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Community pharmacy

Pharmacists must move with the times

Pharmacists should leave quackery in the past and focus on evidence of efficacy when selling over-the-counter drugs.

Painting of an 18th century apothecary

Source: Jean-Loup Charmet / Science Photo Library

Community pharmacists should stop selling over-the-counter (OTC) medicines that have little evidence of efficacy if they want to ensure the best treatment for patients.

Although evidence-based medicine (EBM) is widely used for prescribed drugs, it is not currently utilised for OTC medicines in community pharmacies.

Pharmacists have long been providing advice to prescribers based on evidence. Before EBM became widely used in the 1990s, pharmacists ran medicine information centres and answered complex drug queries using the best available evidence. Pharmacists were involved in the development of EBM and its propagation via drug and therapeutics committees, and more recently working with the National Institute for Health and Care Excellence (NICE).

By its very nature, pharmacy is an evidence-based profession in both primary care and hospital care and the industry is undergoing a period of change. Future models of community pharmacy practice that focus on management of long-term conditions will place an even greater reliance on EBM.

Well, that is the case with prescribed medicines. When it comes to OTC products, pharmacists’ approach to evidence seems to be forgotten, with a “what the public wants, the public gets” attitude taking precedence. Of course, patient choice is important. A multitude of factors contribute to customer decisions on OTC products, including culture and health beliefs. These factors also apply to prescribed medicines, but that has not prevented the application of EBM to prescribing.

While the secret shopper work carried out by the consumer watchdog Which? in 2013 investigated[1] the quality of advice on OTC medicines given in pharmacies at the point of sale, an earlier report[2] in Which? published in 2012 focused on OTC products themselves. Among the products that were judged to be below par were sub-therapeutic doses of drugs, dubious herbal slimming tablets, oils that allegedly reduce scarring and some highly implausible alternative remedies. A pharmacist drawing up a local formulary of prescription drugs for a GP would take into account evidence of effectiveness, advice from evidence-based guidelines and a positive risk-benefit ratio. How many OTC products would reach the required standard?

Pharmacists need to find a way to address the apparent double standard in the supply of OTC products. Changes in undergraduate pharmacy education aim to improve the integration of science into practice, but graduates are then placed in a commercial environment that pays scant regard to the application of EBM. Training given on OTC advice is rightly concerned with management of risk and appropriate referrals, but a focus on the suitability of products available within the pharmacy is also required.

The OTC products sold in pharmacies can be split into three categories.

Firstly, the products that would look more at home at a magic fair: electronic machines to improve circulation, red lights to shine up nasal cavities to prevent hay fever, the ubiquitous homoeopathy (clearly against the chemistry that is considered the foundation of pharmacy) and many nutritional supplements. These products undermine the scientific credibility of pharmacists.

The second category is OTC medicines with a basis in science but which lack clear evidence of effectiveness. One example is the rationale for cough medicines that is based on mechanistic explanations of their potential effects, rather than hard outcomes from randomised controlled trials. In this example, drug combinations can be illogical and are often more likely to bring about an adverse drug effect or no effect, such as an expectorant with a cough suppressant. Systematic reviews of cough medicines show a lack of effectiveness, while the lack of a favourable risk-benefit ratio has led to the Medicines and Healthcare products Regulatory Agency (MHRA) restricting their use in children. Although products in the second category may often be requested by the public, pharmacists could sideline or not stock those with the least evidence and medicines with the greatest risk-benefit concerns. Certainly, the lack of evidence of effectiveness must be communicated clearly to patients.

In the third group are OTC medicines for which there is clear evidence of effectiveness, and which can be sold with confidence. Many of these have been used for many years and have data to support their use, such as antifungal creams and painkillers. Others are more recent additions (e.g., sumatriptan, chloramphenicol eye drops), and a greater range of these products would be of benefit to the public and the profession.

There is an argument that the availability of some of the less effective products in pharmacies creates an opportunity for pharmacists to reach patients with more serious health problems and enable referrals. Treating minor ailments through pharmacy also reduces the burden on NHS resources. None of this means the current culture around OTC medicines is defensible. Pharmacists have the skills and knowledge to embrace EBM in the OTC setting, but it is a challenge they are yet to take up[3].

Pharmacists are not alone among health professionals in occasionally endorsing quackery, but they do claim to be the “experts in medicines” and have been branded as “scientists on the high street”. These are justifiable claims to be proud of, but it is time to extend the good work done with prescribed medicines to all medicines: not just how we sell them but, in the case of some products, whether we stock them at all.

 

The OTC market

  • The current value of the UK over-the-counter (OTC) market is £2.5bn.
  • In 2013, sales of OTC medicines totalled 942 million packs.
  • The highest value product categories are pain relief (£544m), cough/cold/sore throat (£444m) and skin treatments (£415m).

Source: International Research Institute

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2014.20066088

Readers' comments (6)

  • I am a big fan of evidenced based medicine and where there is evidence of harm, then such products should not be sold. But there are pharmacists who are registered homeopaths, registered herbalists, or qualified to sell nutritional supplements. Are you suggesting they should not be allowed to sell such products from their pharmacy?

    I personally don't want to be the 'scientist on the high street' (a description I am not sure any member of the public would recognise) but I do want to be seen as an expert in medicines. And that is is how I believe the public recognises us. But medicines are supposed to help people feel better......and there are some very unscientific things that come into play at that point.

    If all the products you disapprove of are removed from pharmacies the people who want them will go the Holland and Barrett. At least if they are in the pharmacy we are in a position to intervene if they are purchasing something that will interact with their prescribed medicines. Pharmacies not stocking them will not remove the demand.

    I had a conversation the other day with the wife of a pharmacist who could not understand how I could be a registered pharmacist and a complementary therapist qualified in (among other things) reiki and indian head massage. The answer is simple. By applying scientific method I have discovered science doesn't have all the answers.

    There is as much art as there is science when it comes to what makes people feel better.

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  • In my experience for every scientific article praising a drug or appliance there are just as many articles deriding them.
    The public are overwhelmed with conflicting reports of evidence of the benefits or dangers of the same drug etc, and so rely purely on the most recent advertisement in the paper or on TV.
    It is not the pharmacists who are to blame for selling drugs and appliances of dubious use it is the media, who happily accept the advertising revenues for a product one day and a week or two later blame Community Pharmacist for selling them.
    The basic problem of Community Pharmacy is the way we are financed to do what we are qualified to do,
    .There is no profit or advantage in telling a customer that a drug is a waste of money especially if your PLC Multiple Pharmacy chain has set targets for the number of units sold.
    Do not blame Pharmacists for dubious products --Blame the System we work with

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  • I can agree with this article. I particularly identify with the post-registration feelings of 'where is the evidence for that?' on arrival in community pharmacy. Personally, I won't recommend anything that I wouldn't buy myself, so that rules out the many derivatives of Sudafed and Lemsip with identical or similar ingredients/formulations. You could quite literally put every worthwhile OTC product in community pharmacy on one shelf. But with £2.5bn in sales, don't expect the manufacturers or the PAGB to line up to support evidence based OTC...

    I can also agree with some of Sally's comments. Whilst I wouldn't recommend some of the questionable products, I wouldn't deny patients the opportunity to use them. Perceived effectiveness isn't always attributable to chemical efficacy - belief and placebo have their part to play in personal wellness.

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  • 100% of what Tariq said

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  • Sally Haynes: the fact that some pharmacists are homeopaths is a point against you, not for you.

    It is not clear to me how anybody can complete a pharmaceutical education and leave with a belief in homeopathy intact. Where in the average pharmacology degree are you taught that like cures like, or that dilution increases potency? Where are you told that the Avogadro number doesn't matter if you shake the product in the magical way? At the very least this would require a validated rule for the number and force of shakes, but in fact homeopaths cannot even agree if the magic shaking is necessary at all.

    Not only is there no good evidence that homeopathy works other than as a placebo, but there is no reason even to suppose it should work - and of course no remotely plausible way that it could work.

    Homeopathy is actually a great litmus test. If someone's method for separating truth from falsehood does not lead them to discard homeopathy, then their method is flawed and requires revision.

    In the UK we're conditioned to think of homeopathy as a harmless delusion, fit for the imagined ills of the worried well. Most British pharmacists are likely unaware that there are homeopaths in the UK promoting sugar pills as a cure for everything form Ebola to cancer, homeopaths proposing sugar pills as an alternative to vaccines (including, shockingly, the owner of Ainsworths pharmacy), homeopathic colleges that teach germ theory denial. Yes, you read that right: in the 21st Century homeopaths in the UK are being taught that viruses and bacteria are symptoms, not causes of disease.

    I think we will know that evidence is finally taking the lead over dogma and superstition when homeopathy is no longer available form any British pharmacy, doctor or NHS-funded clinic.

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  • I am still surprised when eminent science writers, who are supposed to be rational and objective, use emotive works like ‘quackery’ to push a point home. This article makes an accusation and infers there is some willful fraudulent medical practice, on the part of industry, which is not true.
    In the case of homeopathy, like it or not the remedies in common use are medicines in both EU and UK law. There are monographs and methods for their manufacture in the European Pharmacopoeia (PHEur) for goodness sake. The UK homeopathic manufacturers are a well established and vibrant part of the British pharmaceutical industry. Community pharmacists can still be in receipt of an FP10 for a homeopathic medicine prescribed by a specialist doctor. A significant number of medicines used in practice are not high dilutions but low dose poisons needing a pharmacists knowledge of contra indications and drug interactions.
    Homeopathic medicines are licensed to the same standards of quality and safety as any drug and their traditional use data is a legally recognized reference for products with indications. The same goes for herbal medicines and these traditional use products are here to stay and as medicines should be part of the remit of pharmacy. Pharmacists are rightly free to choose what they provide and are obliged to have the necessary training and knowledge to support their choices.

    If you cull all the OTC products on pharmacy shelves, which do not yet have the clinical evidence required, who will benefit? The health shop industry for sure, but not the customer for whom that cough mixture or supplement worked. Also our own fellow RPS members, particularly the already NHS squeezed independents, will only suffer further as their denuded shelves force them into more diversity or retirement.

    John Morgan MRPharm.S
    Helios Homoeopathy Ltd

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