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.
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 the quality of advice on OTC medicines given in pharmacies at the point of sale, an earlier report 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.
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
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