Should pharmacies sell natural health products?
Suffering from migraines, back pain, acne, diarrhea or constipation? Rexall pharmacies have a product that might help, but it’s not medication or an over-the-counter fix.
Rather, it’s an IgG test called Hemocode that looks for 250 food intolerances – and costs $450. The test, which is done off-site, returns results that the pharmacist shares with the customer, who then talks to a naturopathic doctor about recommended foods to eliminate, and vitamins and supplements to add.
The problem: the science behind it is lacking. IgG is believed to show exposure to foods, not an intolerance. (Food intolerance does exist, but the best way to diagnose it is through a food diary and an elimination diet.)
The Canadian Society of Allergy and Clinical Immunology has come out against IgG tests, saying: “The CSACI does not support the decision of licenced physicians and our pharmacist colleagues to offer such testing, given the overwhelming consensus against the validity of such tests.” It also points to potential dangers, such as exclusion diets for children and an increase in referrals to overburdened allergists.
Other natural health products line the shelves of many pharmacies. Next to traditional over-the-counter medication, such as acetaminophen or antihistamines, customers will find homeopathic remedies, supplements and vitamins, and diet pills.
Touted as the most accessible health care providers, pharmacists have specialized education and they’re a regulated, science-based profession driven by the desire to help patients.
The Ontario College of Pharmacists of British Columbia’s code of ethics says pharmacists must “provide information that is evidence based, relevant, up-to-date and consistent with the standard of care.” The code of ethics for the Ontario College of Pharmacists isn’t so direct, but says they are “obliged to act in the best interest of and advocate for the patient.” They also point to the national Model Standards of Practice, which emphasizes an evidence-based approach and recommends “appropriate recommendations to patients requiring non-prescription drug therapies” and “appropriate education of patients to whom [pharmacists] sold non-prescription medications, or to whom they recommended self-care.”
Yet since they work in a for-profit, retail environment, there’s a potential conflict between what’s best for the client and what’s best for the bottom line.
Thanks to the popularity of complementary and alternative medicine, consumer demand for natural health products is rising. Seventy three per cent of Canadians take natural health products and 13% of Ontarians see alternative health care providers. So what are pharmacists’ responsibilities when it comes to stocking complementary and alternative medicines, and what do they need to tell patients about them?
What should pharmacies stock?
Across the country, there are about 9,000 community pharmacies. Chain stores make up only about 16% of the industry’s revenues, while the rest comes from independents. Recently, both types in Ontario have faced financial challenges as a result of the lower reimbursements for generics.
Meanwhile, pharmacists have expanded their scope of practice, taking over duties traditionally performed at the doctor’s office. Ontario pharmacists can refill prescriptions and prescribe medication to help people stop smoking. In 2012, they began to offer flu shots, which pharmacists across the country can now do.
The Ontario College of Pharmacists has also directed its pharmacists not to sell complementary and alternative products that haven’t been approved by Health Canada. (Products that have applied for approval but not yet passed it were previously allowed to be sold.) All of those products should now be approved natural health products or approved homeopathic remedies. Health Canada’s approvals mean that the products are safe and meet quality standards – but there is a lower standard to prove that they work than there is for drugs, which go through clinical trials.
Health Canada compiles research on natural health products, but for most of them it’s of a smaller scale than that from drug company trials, explains Sean Simpson, who owns a pharmacy in Niagara-on-the-Lake and is vice chair of the Ontario Pharmacists Association.
Some argue pharmacies shouldn’t sell products that don’t have strong science behind them. “There should be good evidence to support a therapy if it’s going to be sold in a pharmacy,” says Scott Gavura, an Ontario pharmacist who writes the blog Science-Based Pharmacy. “There’s the risk that if there are products being sold in the pharmacy, those products are being given the veneer of authenticity.”
That was one of the issues the Canadian Society of Allergy and Clinical Immunology had about IgG tests, says Stuart Carr, past president of the society. “It concerned us because there’s sort of an implicit endorsement of an approach like this when a group of accredited professionals like pharmacists are offering it.”
A recent article in the Canadian Pharmacists Journal by Neal Davies, dean of pharmacy at the University of Manitoba, made the same argument. “Why do we still sell products without scientific merit and research to support their use?” it asks. “We have an ethical duty to our patients to promote sound, evidence-based pharmacy practice. Unless product claims can be backed by solid evidence, we need to quit our addiction and stop selling products with no or questionable health value.”
Others say it’s better for consumers to buy natural products in a pharmacy, where they can discuss the potential risks or benefits with a pharmacist. A 2009 review of the literature by Heather Boon, now dean of the faculty of pharmacy at the University of Toronto, found “Most of the literature either explicitly or implicitly identified that pharmacists have a key role to play with respect to NHPs [natural health products]/DS [dietary supplements].”
That support, it says, comes from the idea that pharmacists are in a unique position to counsel people on the use of those products, as well as possible interactions, especially since many patients are already using these products.
Simpson’s pharmacy boasts a broad selection of natural health products. He decided to stock them so that his patients have a chance to talk to a pharmacist about possible benefits and harms. “If we’re not having that conversation, they could very well be buying it at a natural health food store, and not necessarily be aware of all of the issues… our customers are engaging more informed pharmacists, and not necessarily making choices based on the recommendations of Dr. Oz.”
He also feels that there’s evidence to support many of natural products, such as probiotics and omega 3s. “Natural health products may not have the ‘high quality’ evidence that some drugs may have, but it does not mean there is zero evidence to support their use,” he says. “There’s some products that have a great deal of evidence, and then there are some things that are emerging.”
The range of natural health products
The evidence behind natural health products can differ substantially. The most popular offering is vitamins and minerals, which are taken by just over 50 percent of Canadians. Prenatal vitamins and those to treat B12 or iron deficiencies, for example, are well-supported by evidence; others, such as vitamin A and E, have been proven ineffective and possibly even harmful in recent years. Some other solutions, like neti pots for colds and pesticide-free lice removal kits that use lice combs are also sold under the banner of complementary and alternative medicine, but backed by strong evidence.
On the other end of the spectrum lie remedies with no science behind them, such as homeopathic preparations. These are especially prominent with cold medications due to a gap in the market. Since 2008, Health Canada has banned cough syrup and cold medication being sold to kids under six. But homeopathic cough remedies advertised towards that age group are still on shelves – often right next to more traditional cough syrups.
Is it reasonable to expect consumers to know the difference? Gavura argues it’s not. “The labelling is misleading, and implies there are active ingredients,” he says. “The only reason they are permitted to be marketed for use in children is because they don’t contain medicine, ironically.”
He says he’s told many parents cough remedies are homeopathic, and they had no idea that was what they were buying.
Edzard Ernst, a prominent alternative medicine researcher in the U.K. and the author of Trick of Treatment, agrees. “Pharmacists have an ethical duty to sell only products that are backed by reasonably sound evidence,” he says. “At the very minimum, they should inform their customers objectively about the evidence.”
Simpson focuses on informing consumers, rather than limiting those products. “I don’t think I would ever pull a bottle of homeopathic cough syrup off the shelf and say here, this is what I recommend,” he says. “At the end of the day, the evidence is lacking. But it comes down to having somebody make an informed decision. If somebody wants to choose a homeopathic product, I want to do my best to help them choose the right one for them.”
An on-the-ground compromise
Jim Semchism owns a pharmacy in London, Ont. and has been in business for 33 years. He has a small store, and 90 percent of sales comes from the dispensary, rather than over the counter products. He doesn’t normally stock natural health products, though he will bring them in on request. And he tries to keep his customers informed of the most current research. For example, he’s talked people out of taking vitamin E as the evidence against it has mounted – but still brings it in for a few clients who feel that it helps them.
“I think most pharmacists of my vintage and even the more recent grads probably have a certain amount of skepticism about non-traditional therapies,” he says. “But I do have a few colleagues that really think that complementary medicine has a lot to offer, and they really promote it.”