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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 video on Rexall’s website that explains the Hemocode System. (From Neil Dankoff on Vimeo.)

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.”

Should pharmacies sell complementary and alternative medicine?

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13 comments

  1. Douglas Robb - @healthhabits

    Yes. Under the condition that they don’t offer PROFESSIONAL advice about products that they have no business offering PROFFESIONAL advice about…ie Neti pots, sketchy supplements, shampoo, candy, newspapers, or any other the other products sold at Canadian drug stores.

    They have received years of education about pharmaceutical drugs. Because of this education, the general public trusts their opinion.

    It’s wrong to attach the same level of respect to their opinion about non-pharma products

  2. Don Taylor

    I like Simpson’s balanced approach – to help inform his customers. I (and I suspect most people who go into a “drugstore”) are well aware that the pharmacy is only one department in the drugstore. And the pharmacist is someone we can consult when we have questions about a particular over-the-counter product. That advice is not available if we buy these products from our local corner store.

    Besides, selling these over-the-counter products would seem to be no different than other non-prescription products drugstores sell these days: groceries, make-up, tooth brushes, etc. As a customer, I assume the drugstore stocks only products, whatever their purpose, that are subject to some reliable regulatory or quality assurance oversight.

    We also appreciate that convenient access to a pharmacy and these OTC products, may well require the pharmacist to sell products other than prescription drugs to be a viable business.

  3. VJ Basque

    After 35 years in pharmacy (15 yrs hospital & 20 yrs retail), I say they should not carry these unproven products. We are fooling our patients in these Placebo treatments.
    Just compare a hospital drug formulary and a retail pharmacy inventory and you’ll find that 60-70% of the OTC’s we carry are ineffective and worthless.
    Let’s practice evidence-based pharmacy!
    VJ Basque,BSc BEd BPharm ACPR

    • Rola Priatel

      So who will educate the patients then on the lack of evidence? the grade 5 graduate at your neighbourhood mall?

  4. Norm Umali

    No. If pharmacies are disallowed from seling products lacking a shred of evidence, then these products would be sold at health food stores. Then, the health food store industry would probably explode, the salespeople at the health food stores will be the only people around to provide the advice to consumers. Trust in pharmacists would not change, in fact, it could increase. This could create pressure for these multimillion dollar supplement companies to start investing in proper research, to get their products back into pharmacies.

    Why don’t we try something more realistic. Pharmacists can start actively contributing to safety research. All of these sketchy supplements can be sold at pharmacies, status quo, but with every sale of these products, pharmacists ask the consumer to let them know if there is an adverse reaction, we can apply some validated tools to determine if a reaction likely occurred from the supplement. As the incidents are reported, the pharmacist would report those incidents into a database like cmirps. 9000 pharmacies contributing safety data; pharmacists emphasizing safety over the far fetched notion of a cure in a pill. This would also give pharmacists more confidence in telling consumers “I have no way to tell you if this supplement will work for you, but, my interest is your safety, so I participate in a pan-canadian program where we collect this kind of information to help other Canadians, so, if you get an adverse effect, you need to tell me”

    • Rola Priatel

      Pharmacists already do what you recommend in your second paragraph. It is fantastic if they could have more time to follow up as we, as a collective, could learn so much more so fast about risks versus benefits….Pharmacists get paid well, but they get paid a salary so to find the time to follow up with every consumer would be beneficial if they could justify that time spent away from their usual consults and workload! When I practiced as a community pharmacist in the mid 1990’s , I had reported one of the first interaction cases to HPB (Health Canada now) of St John’s Wort with MAOI’s but it consumed hours of my time to try to find a cause-effect relationship and subsequent followups with the patient….

    • Elizabeth Rankin BScN

      Agree with having pharmacists be the local “research monitor of regulated and unregulated drugs.” Drugs that come to market from any research trial requires no further monitoring and we know there are many ADR’s that are not reported often because the doctors that prescribe don’t recognize the side effects of the drugs they prescribe. I know this first hand! I had difficulty with one class of drug that gave me no end of ongoing problems with symptoms that were never picked up by the prescribing doctor nor any doctor at any hospital I went to over a period of years even though I’d get a diagnosis and often, no diagnosis.

      So much for the regulated process as being touted as the “best practice” implying they are the safer drugs to take.

      Having both a science background and studied the research process I’ve yet to be impressed enough to rule out homeopathic remedies. For those who may not know the facts, we had homeopathic hospitals in Canada and the U.S. until the medical societies ensured their demise. The medical community hasn’t always recognized other professionals as having “enough” to offer “their patients” compared to what they feel they can offer.

      I’m for good research for sure but anyone without blinders on knows well enough that the current state of research trials is not always what we are led to believe it is, nor is the reporting process. Check out the Cochrane Collaboration and Dr. Ben Goldarcre’s book: Bad Pharma.

      When I was finally clued in about my drugs side effects it was a pharmacist not a doctor that told me all my problems were caused by my statin drugs. I was both relieved and shocked to think that the pharmacist is more knowledgeable than doctors. To confirm my revelation I contacted another pharmacist who went even further: ” I wouldn’t touch these drugs with a ten foot pole!” When I said “you dispense these all the time so why would you say this?” He told me: ” because I see patients with all their side effects and they are afraid to discuss these with their doctors!”

      Yes: It is time to have another role for the pharmacist: To be the watchdog for their clientele since it isn’t the doctor that patients can rely on and further: so they can support the number of real problems patients have with the drugs they take: and: TO REPORT “research findings” on an ongoing basis that the failure of the medical system hasn’t provided to the public “on the ongoing safety of the “science evidence- based trial drugs” they take!”

      So, why not add the homeopathic remedies to the trial basis? We might conclude that cold, flu and other problems patients have that they take something for other than a prescribed drug that patients say that it actually helps them without the side effects that prescribed drugs create would support they should be on the shelves of pharmacies.

      This is the type of ongoing comparative research we need.

  5. Rola Priatel

    Pharmacists should definitely be accessible to give Benefits versus Risks data and detailed information to patients on all medications including herbals as even in approved Prescription medicines the evidence lacks for many, so why draw the line on herbals? At least a patient may walk away buying nothing as the situation often happens in a pharmacy while at the health food store with a clerk behind the counter, more often that not patients will walk away buying much more than they needed or originally came in for. The conflict of interest is worse at the Naturopathic Office were the product is sold at the source of prescription! The business versus ethic sense could become more of a factor there.

  6. scott

    Health Professionals should not sell unproven medical therapies to patients, nor should they sell Coca Cola and potato chips.

    Retailers and grocers can do both.

    Pharmacists have to decide whether they want to be taken seriously as Health Professionals or if they want to be retailers.

  7. Zach S

    Another important factor in legitimizing ineffective treatments is the language that we use to describe them. The acceptance of the label “complementary and alternative” was a big win for peddlers of junk because it allows them to imply that their therapies provide added benefit or a second stream of equally effective treatments. This is exacerbated when we include effective modalities like exercise and diet change under the CAM banner, thereby suggesting further legitimacy for nonsense treatments that are offered alongside these effective methods.

    Similarly, the use of the term “natural health products” is also extremely problematic as it provides an exemption – both legal and rhetorical – to certai classes of products. How are highly processed and purified vitamin formulations any more “natural” than synthetic pharmaceuticals? Natural implies “from nature”, so unless these products are literally picked from someone’s garden (in which case they would be unapproved) then this term mis-leads the public and plays into a popular attraction to the magical powers of all things “natural”.

    A better language is needed. And until the current naming scheme can be downplayed or eliminated it will be challenging for health professionals to have legitimate conversations with clients. The inclusion of illegitimate products such as homeopathy alongside legitimate and effective treatments in the pharmacists office can only add to the veneer of legitimacy that nonsense treatments are gaining. And I highly doubt that any advice from a pharmacist can overcome the implicit marketing of placing junk alongside real medicine.

  8. Steve Roedde

    Of course the pharmacists profit when they sell essentially worthless “over-the counter” remedies already (think cough and cold “patent medicines”). In Ontario they are in a direct conflict of interest position now that they can prescribe, as well as sell, medications. Not to be trusted for any health advice! They are chemists who sell stuff…. and profit from selling it.
    In contrast, hospital pharmacists are a distinctly different breed. Skilled, objective and wise!

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