Editorial
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Complementary Medicines Surveyed
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PDF version | Neil Johnston |
Neil Johnston is a pharmacist who trained as a management consultant. He was the first consultant to service the pharmacy profession and commenced practice as a full time consultant in 1972, specialising in community pharmacy management, pharmacy systems, preventive medicine and the marketing of professional services. He has owned, or part-owned a total of six pharmacies during his career, and for a decade spent time both as a clinical pharmacist and Chief Pharmacist in the public hospital system. He has been editor of i2P since 2000. | |
Recently, a research report was published online in BMC Complementary and Alternative Medicine that highlighted Australian consumer attitudes towards complementary medicines and pharmacists selling complementary medicines.
An abstract is published below.
Consumers have indicated in earlier surveys that they wanted pharmacists to be the primary source of information for them and to keep a range of products that they could feel safe with.
The profession initially responded to those needs with the PGA setting up a College of Clinical Nutrition and many pharmacists (including this editor) completed the Advanced Diploma of Clinical Nutrition (Pharmacy).
Unfortunately, the college was closed and an alternative resource was never re-established.
People who did receive training in the use of nutritionals gained a new perspective in respect of practicing their profession and tended to work in the area of preventive medicine when an opportunity presented itself.
We have again asked Mark Coleman to comment on the survey and his report appears below the article abstract.
Perceptions, use and attitudes of pharmacy customers on complementary medicines and pharmacy practice
Lesley A Braun email, Evelin Tiralongo email, Jenny M Wilkinson email, Ondine Spitzer email, Michael Bailey email, Susan Poole email and Michael Dooley email
BMC Complementary and Alternative Medicine 2010, 10:38doi:10.1186/1472-6882-10-38
Published: 20 July 2010
Abstract (provisional)
Background
Complementary medicines (CMs) are popular amongst Australians and community pharmacy is a major supplier of these products.
This study explores pharmacy customer use, attitudes and perceptions of complementary medicines, and their expectations of pharmacists as they relate to these products.
Methods
Pharmacy customers randomly selected from sixty large and small, metropolitan and rural pharmacies in three Australian states completed an anonymous, self administered questionnaire that had been pre-tested and validated.
Results
1,121 customers participated (response rate 62%). 72% had used CMs within the previous 12 months, 61% used prescription medicines daily and 43% had used both concomitantly. Multivitamins, fish oils, vitamin C, glucosamine and probiotics were the five most popular CMs. 72% of people using CMs rated their products as 'very effective' or 'effective enough'. CMs were as frequently used by customers aged 60 years or older as younger customers (69% vs. 72%) although the pattern of use shifted with older age. Most customers (92%) thought pharmacists should provide safety information about CMs, 90% thought they should routinely check for interactions, 87% thought they should recommend effective CMs, 78% thought CMs should be recorded in customer's medication profile and 58% thought pharmacies stocking CMs should also employ a complementary medicine practitioner. Of those using CMs, 93% thought it important for pharmacists to be knowledgeable about CMs and 48% felt their pharmacist provides useful information about CMs .
Conclusions
CMs are widely used by pharmacy customers of all ages who want pharmacists to be more involved in providing advice about these products.
Mark Coleman
I have been asked to comment on the above survey, so here is my 5 cent's worth.
Most of the information contained in this survey has been known in some way previously, but this survey neatly quantifies this knowledge.
It also illustrates that the community at large has identified a need and that most community pharmacists have ignored that need.
Given that there is such widespread usage of complementary medicines (CM's) across all age groups and the need exists in consumer minds for some aspects of information and services, why hasn't this void been filled?
Certainly the cessation of the Pharmacy Guild College of Nutrition may have blunted the training aspects to equip pharmacists for the job, but there are alternatives.
Given the further need for pharmacists to earn CPD points to maintain their registration, the PSA may be able to step in here and fill a gap by nominating a reliable educational organisation, or tailoring some of their own courses.
The use of nutritionals and certain other complementary medicines has a place in preventive medicine which is certainly a direction that pharmacists should be planning for.
Complementary medicines is just one segment of pharmacy activity that is not being done very well.
Another is that of Schedule 3 medicines.
Specialised cosmetics to assist patients after surgery is another that comes to mind, along with the supply and fitting of surgical aids and assisted living needs, also wound dressings and the provision of information to manage wounds.
Why not group all of these specialty activities together under a clinical pharmacist aided by a well-trained clinical assistant and separate these out of the normal retail flow, as well as the dispensing flow?
Focusing attention on these specialties will provide the marketing approach that would automatically include provision of information and patient counseling that is difficult to provide within existing work-flows and shop design.
Some attempts to correct the marketing approach currently utilised to service the above specialties have included the use of a separate room to create a privacy environment.
Systems also need a review and a program that could be adapted for the dispensing of complementary medicines would be a first priority, closely followed by an electronic library of references to support the use and recommendation of various complementary medicines.
Recording of all clinical information may make a valid contribution to patient primary care and also take its place along with other electronic health records.
It could validate a place in the new primary health care organisations currently being established.
It is also true that many complementary medicines are not evidence-based and it is here that pharmacists could provide some sort of a clearing house to qualify some of the information that is freely available to patients on the Internet.
As I have commented in this column previously, just because a complementary medicine has not had clinical trials established, it does not mean that it will not work.
Complementary medicines don't represent a great opportunity for manufacturers to patent and make super profits (as in the drug arena) so there is no incentive to fund clinical trials.
However, this is an area in which pharmacists can utilise their training and experience to guide a patient who wishes to use a particular CM.
The survey above indicates that many people access CM's and it follows that done properly, pharmacists could make this a safe experience.
I don't buy the argument that because pharmacists are involved in the sale of CM's that this in some way represents unconscionable conduct as some critics claim.
But there is an obligation to provide the best evidence available, or at least inform the patient that the evidence is weak or non-existent, with the final decision left up to the patient.
Most CM's are currently self-selected by patients without any professional advice.
The above survey discloses that 72% of patients rated their CM products as "very effective" or "effective enough".
That is a very high satisfaction level and is one that would not be emulated in the orthodox medicine area.
The survey also notes that many patients want a CM practitioner on staff.
Perhaps this is because the pharmacist is not readily available because the dispensing of orthodox medicines is the primary focus, or it may be that the pharmacist is inadequately trained.
Whatever the reason, I believe that if a pharmacist fronted in the complementary medicines area, there would be immediate acceptance and that segment of the business would begin to provide a great return on invested capital.
Of the people surveyed, 92% wanted a pharmacist to provide safety and other information pertaining to CM's.
Responding to the survey results is a simple marketing exercise.
Ignoring the survey results means that some other health profession (maybe nurses?) will train up and fill the gap. Many already do naturopathy in conjunction with their nursing degree.
Despite criticism by certain groups, the survey results indicate that the community wants complementary medicines and is prepared to do their own research and purchase on their own responsibility.
Let it be transparently seen that pharmacy supports their choices by ensuring that safety issues are attended to.
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Submitted by Peter Kennedy on Thu, 30/09/2010 - 10:40.
I see, you refuse to address the points I have made and merely continue your personal attack on me. I have no "agenda" as you scurrilously assert, other than wanting to refute fallacies and make known the facts. I welcome the fact that others have alternative viewpoints to mine, and I have made no suggestion that I wish to suppress their opinions as you scurrilously imply.
Not that it's any of your business, or of any relevance to the facts of the matter which I for one am trying to discuss here (though it seems like a one-sided conversation), but I do not have any vested interest in this matter and I am a qualified health practitioner. How about you? Maybe you work for the immensely profitable billion-dollar so-called "alternative" medicine industry. I don't care whether you do or not, but for Pete's sake address the points at issue and stop "playing the man and not the ball".
Submitted by Peter Kennedy on Mon, 27/09/2010 - 08:56.
If I am "manipulating" your words in any way, please explain how? I am merely highlighting the contradictions in what you have said.
I don't mind debate, but please don't turn it into an ad hominem attack on me. Address the facts and the points I have made, not the person who happens to have made them.
Submitted by Mark Coleman on Mon, 27/09/2010 - 17:59.
No attack, just the answer to the two simple questions that were asked:
"Do you work for a drug manufacturer?
If not, what are your formal health credentials?"
It is not unreasonable to try and understand what the underlying agenda is.
I am beginning to sense that you may be closeted away in the health bureaucracy somewhere.
Nothing wrong with that but thank heavens there are others with an alternative viewpoint.
Submitted by Peter Kennedy on Tue, 10/08/2010 - 11:46.
Dear Mark,
I certainly didn't mean to be "offensive" to anyone. I thought that what I said was a fair paraphrase of what you had said. I am glad to see that I had misunderstood you and that you have now explained that you wish pharmacists to use at least some professional scientific rigour regarding what they say about so-called "complementary" medicines. Perhaps even equal to the rigour which they would apply to medicines which have been proven to work?
If a manufacturer of a fish oil product was able to show that his product has "known benefits to the vascular system and blood lipids" and so was able to supply it as a Registered medicine, rather than merely a Listed medicine, it may be appropriate for a pharmacist to recommend it.
But if there is any chance that a Listed medicine, which by definition has not been shown to be effective and may be of no benefit, might interfere with treatment with such a potent drug as warfarin, surely the only scientifically logical professional advice, from a Quality Use of Medicines and best-practice patient care perspective, would be "DON'T take the Listed medicine". Not "Keep taking it but adjust the dose, dosing time and brand to try to avoid the problem"!
Submitted by Mark Coleman on Sun, 15/08/2010 - 15:23.
Dear Peter: I expect pharmacists to diligently employ their training and apply their own professional discretion.
That does not mean to the exclusion of complementary medicines.
The rigour that you imply is the preserve of medicines that have proven to work has to be balanced in respect of the harm they have proven to inflict.
For example, the evidence-based research that launched drugs such as Avandia and Vioxx is tainted by the known side-effects that lead to heart failure.
My personal wish would be to see these types of drugs totally banned.
Fish oil has had many studies done over the years and is endorsed by reputable organisations such as the National Heart Foundation.
My hope is that some of the reputable manufacturers of this product will begin the process to have it listed as a Registered Medicine. In the interim I am happy to recommend the use of this product because of its safety profile.
And as for its use with warfarin, a drug with a high risk profile I prefer that a lower dose coupled with the benefits of fish oil creates a better outcome for a patient.
When a patient presents with a prescription for warfarin, it is a general problem that the patient will already be taking other prescription drugs that will interact with warfarin.
Titration of warfarin against a known intake of medications and dosage times is standard practice and the addition of fish oil to the mix should make no difference.
That has been my experience and I will continue to go with what I believe in my professional discretion, is the best and safest option for such patients.
Submitted by Peter Kennedy on Wed, 18/08/2010 - 13:04.
You hope that someone someday will be able to prove that fish oil works so that it can become a Registered medicine. Yet your personal wish is to see Registered medicines (those which have been proven to work by evidence-based research) totally banned. Sorry but I am quite unable to comprehend any logical processes behind your comment.
Submitted by Mark Coleman on Wed, 18/08/2010 - 18:23.
Hi Peter: I think you enjoy the argument more than any form of objectivity.
What I said was that we have many dangerous medications on the market (and there is no doubt about the medications quoted - Avandia and Vioxx), that entered the marketplace through a dubious and manipulated process.
"First do no harm" is how we are supposed to work - if you want to use medicines shown to be harmful then I would not like to be under your care.
Fish oil, on the other hand, has had numerous studies done and it is very safe.
As I pointed out, reputable organisations endorse its use because they achieve benefit.
Whether it is registered or not is immaterial to me, because I know first hand of its benefits and will continue to use it.
If registration is possible for a nutritional supplement, then that simply provides a higher level of confidence for skeptics like yourself - it doesn't make it work any better, just more expensive.
If you can prove it to be harmful I may consider an alternative.
Submitted by Peter Kennedy on Wed, 22/09/2010 - 15:02.
You claim that the process for proving that medicines are safe and effective has been in some cases "dubious and manipulated".
If this were true the obvious course would be to tighten up the process. Instead your proposed "solution" is to abandon any pretence of testing medicines for safety and efficacy at all, on the grounds that its only effect is to make medicines more expensive!
And in the same breath you hypocritically accuse ME of being needlessly argumentative and of not being objective! Well you have a lot of chutzpah, I'll give you that.
Submitted by Mark Coleman on Wed, 22/09/2010 - 17:42.
Hey Peter - I don't mind debate but I will not chase the manipulated form of words you are responding with.
Do you work for a drug manufacturer?
If not, what are your formal health credentials?
Mark
Submitted by jenn on Thu, 05/08/2010 - 03:19.
There can definitely be some major drug interactions when it comes to CMs, and I agree that recording CM information down in a patient's profile is ideal. Nonetheless, (or perhaps logically, given the focus on EBM) the approach towards CMs in the pharmacy school I attend tends towards nonchalance at best, and 'snake oil alert!' at most. Except for a few notables, like fish oil, that have made it into guidelines. At least they're actually covered, and we did do a project on some, though. :)
Submitted by Peter Kennedy on Wed, 04/08/2010 - 11:27.
"if a pharmacist fronted in the complementary medicines area, there would be immediate acceptance and that segment of the business would begin to provide a great return on invested capital."
You seem to assume that a professional pharmacist would say "take this stuff, it works!" when he knows that it doesn't, so that he can increase his income.
Is it professional for a pharmacist to "support the choices" of ignorant people who want to "purchase on their own responsibility", encourage their ignorance and intervene only if there are glaringly obvious "safety issues"? Why should he remain silent, or even lie, about lack of efficacy issues?
Submitted by Mark Coleman on Sat, 07/08/2010 - 07:24.
Peter, it is well known within pharmacy that if a pharmacist is able to "front" for any department within the pharmacy, there is an exchange of information and a sales stimulus is the result.
Consumers want access to pharmacists and one of the frustrations of pharmacists is that they are often bound down under the pressure of PBS dispensing and cannot provide the service they would like.
Given that most pharmacist information is provided free of charge, there has to be a balance in all activity to ensure that the pharmacist is able to be paid.
This does not mean a dishonest exchange.
For example a patient may be taking a fish oil supplement and has been prescribed warfarin.
If the fish oil dose is variable in strength and is taken at different times of the day, it may cause fluctuations in INR levels that might be unsafe.
My advice to that patient would be to standardise on one brand of fish oil, standardise on the dose and time taken, let your doctor know you are taking fish oil and ask your doctor to titrate warfarin against that process.
The patient benefits because the dose of warfarin generally will be lower to reach the target INR plus continue to receive the known benefits of fish oil to the vascular system and blood lipids.
From my point of view I have given information for the patient to take responsibility for their condition in a safe manner.
The fact that it may increase the sale of fish oil to that patient is acknowledged, but it is not an improper process and does not have to be defended.
Your inference that I would say "take this stuff, it works" for any complementary medicine is offensive to me and any other pharmacist.
Your other comment regarding supporting the choices of ignorant people is also offensive.
The primary health objective is to enable patients to take control and be responsible for their own health conditions.
Patients these days are decidedly more health literate and use the Internet as a primary source of information.
It is definitely the job of a pharmacist to help interpret and modify that information to ensure patient safety.
It is also a pharmacist responsibility to highlight lack of efficacy or suggest alternatives from within their own professional experience.
Government nominated pharmacists as the best equipped health professionals to be gatekeepers for complementary medicines and provide advice based on their formal training in pharmacology.
This is not necessarily perfect, but it is, for the moment, the best solution.
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