Australia’s first comprehensive pharmacy review in two decades, released this week, asks the important question:
“Is it confusing for patients if non-evidence based therapies are sold alongside prescription medicines?”
Let me save the reviewers some trouble: the answer is “yes”.
The harder question, of course, is “What, if anything, should be done about it at a regulatory level?” I don’t pretend to have an answer, but doing nothing at all will be a poor outcome for consumers.
The Review of Pharmacy Remuneration and Regulation (the ‘King review’) can be found here (pdf).
I spend a lot of effort highlighting potential conflicts of interest when it comes to doctors’ prescription decisions being swayed by marketing rather than evidence. But this is merely fine-tuning within a system already ensuring most doctors gain no direct financial reward.
The community pharmacy model is, necessarily, far more prone to financial conflicts of interest. Arguably, this could loosely apply to any business with a cash register, but the health industry requires particularly careful oversight.
“Would you like supplements with that?”
A teenager suggesting you upsize your fries is just clever marketing, but a health professional asking if you’d like a bottle of supplements with your prescription warrants scrutiny at a broader level.
Unbeknown to the consumer, those pills may contain substances which have not been shown to work (vitamin supplements in most circumstances), or even worse, have actually been shown NOT to work (homeopathy in all circumstances).
Where there’s a market, there’s a seller, of course; nothing wrong with that. But the issue is that this seller might potentially leverage their well-deserved respect as a medicines expert, and use it to sell a product which will not improve health. This situation, while often handled well by the pharmacist, is intrinsically vulnerable to a conflict of interest, and therefore worth reviewing.
Most employed community pharmacists I speak to (admittedly a biased sample) consider this aspect of their work somewhat distasteful – they are intelligent folk who entered a science-based profession.
And many of their pharmacy bosses genuinely struggle in the knowledge that their business viability relies on a turnover of non-evidence based products.
But lost somewhere in this current financial model are consumers, who are at risk. For prescription medicines, they have good reason to trust the advice of the expert, but they may be unaware of the inherent potential conflict as they walk towards the non-evidence-based shelves.
Individual pharmacists already successfully deal with this risk, but regulation applying to everyone would be fairer.
drjustincoleman 
The first thing undid when I bought my pharmacy was to remove all homeopathy.
I also do not sell anything that is featured on tabloid news Television.
For those pharmacies that claim that selling homeopathy is the only way to address these patients and dissuade the sale – I can say that I still get patients looking for homeopathy, and as a result, every single one is given evidence based advice as a result (or no self-selection)
I personally think that a lot of health professionals allow anecdotal evidence to rule their perception of this issue…. Yet I don’t recall seeing any evidence or studies on the actual incidence of sales of products at pharmacist recommendation where the pharmacist knew (or should have known) that the product they were recommending has evidence for a lack of effect, or no evidence for the current recommendation….
Ironic really, since the basis of these arguments is that evidence is King (bad pun intended)
I’m not a huge fan of extra regulation, but this is one area I would like to see strengthened. I’ve often lamented the fact that pharmacy peak bodies and representative groups have no method of preventing members or non-members from selling products that are questionable.
Similarly, medical groups do not have a method of preventing prescribers from providing services or recommendations that aren’t evidence based, or from practicing in a way that maximises Medicare swipes without improving patient outcomes.
My point there is that every single professional has a conflict of interest while heir income is subject to their recommendations or moral hazard. It’s easy to target pharmacy due to the assumption that the sale of a product is somehow more exposed to conflict of interest than any other kind of professionally remunerated service.
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Thanks Jason for your interesting observations. It is great to see a viable business model which doesn’t involve homeopathy.
Interestingly, when I write about doctors’ conflicts of interest, I routinely get replies from unhappy GPs saying, “Why pick on us? You should see the pharmacists!” Or lawyers, politicians etc.
In the end, I write about the small parts of the world I know. Conflict of interest is not always bad, nor is it always avoidable. However, I think there is benefit in shining light into the room. Transparency helps.
Regulation has the unique capacity to apply to everyone equally, rather than relying on individuals being willing to disadvantage themselves compared to their less scrupulous peers. Education (of pharmacists and consumers) is important, but on its own doesn’t quite have the same bite.
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Ideally the businesses would be entirely split from each other as per Q27 in the discussion paper. A dispensary that deals with prescription medication, OTC medicines and devices with an evidence base (like the dispensaries you find in hospitals) and ‘holistic health shops’ that sell cosmetics and whatever Dr Oz is flogging this week. The latter would be pretty much indistinguishable from the sort of New Age alt.health outlets that are already common in Australian shopping centres and would be forbidden from promoting themselves as health professionals regardless of their qualifications. There’s probably an argument for removing dispensaries from the commercial environment and running them as a purely government service.
But more realistically pharmacists should be removed from the official medical advice loop entirely with all attempts to increase their role in recommending treatments slapped down hard and publicly. In my experience the medical ‘advice’ offered by pharmacists is sometimes seriously flawed even when there’s no obvious conflict of interest.
And yes, I do acknowledge there are many pharmacists out there who’d rather do science than sales. But thus far I’ve seen no attempts to reform the industry from within beyond a bit of private grumbling. What I also haven’t seen are the community pharmacists the DP says go “above and beyond in providing additional services that are in the patient’s best interest, even though they may not be compensated for these valuable services”. Maybe I’ve just been very unlucky.
BTW, the situation is worse than you suggest. I’d rather take a homeopathic pill that does nothing than some pharmacy products (especially those promoted for weight loss) that can cause harm, either of themselves or in combination with other substances.
I find it ironic that discussion paper Figure 9 features quetiapine prescriptions, considering the evidence for quetiapine above placebos is barely better than it is for homeopathy. I wonder what the graphic would look like if it included cost estimates for treating adverse events and side-effects. (Placebo researcher Irving Kirsch has suggested that the only difference between many psychiatric medications and placebos is the side-effects. They act to confound the blinding in clinical trials and artificially boost apparent outcomes in the treatment group).
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You are a skilled and judicious man Justin.
Your low-key, under-criticising approach still made the point but also drew out some healthy responses. Your reply to Pharmer4 was, if anything, even more skilful than the article itself
Dr John Buckley
Director Medical Education
General Practice Training Queensland
Unit 1/32 Billabong St, Stafford QLD 4053
PO Box 1275, Stafford QLD 4053
P: 07 3552 8100 | F: 07 3552 8108 | mailto:jbuckley@gptq.qld.edu.au | http://www.gptq.qld.edu.au
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