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Editor's Note: Stuart Adams is a nutritional activist with a passion for evidence-based professional advice.
He has observed the quality of advice some pharmacists give in their daily practice when recommending nutritional supplements, and he finds it lacking.
Given that pharmacy has a commitment to excellence and has been diligently working to raise accreditation standards, what is going wrong in the nutritional advice area?
In a two-part series starting in this month's edition of i2P and finishing in the March edition, Stuart talks of his observations and first-hand experiences when working in a pharmacy environment.
You may disagree with him - that is your prerogative.
But if you catch a glimpse of your reflection within this well researched article, then please take this as an opportunity to raise the barrier.
If Stuart has found these "holes" within the pharmacy profession, others will have surely noticed, and the reputation of all pharmacists declines accordingly .
I value the reputation reported in past surveys of the Morgan Gallup Poll, measuring public opinion for the trust and integrity of pharmacists.
I believe that the ratings were justifiably earned over past years.
Please take this as a wake-up call and examine your professionalism against the following commentary.
Pharmacists have always been thought of as reliable health care providers – someone you can go and have a chat to when you don’t have time to line up to see a G.P.
Given the enormous amount of money that Australians spent on Complementary and Alternative Medicines (CAM) now days however (more than double what we spend on prescription medicines1) many pharmacy proprietors are taking advantage of this recent trend in the market and practically doubling as health food stores.
Considering the questionable efficacy (and safety) and little or no science that such products are often based on, their sale among more scientifically validated medicines in the pharmacy setting has raised questions about the reliability of the pharmacists advice, and saw the 2006 Australian Skeptics ‘Bent Spoon Awards’, given to “the pharmacists of Australia who manage to forget their scientific training long enough to sell quackery and snake oil in places where consumers should expect to get real medical supplies and advice.”
Legitimate Use?
Not all supplements and other complementary medicines sold on the pharmacy shelves are worthless of course – some certainly have a legitimate use (as I mentioned briefly in my article in the Autumn 2006 issue of the Skeptic).
Given the enormous number of mega dose vitamins supplements, herbal products and other complementary products (not to mention homeopathic products) that are routinely sold on pharmacy shelves, it’s tough to imagine that pharmacists out there are always giving honest, reliable advice about them.
After all, if they weren’t going to recommend them, why would they sell them?
If for example someone were to pick up a bottle of 1000mg vitamin C tablets, or a bottle of 500 IU vitamin E capsules (two of the most popular purchases), and ask the pharmacist if they were any good, what are the chances they would be told:
“No – your body can only deal with around 200mg of vitamin C at a time2, and the average intake among Australian adults far exceeds that anyway3, with additional doses being contraindicated in several common medical conditions4 and may potentially interfere with sex hormone regulation, capable of inducing preterm birth in pregnant women5 and has been shown to induce abortions in rodents6,7 (even though it says none of this on the label of course).
As for the vitamin E, although the label may say “for heart health”, it does not say that it will actually prevent heart disease, because this would be an illegal claim.
In reality, although it is the subject of considerable debate,8 there is at least some evidence that doses in excess of 400IU daily may actually increase the risk of death.9”
Although the odds of hearing that from pharmacy staff would be next to zero, once upon a time, there were a couple of pharmacies where you may have been likely to be given a response similar to that; the ones which I worked in!
Confessions of a former pharmacy assistant
After completing my nutrition degree a while back, my first position was in a pharmacy which advertised itself as specialising in nutrition.
The major strategy was for the pharmacist on duty to ascertain the patients medical conditions(s) upon receiving their prescription, and then send them over to me where I was meant to advise them that they needed to fill their baskets up with additional ‘natural’ goodies in order for them to get the best for th eir treatment.
I was even given a white pharmacist coat to wear, to give myself a more ‘clinical appearance” so that customers would be more inclined to trust me, (and they did).
Stuart Adams in his role as pharmacy clinical assistant in a white coat
As training, I had to witness and take notes as the proprietor / head pharmacist gave advice to different customers regarding a variety of health complaints, to which he would recommend a plethora of supplements, herbs and even homeopathic remedies.
I simply don’t have room to mention all the many weird and wonderful product recommendations he made to patients, though suffice it to say; they were based on little or no supporting evidence.
In fact, I was instructed that peer reviewed literature was not appropriate for me to be looking at for additional information, and that better sources included supplement companies literature and other pro-CAM websites.
In fact, I learnt that many pharmacy staff received product training directly from supplement companies such as Blackmores, in order to ‘enhance’ their knowledge of the products uses in order to help boost sales.
Any safety issues I ever raised with the boss were quickly dismissed, as apparently it was unnecessary to worry the customers about any safety concerns unless it specifically stated them on the label.
For example, according to him, there was no need to worry about past history of intracranial bleeding or warfarin use before recommending anti-coagulant (blood thinning) supplements such as fish oil, vitamin E, garlic, Ginkgo biloba and other herbs (despite the documented though not-so well known contraindications4,10,11).
There was no need to worry customers about whether or not they were on the contraceptive pill (let alone other medications) before suggesting St Johns Wort (despite the potential risk12) and there was certainly no need to tell a customer to go and ask their doctor first before taking any complementary medicines – that was something he was especially adamant about.
Apparently, this was because the patients had come to us for help because they wanted something quick that they could buy over the counter because they did not have time to go and see their doctor, who may well advise them not to go and buy ‘natural stuff’.
Essentially, I was not employed to give honest advice.
I did anyway of course, so obviously the job didn’t last too long, which, given the constant need for dishonesty and deception, was not terribly upsetting to me.
What was upsetting however was to see so many vulnerable customers (often elderly pensioners) being ripped off, as trusting their pharmacist as a reliable source of health related information of course (or anyone else wearing a white coat) they simply did whatever they were told.
I figured that this must have been a one-off, and that surely, the kind of corruption going on in this pharmacy was an isolated problem.
However, on the first day of my next pharmacy job, I was told quite clearly, that I was there to “push the vitamins”, and that if I “pushed” a particularly larger amount of them in a month than usual, I would be offered a proportion of the additional profit.
Once again, I witnessed this pharmacy proprietor telling their customers all sorts of nonsense (some of which was even potentially dangerous) in order to get them to buy supplements, and it was made abundantly clear to me that I was not there to give any professional or honest advice to customers unless it meant recommending a product that we were selling.
I generally had to make sure I looked over my shoulder every time to make sure that the boss wasn’t watching before offering anything even remotely resembling honesty.
To give another couple of examples – two of the most common products I was asked about there were both Centrum multivitamins as well as various herbal weight loss pills such as Fat Blaster, Blackmores Metabolism Advantage and of course, Xantrax (which conveniently sounds very similar to a different weight loss pill which, although is not without deceptive marketing issues of it’s own, actually works13).
My responses were generally as follows:
“As the label says, vitamins may only be of assistance if your dietary intake is inadequate, which, although the label doesn’t mention, is very unlikely3, so no – this product will not give you “energy” or make you “feel 100%.”
When they say “unlock energy” they mean chemical energy (Calories / kilojoules) not feeling energetic, though given their clever wording and athletic spokespeople, you could be forgiven for being confused.
If you are feeling fatigued all the time, you may not be sleeping well, and should see your doctor to rule out anything more serious.
As for the other product, this combination of herbs and nutrients has never been studied.
Given all the available evidence20-24, it is not likely that you would lose any more than about 1 kg every 4 months (best case scenario), and even then it would only occur if on a hypocaloric diet (in which case you would be loosing weight anyway).
Given that it will cost you over $100 a month, you would be better off learning how to improve your diet and getting more exercise, or even going with a product that actually works.”
Funnily enough, the vitamins weren’t being ‘pushed’ as much as they had expected (I can’t imagine why!).
Isolated Incidents or Widespread Dilemma?
If it were a health food store worker, a Multilevel Marketing (MLM) distributor or even a naturopath, then at least the public would be more aware that the advice being offered may not be in sync with official mainstream medicine and instead stem from ‘alternative’ philosophies.
Pharmacists however are, presumably, supposed to be recognized as reliable health care providers you can trust, and when you’re a vulnerable pensioner with no medical training, all you have to go on is trust.
So should we be putting our trust in the hands of a pharmacist as a reliable source of mainstream medical advice, or are they becoming nothing more than a glorified health food store clerk?
In September 2005, researchers from Charles Sturt University published the results of a survey that more than four hundred pharmacists across NSW had taken part in.19
The large majority of pharmacists surveyed reported that CAM products “enhanced the customers' image of pharmacy”, believed that they could “increase customer numbers” and “could increase annual sales”.
According to this survey, the main reasons these pharmacists gave for recommending CAM products was based on “evidence of efficacy and to maintain general health” (though I doubt that “purely to increase sales” was an option).
These pharmacists knew that their responses were being surveyed as part of a study however, so we can’t know precisely what they would be telling their customers.
The only way to do this would be for researchers to pose as a customer, ask a bunch of questions about CAM products and record the pharmacist’s response.
Although it was not published as an official ‘study’ as such, the Australian Consumers Association’s “Choice” magazine did just that, and found that advice given in 58 out of 87 pharmacies was rated “poor” by their experts.20
Not all pharmacists are bad
In pharmacists defence however, I must admit that a lot of employed pharmacists I have known and worked with are not in the habit of lying to their customers, and do recognize the problems and conflict of interest associated with selling complementary medicines in the pharmacy setting.
In fact, after writing an article very similar to this on a hobby blog, I assumed that any pharmacists who would come across it would consider it ‘pharmacist bashing’ and instantly disagree with me.
As it turns out, several pharmacists wrote to me telling me that they could not agree more, and I was even asked to contribute a regular column to an electronic journal (run by pharmacists) called ‘Information 2 Pharmacists’ (http://www.i2p.com.au).
One problem seems to be the lack of formal training that pharmacists receive (or rather, don’t receive) when it comes to CAM’s.
A recent survey of Australian pharmacists found that whilst 95% reported that they frequently received patient enquiries about CAM’s, less than 15% could say that they were ‘very confident’ when it came to giving advice about their safety and efficacy.21
Whilst some pharmacists reported using peer-reviewed journal publications as a source of information, a lot of their information appears to stem from less-reliable sources such as that provided by the supplement companies themselves (who have no real incentive to provide non-biased information anyway).
I really don’t think that this is a valid excuse however, as the real research certainly is out there. I’m sure that pharmacists could access it if they really wanted to.
The major determining factor however that I perceive to be, (and which none of these studies have taken into account) would be whether or not the pharmacist on duty is the proprietor.
If they are an employee, then they would have less incentive to give dishonest advice (as they are paid a flat, hourly wage), but when the pharmacist on duty is the boss, then honest advice may mean missing out on additional income.
I don’t believe that pharmacy proprietors are necessarily bad people – they are simply trying to run a business.
The question is, should employee pharmacists have to compromise their professional integrity for the sake of boosting the boss’s income, and more importantly, should the public's trust be exploited or their health be jeopardized as a result?
Editor's Note: Part Two follows on next month and talks about possible solutions
References
1. MacLennan AH, Wilson DH, Taylor AW. The escalating cost and prevalence of alternative medicine. Prev Med. 2000;35:166-73
2. Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids. Washington, D.C.: National Academy Press; 2000.
3. Australian Institute of Health & Welfare. Apparent Consumption of Nutrients Australia 1997-1998. Canberra . December 200
4. Hendler SS, Rorvick D. PDR for Nutritional Supplements. Medical Economics Company. 2001; Montvale , NJ
5. Rumbold A, Crowther CA. Vitamin C supplementation in pregnancy. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD004072.
6. Samborskaya, E.P. The effect of high ascorbic acid doses on the course of pregnancy on the guinea pig and on the progeny. Byull Eksp Biol Med. 1964; 5: 105-8
7. Fahim, MS., Hilderbrand D, Wilson R, Harman JM, and Hall DG. Effect of high doses of ascorbic acid on female reproduction. In. Fifth International Congress on Pharmacology, Abstracts of Volunteer Papers. San Francisco. 1972:66.
8. Blatt DH, Pryor WA. High-dosage vitamin E supplementation and all-cause mortality. Ann Intern Med. 2005;143:150-1;
9. Miller ER 3rd, Pastor-Barriuso R, Dalal D, Riemersma RA, Appel LJ, Guallar E.Meta-analysis: high-dosage vitamin E supplementation may increase all-cause mortality. Ann Intern Med. 2005;142:37-46.
10. Hu Z, Yang X, Ho PC, Chan SY, Heng PW, Chan E, Duan W, Koh HL, Zhou S. Herb-drug interactions: a literature review. Drugs. 2005;65(9):1239-82
11. Heck AM, DeWitt BA, Lukes AL. Potential interactions between alternative therapies and warfarin. Am J Health Syst Pharm. 2000 Jul 1;57(13):1221-7; quiz 1228-30
12. Izzo AA. Drug interactions with St. John's Wort (Hypericum perforatum): a review of the clinical evidence. Int J Clin Pharmacol Ther. 2004 Mar;42(3):139-48.
13. Henness S, Perry CM. Orlistat: a review of its use in the management of obesity. Drugs. 2006;66(12):1625-56
14. Egger G, Cameron-Smith D, Stanton R. The effectiveness of popular, non-prescription weight loss supplements .Med J Aust. 1999 Dec 6-20;171(11-12):604-8
15. Saper RB, Eisenberg DM, Phillips RS. Common dietary supplements for weight loss. Am Fam Physician. 2004 Nov 1;70(9):1731-8.
16. Pittler MH, Ernst E. Dietary supplements for body-weight reduction: a systematic review. Am J Clin Nutr. 2004 Apr;79(4):529-36.
17. Sharpe PA, Granner ML, Conway JM, Ainsworth BE, Dobre M Availability of weight-loss supplements: Results of an audit of retail outlets in a southeastern city J Am Diet Assoc. 2006 Dec;106(12):2045-51.
18. CHOICE. Test: Slimming Pills. May, 2005. Available at: this link
19. Naidu S, Wilkinson JM, Simpson MD. Attitudes of Australian pharmacists toward complementary and alternative medicines. Ann Pharmacother. 2005 Sep;39(9):1456-61
20. Choice Magazine: Pharmacy Advice in the Spotlight. Online version available at: http://www.choice.com.au/viewPressRelease.aspx?id=104444&catId=100202&tid=100010&p=1
21. Semple SJ, Hotham E, Rao D, Martin K, Smith CA, Bloustien GF. Community pharmacists in Australia: barriers to information provision on complementary and alternative medicines. Pharm World Sci. 2006 Nov 21
22. Barrett, S. Don't Trust Advice from Health-Food Retailers! Quackwatch. See:
http://quackwatch.org/01QuackeryRelatedTopics/hfsadvice.html
23. Meijerman I, Beijnen JH, Schellens JH. Herb-drug interactions in oncology: focus on mechanisms of induction. Oncologist. 2006 Jul-Aug;11(7):742-52.
24. Malekzadeh F, Rose C, Ingvar C, Jernstrom H. Natural remedies and hormone preparations--potential risk for breast cancer patients. A study surveys the use of agents which possibly counteract with the treatment Lakartidningen. 2005 Oct 31-Nov 6;102(44):3226-8, 3230
25. Begbie SD, Kerestes ZL, Bell DR. (1996) Patterns of alternative medicine use by cancer patients. Med J Aust. 18;165(10):545-8.
26. Miller M, Boyer MJ, Butow PN, Gattellari M, Dunn SM, Childs A. The use of unproven methods of treatment by cancer patients. Frequency, expectations and cost. Support Care Cancer. 1998 Jul;6(4):337-47.
27. Ernst E. Iridology: A systematic review. Forsch Komplementarmed. 1999 Feb;6(1):7-9
28. Ernst E. A systematic review of systematic reviews of homeopathy. Br J Clin Pharmacol. 2002 Dec;54(6):577-82
29. Smith C, Martin K, Hotham E, Semple S, Bloustien G, Rao D. Naturopaths practice behaviour: provision and access to information on complementary and alternative medicines. BMC Complement Altern Med. 2005 Jul 11;5:15..
30. Preuss H, Garis R, Bramble J, Bagchi D, Bagchi M, Rao C and Satyanarayana S Efficacy of a novel, natural extract of (-) hydroxycitric acid (HCA-SX) in Weight Control. Int J Clin Pharm Res.2005; XXV (3):133-144 (N.B – I can’t even find this paper anywhere – it certainly isn’t listed with PubMed)
31. Hilton M, Stuart E. Ginkgo biloba for tinnitus. Cochrane Database Syst Rev. 2004;(2):CD003852.
32. Burton B. Australian court suppresses report questioning effectiveness of complementary remedy. BMJ. 2006 Jul 15;333(7559):116
33. Burton B. Regulator finds advertising of complementary product "misleading".
BMJ. 2006 Dec 2;333(7579):1141.
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