Pharmacists Role in Complementary & Alternative Medicines

The first section of this paper will provide background information on the use of complementary and alternative medicines (CAMs) and their associated risks and benefits. Additionally, information on the pharmacists’ role in CAMs and services in their pharmacies will be discussed. Next, the theory that potential ethical conflicts arise for pharmacists between keeping the health and wellbeing of clients and the community as their primary concern versus the prospect of turning a profit will be considered. Before concluding, other important ethical issues including duty of care, and liability will be discussed.

Background

The term CAM refers to any healing practise that doesn’t fall under the heading of conventional medicine. It encompasses not just pharmaceutical preparations, but diet, and traditional forms of health care including acupuncture, Chinese medicine, homeopathy, etc.1

In the past, people who sold CAMs were sometimes referred to as quacks, or someone who promotes unsupported methods that lack scientifically credible rational.2 CAMs were regarded as old wives tails, and their claims dismissed by the medical community.3

More recently CAMs have become a prominent feature in today’s health care regimens. In 2000 according to the Therapeutic Goods Administration (TGA) 52 percent of Australians were using at least one non-prescribed complementary medicine.4 The Therapeutic Goods Act of 1989 effectively legitimised CAMs by allowing them to be entered into the Australian Register of Therapeutic Goods (ARTG) as a listed medicine. They have to meet a lesser set of standards than conventional medicines, which is one of the major concerns of allopathic practioners.5 With the passing of this act, pharmacies could legitimately sell two types of products; medicines for which there is scientific evidence  (prescription and over the counter products) and unproven medications (some CAMs) that may lack efficacy.

There are many risks associated with using CAMS including direct risks, substitutions made, nonprofessional advice received, and unreliable diagnostic tests.6 In some cases, CAMs have caused serious harm. The adverse effects range from infection due to dirty acupuncture needles, altering the effectiveness of other pharmacologically proven agents, to death from chiropractic manipulation. Substitutions pose a great risk for serious conditions. Replacing conventional treatments with CAMs can lead to many adverse effects. For example, treating melanoma with a herbal ointment rather than surgery, radiotherapy, or chemotherapy can have disastrous consequences. Some patients, especially those with life threatening illnesses, will try anything to improve their symptoms. Some CAM practitioners take advantage of this and recommend treatments that are very costly and at the expense of other proven treatments. Unproven tests include, but aren’t limited to, reflexology and electro-dermal testing.6 The danger in this type of testing is the high likelihood of misdiagnosis.  Despite the large body of evidence in the scientific community of the poor efficacy of CAMs, there is some evidence for their use as seen in cranberry for urinary tract infections St. John’s Wart for depression and a variety of others.7

In 1993 Australians spent an estimated 1 billion dollars on CAMs and by 2000 that number had risen to 2.3 billion.8  Shockingly, only 57 percent of Australians reported or discussed the use of these products to their doctors.9 The potential dangers outlined above and these statistics show the need for a pharmacists intervention.

Pharmacist’s Role

Pharmacists are a vital part of the allopathic health care team, often being the first port of call for patients requesting CAMs.10  The community pharmacy is an ideal environment to deliver quality, cost effective, and professional services to the general public. Patient’s safety and access to this high quality care is of paramount importance.11 Pharmacists counsel life style choices, recommend an appropriate non-prescription medication, or refer patient’s to a physician to improve outcomes.12

When responding to enquiries about CAMs pharmacists need to consider a variety of issues. The customers’ cultural and social beliefs and desire to take control of their own treatment should be viewed non-judgementally. Pharmacists need to stay up to date, and be aware of evidence to support the use of different products. Information about CAMs should be provided on an evidence-based level so the most accurate information is delivered to the patient. Pharmacists also need to be aware of potential interactions with conventional products, and report adverse drug reactions to both the Adverse Drug Reaction’s Committee and the product’s sponsor.7 Furthermore, pharmacists must remind patients that CAMs are medications and should be openly discussed so potential interactions and side effects can be identified.

Ethics and profit

In a 2005 study of 484 community pharmacists in New South Wales 77% of respondents personally used CAMs and said that they offered CAM products for sale in their pharmacies. A majority of the pharmacists believed CAMs enhanced customers’ image of the pharmacy and 87% reported they increased customer numbers and annual sales.13

From these results it is evident that a potential conflict between promoting and selling CAMs and ethics could arise.

Pharmacists are intrinsically placed in an ethical dilemma daily. They have dual roles as health care providers and businesspeople. As health care professionals they are expected to provide a high level of unbiased health care, while their business side is expected to sell products and generate a profit.

Professional and business roles are generally believed to be in conflict with each other and roles are traditionally viewed as being exclusive. According to Chappell et al community pharmacists are one of the few occupations where professional and business values co-exist.  They found no correlation between the value placed on business and the level of care or “professionalism” displayed by the pharmacists. This suggests pharmacists are able to act dually as a salesperson but still deliver professional information.14

The degree of professionalism has been called into question by Kennedy et al. They demonstrated that in some cases pharmacists, especially proprietors, sometimes recommend more expensive products when a cheaper generic version is available, but the overall outcome was satisfactory. All pharmacists recommended an appropriate treatment for the condition but the product selected differed among owners and employee pharmacists. Although the patient received a high level of care, the fact that he or she had a cheaper option calls the level of professionalism into question.

Further evidence for professionalism is seen in a study by Perepelkin et al. where they found pharmacists, regardless of their ownership structure, are professionally oriented in their practise. The difference in services provided was only seen in terms of professional autonomy, decision-making and amount of control. There was no difference in the amount of profit-driven goals between the groups.16

Similarly, in a recent study, Kronus found that pharmacists, regardless of their role orientations (business versus professional), were similarly motivated by service and income values. She suggested that the theoretical model suggesting that business is based on extrinsic values and professionalism is based on altruistic values should be revised when talking about pharmacy. She found altruism (professionalism) was the dominant factor in the field of pharmacy. Since most pharmacists are salaried employees there is little pressure to increase profit by pushing CAMs with no supporting evidence. It would be very easy to jump to the conclusion that the need to make a profit would in some way have a negative effect on pharmacy owners or employed pharmacists (reward systems) to act as independent ethical health care providers when CAMs are viewed as huge profit generators.17 Wingfield et al suggest that ‘ethics is so integrated and intrinsic to daily practise that there is no need to single ethical issues for special attention,’ as demonstrated by a lack of a journal dedicated to pharmacy ethics (there are ethical journals for medicine and nursing). Rather the ethical behaviour of the pharmacist is displayed in all aspects of daily practise culling the drive for profits.18 In Australia the behaviour of pharmacists is guided by the Pharmaceutical Society of Australia’s Code of Professional Conduct (PSACPC).7

Pharmacists sell CAMs in pharmacies that does give credibility to CAMs and to some extent promote their usage.  Also, pharmacists are in a unique position to influence the sale of certain products. For example, CAMs are used by 60 to 80% of oncology patients. According to the British Columbia Cancer Society the psychosocial needs of patients including ‘increased anxiety, need for information, maintenance of a sense of hope, a sense of control, negative experience with conventional medicine, and perceived holistic nature of complementary medicine,’ is the reason for the high percent of people using the medicine and not the availability of the product in pharmacies.19 Pharmacists don’t need to promote these products as psychosocial needs are very powerful and patients are clamouring for these medications in increasing numbers. Although the pharmacy is a business, business objectives wouldn’t necessarily suffer, as knowledgeable and honest patient counselling plays an important role in customer satisfaction and thus profitability. An unsatisfied customer would certainly seek another pharmacy.20 These satisfied customers will keep coming back to the pharmacy not just for CAMs but for prescription and personal products as well. This is a win-win situation for both the customer and the pharmacist who now has the opportunity to play an active role in the health of the patient as well as make a decent living. It is the pharmacist who provides the factual advice for patients who seek out these products. Through professionalism this temptation to take advantage of this behaviour is easily removed. Pharmacists develop close relationships with their customers by taking time to talk about medications. Professional orientation happens because patient counselling of all medications including CAMs is at the cornerstone of ethical pharmacy practice and high quality care. As previously stated, the pharmacist’s role in counselling in the use of CAMs is the most effective in ensuring the health and safety of patients.

When counselling patients, pharmacists follow the PSACPC. By following the PSACPC pharmacists remain in the scope of their practice, are covered for malpractice liability for negligent care and for informed consent issues, and foremost, ensure the health and well-being of clients and the Australian community. Under the 9 key principles of PSACPC, counselling advice for CAM usage is about adhering to the principles of evidence based medicine and critically examining and honestly informing patients of unproven medications and therapies. Pharmacists must also respect the beliefs and judgements of patients and other health professionals while regarding the patient’s autonomy to make decisions regarding their own treatment but at the same time offering guidance and advice based on evidence-based information.21

Thus, when a pharmacist gives advice on the use of Cams based on PSACPC guidelines after considering clinical and patient factors there may be commercial benefits but they do not necessarily compromise the quality of the recommendations. In pharmacy, ethics and profit can and do exist without conflict in the sale of all products.

Duty of care regarding informed consent

As outlined above a majority number of Australians are using and want to use CAMs. It is therefore the duty of pharmacists to discuss these treatments with their patients.22

A study in the US found almost three-quarters of the pharmacists surveyed worked in stores where herbal medicines were sold.23 Almost half of the pharmacists agreed with the statement, ‘herbal medicines are not accepted by the majority of my colleagues’ and only a quarter agreed with the statement ‘herbs are efficacious’.24 25 It can be seen that most pharmacists don’t believe in the products so recommending them is difficult. But, they have an ethical obligation to adhere to the PSACPC and respect the autonomy and dignity of the patient to make informed decisions.21 Once the pharmacist has disclosed and openly discussed the different treatment options his or her ethical obligation has been fulfilled. In the United States this is taken one step further.  It is a legal obligation for practioners to disclose information for CAMs if they are generally accepted within the medical community. Failure to do so can result in legal action.26

Liability in referring to CAMs

Liability issues are new territory for pharmacists recommending CAMs to patients. Homeopathy, for example, is completely contradictory to the principles of modern pharmacology. The incompatibility of homeopathic paradigms with all of basic science must be taken into consideration.22

Keeping in line with the PSACPC, pharmacists cannot ethically recommend a product or service to which they know there is no evidence to support its use, and is not in the best interest in the health and well being of the patient or community. In Canada, The Pharmacy Code of Ethics requires pharmacists to never knowingly provide any products which are not good quality.27  In the United States medical practitioners can be held liable for referring patients to a CAM practitioner if they “should have known” the CAM practitioner might be “incompetent”. This shows that medical professionals are not just ethically but legally responsible for protecting patients from inferior medical treatments.28 CAM practitioners argue that their treatments are holistic and some of the therapeutic benefits are unmeasurable. Because western medicine supports evidence based on quantifiable outcomes the two doctrines of practise often clash. It is very difficult to compare the spiritual healing power of CAMs to the physical healing of western medicine.28 As long as the CAM treatment is not interfering with a patient’s level of care, there is no reason to discredit a potential treatment that may make a patient ‘feel’ better. An honest answer to the efficacy of a specific CAM and reporting that some people say it makes them feel better is the best course of action.

Further compounding the issue is the training level of the CAM providers. Most are not ‘health care professionals’ and have inadequate understating of biology, pharmacology, patho-physiology, and other sciences that govern western medicine. Since pharmacists cannot ethically refer a patient for a treatment that they believe may affect their health or wellbeing the ethical dilemma of whether to recommend this option is exacerbated. Although, a recent Canadian study reported only 2% of pharmacists felt they had adequate information about complementary and alternative health care, they are still better suited than CAMs to provide information on the prodcuts.10 A pharmacists guidance is based on principles 1 and 8 of the (PSACPC), advising patient of the scientific evidence available while still respecting their autonomy.28 Where CAM providers have no such code of ethics.

Conclusion

This paper examined the background issues associated with complementary and alternative medicines (CAMs) and the associated risks and benefits that go along with them. Additionally, the pharmacists’ role in providing CAMs was discussed. The many ethical issues, including profit, although seemingly complex can and should be negotiated using the PSACPC guidelines. The introduction and sale of CAMs have not changed the pharmacist’s code of ethics where the patient’s well-being and health remains the focus. As CAMs are becoming more popular and accepted by the public, pharmacists need to have a high level of understanding of the many issues associated with them. The ethical issues pharmacists face daily are apparently being handled appropriately according the literature cited, and based on the public’s perception of pharmacists being one of the most trusted health professionals.