Pharmacists, not pharmacy assistants, need to intervene more in complementary medicine, writes Karalyn Huxhagen
Self service of all complementary medicines in pharmacy comes with a plethora of issues. How many times have you had a phone call from a customer who says, “I bought this product from your display and I am now reading the packet and it says not to be taken if you have asthma. I have asthma, can I return the product please?”
Have you ever really sat down and thought about your duty of care and liability in relation to selling these products with no intervention or discussion with a trained health professional? I know customers can purchase the same items at a supermarket, clearance store or online, but what should a trained health professional such as a pharmacist really be doing?
Should the person handling the sales of these items be asking the questions that we apply to sales of Pharmacy Only and Pharmacist Only medicines?
I recently performed a HMR for a GP with a great deal of experience who was having a lot of issues with controlling warfarin levels for one of his patients. This lady had lived in far western Queensland and recently retired to the coast.
She has debilitating labyrinthitis and has nearly died previously from a medication interaction causing toxicity to her kidneys.
This lady is clutching at anything for pain relief for two dry sockets she has had since July last year post two dental extractions. She has a belief that mainstay medicine is trying to kill her so she has explored the area of complementary medicine for pain relief.
I cannot blame her as mainstay medicine has failed her by her lack of access to quality follow-up for her dental issues.
At the HMR I discovered three products containing Turmeric, three products that had varying probiotics, vitamins and some minerals and a low-dose Magnesium.
Her daughter had bought some products through a party plan online and sent them to her, she had bought some from the lovely girl in the vitamin section of the pharmacy, and a couple of others from the supermarket.
There were double-ups, insufficient dose for effect and some probable culprits affecting the INR.
Patients requesting complementary medicines in pharmacy, in my opinion, are often really a Medscheck patient. You need to delve to find out the following:
- Who is the medicine for?
- What is the problem that requires treatment?
- Who recommended this product?
- What other medications and CMs are you taking? (do not forget to ask about liquid supplements as the ‘shots’ are often seen as a food and not a CM)
- What have you already tried?
- How long have you had the problem?
Does this look like the protocol questioning for Pharmacy Only and Pharmacist Only medicine requests?
In discussion with the lady above, it transpired that she had taken advice from anywhere that she could. She was an intelligent person but has been debilitated by the ongoing pain of the dry sockets.
A trial of Topamax for the labyrinthitis had nearly killed her as it dropped her BP to virtually non-existent, so she was not keen on TCAs or medications for neurological pain.
There are several questions to consider at the HMR, including: Does Turmeric affect INR? The literature is varied on the answer and the general opinion is no.
In practice I am wary of Turmeric and and anticoagulants, as Turmeric is such a variable herb. It has many properties that are variable in research.
It is a hot herb. Many of the pain patients I see use it, but they do so in a variety of forms and there is so much discussion about which form is pure and best!
I see roots, scones, biscuits, powder, capsules, shots and so much more. Powder taken in honey and some taken in their nutrabullet mixture or similar device.
On discussion with this lady about all of her CMs, she was adamant that the girl in the vitamin section of her local pharmacy was very helpful.
But some of the comments and statements she made about the use of her various products rang alarm bells for me as they were not backed by evidence in my clinical experience.
Had this patient misunderstood the pharmacy assistant? Did this pharmacy assistant have the knowledge that she should have? Is this another area where pharmacy should be providing written detailed advice with the products that they are recommending?
This is why I believe such a case presents an opportunity for a Medscheck consult with a pharmacist.
I use CMs regularly in my practice, but I ensure that I have the clinical knowledge and research to back my recommendations. There is quackery and there is a lot of sub therapeutic dosing in some products.
If one of my patients asks for something from left field, I look at the ability of the product to cause harm or interaction. I also investigate whether there is reliable evidence for benefit.
The amount of money that some patients spend on CMs is exceptional at times. But in the same conversation they will criticise the cost of the GP visit and the cost of regular prescriptions for mainstay medicines.
So my original question still stands. Is self selection of product with no intervention by a competent health professional giving the patient the best service and health outcomes?
My second question is: as retailers of these products, do we have a duty of care to maintain adequate competency and clinical knowledge about the ingredients in the products we sell?
Karalyn Huxhagen is a community pharmacist and was 2010 Pharmaceutical Society of Australia Pharmacist of the Year. She has been named winner of the 2015 PSA Award for Quality Use of Medicines in Pain Management and is group facilitator of the Mackay Pain Support Group.