Issues Magazine

A Critical Look at Pharmacies that Promote Complementary and Alternative Medicines

By Stuart Adams

Pharmacies have a vested interest in selling complementary medicine products that have little or no evidence of efficacy.

Pharmacists have long been regarded as reliable health care providers, and as fast and free alternatives to a GP. According to research published by Alistair Maclennan and colleagues in the Medical Journal of Australia (2006), Australians spend more than double their prescriptive medicine expenditure on complementary and alternative medicines (CAM). Many pharmacies are taking advantage of this trend by doubling as health food stores.

Considering the questionable efficacy, safety and science behind such products, their sale alongside more scientifically validated medicines has raised questions about the reliability of the pharmacist’s advice. In response, in 2006 Australian Skeptics awarded the Bent Spoon (“for perpetrators of the most preposterous piece of pseudoscientific piffle”) to pharmacists who promote quackery under the cloak of science.

Legitimate Use?

Not all supplements and complementary medicines sold on the pharmacy shelves are worthless. Some products certainly have a legitimate use. But given the enormous number of mega-dose vitamin supplements, herbal products, homeopathic products and other CAMs displayed on pharmacy shelves, are pharmacists always giving honest, reliable advice about them? After all, if they weren’t going to recommend the products, why would they sell them?

Confessions of a Former Pharmacy Assistant

After completing a degree in nutrition, my first position was in a pharmacy that claimed to “specialise in nutrition”. The major strategy was for the pharmacist to ascertain a patient’s medical condition upon receiving their prescriptions, and then send them to me. I was instructed to advise patients that they needed to purchase additional “natural” goodies to maximise their treatment. Issued with a white pharmacist’s coat, I presented a more “ clinical appearance” so that customers would be more inclined to trust me (and they did).

During training, I witnessed the proprietor/head pharmacist give advice to different customers regarding a variety of health complaints, and recommend a plethora of supplements, herbs and homeopathic remedies. These product recommendations were based on little or no supporting evidence. I was instructed to shun peer-reviewed literature, and instead consult the literature of supplement companies and other pro-CAM websites. In fact, many pharmacy staff received product training directly from companies such as Blackmores to “enhance” their knowledge of the products and boost sales.

Any safety issues I ever raised were quickly dismissed. Apparently, it was unnecessary to worry the customers about safety concerns unless these were specifically stated on the labels.

I assumed that this practice must be 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 large amount in a month I would be offered a portion of the profit.

Once again I witnessed this pharmacy proprietor telling customers all sorts of potentially dangerous nonsense to persuade them to buy supplements. 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.

Isolated Incidents or Widespread Dilemma?

I assumed that I had just been unlucky. However, an online search for pharmacy roles suggests that my experiences were not unique among pharmacy staff. If it were from a health food store worker, a multi­level marketing 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, but instead stem from “alternative” philosophies. However, pharmacists are recognised as trustworthy, reliable healthcare providers, and when you’re a vulnerable pensioner with no medical training, all you have to go on is trust.

In September 2005, researchers from Charles Sturt University published the results of a survey in which 400 pharmacists across NSW had participated. The large majority surveyed reported that CAM products “enhanced the customers’ image of the pharmacy”, believed that they “increased customer numbers” and “could increase annual sales”. According to this survey, the main reasons these pharmacists recommend CAM products were based on “evidence of efficacy and to maintain general health”, although I doubt that “purely to increase sales” was an option.

These pharmacists knew that their responses were being surveyed as part of a study, 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 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 as “ poor” by experts.

One problem seems to be the lack of formal training that pharmacists receive, or rather don’t receive, when it comes to CAM. A recent survey of Australian pharmacists by Susan Semple and colleagues (Pharmacy World & amp; Science, 2006) found that while 95% reported that they frequently received patient enquiries about CAM, less than 15% could say that they were “very confident” when it came to giving advice about their safety and efficacy. Some pharmacists reported using peer-reviewed journal publications as a source of information, although a lot of their information appears to stem from less-reliable sources, such as those provided by the supplement companies themselves, which have no real incentive to provide non-biased information.

The major determining factor, which none of these studies has taken into account, is 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. However, 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’ income? More importantly, should the public’s trust be exploited or their health jeopardised as a result?

What Are the Alternatives?

One might reasonably argue that pharmacists should not be allowed to sell any unproven medicines. Unfortunately, this could be dangerous from a public health perspective, as people seeking complementary medicines would instead have to visit health food stores, whose advice has been disastrously unreliable (quackwatch.org/01QuackeryRelatedTopics/hfsadvice.html).

Another suggestion may be to allow pharmacies to sell CAMs if they have a qualified naturopath working there. After all, many naturopaths have university science degrees these days, and many naturopathic associations would be equally concerned about people receiving advice from inadequately qualified people. However, I would have to disagree that a naturopathic university education does much to protect consumers.

During my studies I took “Herbal Medicine” as an elective, a compulsory unit for naturopathy students. After an entire semester, and discussions with naturopathy students, including a focus group study I conducted to canvass student opinions about CAM use in Australia, several things became clear.

Naturopaths do not like medical doctors or orthodox medicine in general, and give the impression that they would not agree with most orthodox medical treatments. This is not very comforting given the high number of people who seek treatment from naturopaths and other CAM therapists, especially cancer patients. This is even more worrying given the potential for CAMs to interact with chemotherapy, and the fact that many patients do not inform their doctors that they are using CAM treatments.

Naturopathy students are not taught that modalities such as homeopathy and iridology are unproven (let alone implausible) hypotheses, but instead that iridology is an effective means of assessing a patient’s health status and that homeopathy is an effective means of treating almost every disease. According to Caroline Smith and colleagues (BMC Complementary and Alternative Medicine, 2005), Australian naturopaths report using unreliable information sources – including “ professional” newsletters, manufacturer’s seminars, patient feedback and personal observation of patients – but not peer-reviewed published research.

Given this unscientific training, placing naturopaths in pharmacies is not an appropriate solution. It may even make the situation worse.

Better Regulation

When it comes to protecting the public against useless or potentially harmful CAMs, and the potential for retailers to give misleading advice about them, the Therapeutic Goods Administration (TGA) regulations are the first line of defence. The TGA separates therapies into two categories: registered therapeutic goods and listed therapeutic goods.

Registered therapeutic goods are medicines that are only available in pharmacies. To be registered they need to be proven efficacious and tested for any potential adverse reactions.

However, for the TGA to label a product as a “listed” therapeutic good, as are most CAMs, all that is needed is to demonstrate that it has been used by three generations of people. Most disturbing is that, with the exception of supplements containing retinol (vitamin A) or selenium, no listed therapeutic good needs to list any potential side-effects or contraindications. Inadequate labelling regulations, and the absence of label warnings, give consumers the impression that these products must be “natural”, safe and harmless.

Many think that the worst-case scenario is simply that the product “doesn’t help”, and assume that the labels would warn them about any potential adverse reactions. The absence of label warnings, especially when registered therapeutic goods are riddled with them, is largely responsible for the widespread misconception that CAMs must be without potential harm. Perhaps the dietary supplement industry is largely dependent on this widespread false sense of security, and that warnings might start scaring off customers.

Australians spend an estimated $2 billion on CAMs each year. Major supplement companies such as Blackmores and Nature’s Own, along with retailers (including pharmacies), are able to take an enormous piece of this complementary pie without having to spend a cent on research to assure safety and efficacy. It’s a win–win situation for them. Unlike makers of registered therapeutic goods, if a listed therapeutic good ends up being safe and effective then the supplement companies (and retailers, including pharmacies) win. If they aren’t safe and effective then they win anyway, because it really doesn’t matter – they will continue to be sold and will never have to bear any warnings on their labels.

Even rigorous testing does not guarantee the safety and efficacy of a medicine, but surely it’s better than the alternative.

Labelling – Safety

Other than mandatory listing of any potential adverse effects, all listed therapeutic goods should bear warnings that consumers should inform their doctor that they are taking it. The marketing director of a major supplement company once told me how delighted he was that the TGA had allowed them to list “health care professional” instead of “doctor”, because this could refer to a naturopath, pharmacist, or someone else who would be more likely to recommend the product (Note: Even though they don’t list any potential adverse effects, Blackmores’ products do list a free naturopathic advice line.)

Labelling – Efficacy

I would also propose that the TGA crack down on current policy loopholes that allow supplement companies to make certain health claims on the labels of their products. Although they cannot technically state that their products can treat or cure a specific medical disease, a frequent method of getting around this is to take a physiological process that a particular nutrient or herb may affect, and carefully word the description to suggest that it may be effective for treating relevant conditions.

For example, vitamin C is needed for wound healing. However, it is extremely unlikely that anyone is going to be so deficient in vitamin C that their wound-healing abilities would be impaired. Therefore, it is misleading for supplement companies to mention this physiological function on their labels. The question we want answered is not what this nutrient’s function is, but whether taking this product is going to make our wound heal any better or any faster than it would if we didn’t take it.

As another example, zinc may be involved in “maintaining a healthy immune system” and is “essential to maintain healthy skin”, but is taking additional amounts of it going to make our immune system work any better, or our skin any healthier than if we didn’t take it? Even if the answer is “yes”, then is it going to make it work that much better that it will have any measurable effect on any specific disease?

Vitamin E might be involved in “healthy heart function” by “reducing oxidation of LDL cholesterol” and helping to “protect capillary function”, but does it treat or decrease the risk of getting heart disease?

The B complex vitamins may indeed “aid the body during times of stress”, and vitamin B6 may be “necessary for the formation of haemoglobin”, but is taking additional doses of them going to help decrease your stress levels and treat anaemia, or will it just change the colour of your urine?

Milk thistle may have “traditionally been used in European medicine to enhance liver function, assisting as a natural liver tonic”, but will it help to effectively treat or prevent any actual disease of the liver?

Astragalus may have been “traditionally used to help support a healthy immune system”, but will it help to prevent or treat any actual medical condition affecting the immune system (let alone HIV and cancer, which university-educated naturopaths use it to treat)?

If the answer to these questions is “yes”, then they should be saying that they will actually treat or prevent those disease states instead of making vague, non-specific statements about what role they play in the body, or comments about “traditional” uses. If the answer is “no”, and it generally is, then these statements may be technically true but they are unnecessary and are deliberately deceptive to the average lay consumer.

The Bottom Line

There is no perfect solution to these complex problems. As it stands, many utterly useless products are available while other products, with some uses, possess deceptively worded and misleading claims. If manufacturers were required to list warnings of any potential side-effects or interactions, as opposed to leaving the customer to discuss it with a “health care professional”, then I would suspect there would be less potential for pharmacists and pharmacy staff to abuse their position and sell products based on false premises to unsuspecting customers.

I strongly object to promoting a message to the public to “ask your pharmacist” specifically about CAMs. I’m sure there are many pharmacists out there providing honest, reliable advice. However, there is too much room for them to exercise dishonesty and let their critical thinking lapse. Restricting the ability for manufacturers to deceive the public is, in my opinion, the best way to stop retailers from doing the same.

Supplement companies and their retailers would fiercely object to tighter regulations, fearing it may hurt the CAM industries, which include pharmacies. However, protecting the financial status or reputation of any industry should not be considered more of a priority than protecting the public from being misled and potentially harmed.

I support the use of dietary supplements, where needed, and perhaps some CAMs, so long as they are used appropriately, and that consumers make an informed decision about their use without being misled, exploited or unnecessarily harmed. Surely that’s not too much to ask.