepted evidence base of the health profession, including clinical outcomes.

And its Guidelines for Advertising of Regulated Health Services state:

A person (or business) must not advertise a regulated health service in a way that is (a) false, misleading or deceptive or is likely to be misleading or deceptive; or (d) creates an unreasonable expectation of beneficial treatment.

Several complaints have now been submitted to the Pharmacy Board of Australia about pharmacists who continue to make claims about products that had been shown to be false, misleading and deceptive by federal court orders and CRP determinations, even after these products were delisted by the TGA. No response has yet been received.

In October 2011, the Pharmacy Board said:

This being the first year of the National Scheme, the Board has taken a largely educative approach to help practitioners understand the law and the new requirements set down in its advertising guidelines. The coming year will see a more structured approach to addressing concerns about advertising. This will include an escalating series of warnings to practitioners, initially reminding them of their obligations about advertising and ultimately, possible prosecution for non-compliance with the board's standards.

In June 2012, it reiterated the obligations of pharmacists under the National Law and noted a changing focus from education to compliance. But no change in behaviour has been apparent to date. It's time pharmacists were prosecuted for non-compliance with their board's standards.

Dr Ken Harvey is Adjunct Associate Professor of Public Health at La Trobe University. He has collaborated with pharmacists in research, publications and teaching over many years. He been paid by the Pharmaceutical Society of Australia to give CME presentations on Evidence Based Complementary Medicines. He lurks and occasionally contributes to the pharmacist discussion forum: http://auspharmlist.net.au/.

The ConversationThis article was originally published at The Conversation. Read the original article.


Comments

    The shelves would be empty...

      So you're saying it's better to fill them with things that are pure quackery and do anything but what they claim, diverting people away from real medicine that can actually be helpful, than it is to have a smaller shop or empty shelves?

    Pharmacists are "trained scientists" bwaaahh hahah haaaaaa!

    How often do you speak to the pharmacist in a pharmacy? Usually its someone much further down the seniority list that makes a case to you for buying some bottle of wonder tonic with unsubstantiated outcomes.

      Agreed, very rarely will people actually talk to the pharmacist themself - most of the time they'll only talk to a sales assistant who has had no training other than in actual sales, not in medicine of any form. If/when you eventually do talk to the mysterious person behind the counter, it seems quite intimidating and you just want to get out of there. That's what I feel anyway.

        There are certain things you can't buy without speaking to the pharmacist - the S3 drugs. More and more things are becoming S3 these days too.

          But they've been through (real) clinical trials....haven't they?

    When I was in my late teens and early 20s I worked at a pharmacy. We stocked all those sort of weight loss things, etc because people would ask for them, but if anyone asked questions, the pharmacist was quick to tell them about the complete lack of evidence and suggest seeing a doctor if they thought it would be necessary to get something WITH evidence. He was also quite against selling vitamins and minerals - he would ask people whether they actually had a deficiency.

    Close resemblance to material presented on "The Checkout" on ABC TV last night. Looks like a legit coincidence, though.

    As a final year Master of Pharmacy student I have thought long and hard about this. The honest truth is that for the most part, the OTC's are the only products that have a decent profit margin on them.

    The government is cracking down more and more on the rebates and incentives that they offer pharmacists for providing their professional services and dispensing scripts (which is where the majority of income was made in the past for pharmacists), which has forced pharmacy as an industry to find other streams of income. Then of course there are the discount chains that by market forces, are driving down profit margins on anything that is not government regulated, screwing the industry (independent pharmacist owner operators) as it does so.
    So as far as I can see, pharmacies now are highly regulated retailers, where pharmacists are rarely acknowledged, or paid accordingly, as high level health professionals.

    Maybe it's time to investigate the true role of the pharmacist in health care. Did you know that pharmacists are the 'last line of defence' with all medications? If you have an allergic reaction, or are prescribed a medicine that is inappropriate, the pharmacist has 60% of the liability in that situation. But the doctors on average get paid 5-6 times more than pharmacists, but only get apportioned 40% of the liability, even though they are in a position to get a distraction-free full history from the patient to make their decision about what they will prescribe. Pharmacists are often treated as though they are the 'poorer cousins' to doctors. But the scary thing is, Medical students only get 2 (yes, two) pharmacology lectures in their entire degree (4-6 years). So there is a real need and place in the system for pharmacists.

    On the industry front: Chemist Warehouse (by getting around the regulations in a very sneaky and unethical way) can get stock in and sell it at retail prices, for less than independents can get their stock at wholesale. The public have gotten used to trying to save a few dollars here and there, which is fair enough in the short term. But what has happened to petrol stations will happen to pharmacies as soon as Woolworths and Coles achieve deregulation of the industry.

    So in my mind there is only one way forward. We need people to vote with their feet and support the independents that value their customers, but as a result of prioritising their time for patients, they need to charge a few dollars more for their products.

    I guess for me it's about values and ethics. I want to be a pharmacist that has their regulars because they know that I am approachable and well informed. I want to know how my patients are progressing, and see their successes and help them recover from their set backs. But the way pharmacy is going, I really feel as though the only people that care about us as an industry are those of us in the industry that care. Support your local pharmacist. Don't take their care for you for granted. Tell them you appreciate them- they work damn hard, and as an industry, there isn't much positive or encouraging happening at the moment.

    Ken Harvey I saw you too watched "The Checkout" on ABC last night and turned part of it into an article.

      Ken Harvey was IN "The Checkout" article on the ABC. I would say that their findings and discussion is largely based on his work as the Chaser boys are hardly experts in the efficacy of medicinal products.

    You go to the doc, they charge a consultation fee, ditto for podiatrists, dentists, physiotherapists etc etc (any other health profession basically). Hell, this often extends to non-health professions as well.. Anyone been charged for a consultation with their lawyer or accountant?

    And yet, the 5 years of training that pharmacists go through ends up being a well of knowledge available for free to the public. This is not necessarily a bad thing - if done correctly as it once was, the pharmacists get their income from the government in the course of dispensing medications etc.

    But as Rubimentary above points out, these have steadily declined to the point that pharmacists now get paid significantly less than they did 10-20 years ago (before even adjusting for inflation). This, combined with the fact that our advice is not something we charge for has led to the situation as it is now:

    1) Less pharmacist-customer face to face time as the pharmacist is taking on a higher volume of jobs to cut costs
    2) A greater push by the owners et al to aggressively push sales with otc's and other pills (i've been denied a job for insisting that I will not do this)
    3) Long-term, it leads to greater rates of hospitalization and fewer early detections which eventually cost the government anyway.

    A bit bleak for pharmacy long-term. What should be done about it? That's a whole other discussion...

    1. Pharmacists are not in a position to judge whether a product works or not - they don't have the necessary training.
    2. There is lots of disagreement in the scientific & medical communities about the efficacy of certain products or substances - so there is no agreed basis on which to decide.
    3. Science is always discovering errors in previous research, and also new research that significantly changes the perception of what works or doesn't.
    4. Western medicine is still quite new compared to older medicines and should not be the only authority on efficacy of medicines.

      1. What are pharmacists educated to do then? Who do you think are running clinical trials, making new drugs in industry, changing medication regimes in hospitals or ensuring that you don't have that allergic reaction to the penicillin that you were prescribed despite telling your GP that you have an allergy? What have I (and all my pharmacist colleagues) done 3 years of pharmacology, molecular biology and medicinal chemistry for?
      2. This is a very vague statement. There is also a lot of disagreement in fashion about what will be the trend next season. Thing is though, science is objective, not subjective. Products and substances are not queried once the science proves the efficacy of the product. You will find the disagreement is more in the alternative health realms, which pharmacists do not have much to do with.
      3. This is not necessarily true. There are not that many medicines that are found to not function the way that they have been purported to. What does happen though, is that side effect profiles are found to be more severe than originally indicated in the Phase 1-3 clinical trials, and as a result, drugs and their indications and approvals are reconsidered/revisited. Also, science is often employed to find valid therapeutic use for substances that have not been considered in the past. Turmeric is a nice example of this for it's anti-cancer properties.
      4. Oh, I see. You aren't a member of the Australian Vaccination Network are you?

      Last edited 25/03/13 9:53 am

    Pharmacists actually have a large amount of training. Most new drugs are discovered, trailed, and marketed by pharmacists and not doctors. Pharmacists learn how to do that as part of their education, and have to do professional placements. Also like most other professions, are subjected to continuing professional development. Pharmacists, like doctors are expected to keep up to date with the latest research from the scientific community.
    A single pharmacist doesn't know everything just as a single GP doesn't, it takes a whole community of health professionals to know as much as we do now. It is the application of organised scientific methods, peers reviews, and regulation which has advanced medicine so quickly in the 20th century.
    Pharmacists and doctors rely on the same publications and disclosures from the government and drug companies to make decisions and dispense advice. Pharmacists have an extra duty of care which requires them to know what other medications you may be taking and know which ones are not to be mixed.

    The public should be aware that there are people out there (especially, re: vaccination) that purposely generate fear, uncertainty, and doubt (FUD) to achieve an agenda.

    Whenever I read medical academics demand that non-evidence-based medicines and treatments should be curtailed, prohibited or outright banned, I recall an article published in the British Medical Journal in 2003 called Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials.

    The introduction and conclusion are gold:

    INTRODUCTION: The parachute is used in recreational, voluntary sector, and military settings to reduce the risk of orthopaedic, head, and soft tissue injury after gravitational challenge, typically in the context of jumping from an aircraft. The perception that parachutes are a successful intervention is based largely on anecdotal evidence. Observational data have shown that their use is associated with morbidity and mortality, due to both failure of the intervention and iatrogenic complications. In addition, “natural history” studies of free fall indicate that failure to take or deploy a parachute does not inevitably result in an adverse outcome.4 We therefore undertook a systematic review of randomised controlled trials of parachutes.

    CONCLUSION: As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials. Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute.

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