The debate on complementary medicines is often so polarised that to date it’s been hard to move forward, says one pharmacy researcher who has created an ethical framework for the sector
The University of Queensland School of Pharmacy Dr Adam La Caze has looked at the ethical challenges for pharmacists posed by the sale of complementary medicines – many of which lack a substantial evidence base – and how pharmacists can improve their use.
Alongside UQ’s Amber Salman Popattia, Dr La Caze has published An ethical framework for the responsibilities of pharmacists when selling complementary medicines in Research in Social and Administrative Pharmacy.
“The discussion so far gets stuck in two extreme points of view – and we need a kind of gateway between those two,” Dr La Caze told the AJP.
One stance is that “unless you’ve got perfect large-scale randomised trials, we can’t possibly have them in pharmacy” while the other, he says, is “We have no obligation whatsoever – we’re just sales people”.
“I think the way the discussion ends up is always between those two – and there’s somewhere in between where we can act to resolve some of the conflicts,” he says. “They come up, but no-one tries to resolve them.
“This is a deliberate attempt to resolve some of those conflicts.”
The research paper recommends pharmacists:
- Provide consumers with evidence-based recommendations, train their staff to do the same and refer to a pharmacist when required;
- Provide sufficient information for consumers to make informed decisions;
- Set up pharmacy processes so consumers are offered advice from a pharmacist when purchasing complementary medicines;
- Ensure pharmacists are available to advise staff and customers;
- Be vigilant for complementary medicine harm and intervene if risk of harm is significant.
The two authors “used a really common ethical framework, the Bioethical Principles, started with that and looked at the actual context of complementary medicines and selling complementary medicines in pharmacy”.
“We recognise that these products are regulated in such a way that the regulatory bodies have decided that they’re safe for self-use, and widely available all over the place,” Dr La Caze says. “Once you accept that they’re on the market, we think the key question is: how can pharmacists make a contribution to the wide use of these complementary medicines?
“And that’s where we can start to have a discussion about the fact that they’re everywhere, so how can pharmacists help?
“There are things pharmacists could do less of, like suggesting that it’s going to work for particular conditions when there is no evidence that it does.”
He cited media reports over recent years, such as a Four Corners piece a couple of years ago on the subject of CMs, saying that “all these were kind of pointing out: can you trust your pharmacist to tell you about CMs?”
“One of the key things that I learned from that was that when people get really nervous is when pharmacists say ‘it works’. It wasn’t really about selling them; it was that pharmacists were saying they work.
“That’s something we can do less. We can be careful about how we talk about therapeutic claims in regard to CMs, and recognise that there’s some CMs that have good evidence, and it’s appropriate to sell them on the base of that evidence, but with others we have to be much more careful about how we talk about their possible benefit.
“Part of it is being clear, saying that we don’t know, we don’t have good evidence for it, but it’s available and if you want to try it it’s safe.”
There are also things pharmacists can do more in this space, Dr La Caze says.
“We can proactively have conversations about complementary medicines. Where possible, part of the framework is that when people come to purchase CMs, ask them would they like to talk to a pharmacist.
“One of the arguments for having them in pharmacy is that pharmacists can do a lot to aid quality use of CMs, but to do that we’ve got to be involved.
“The first level is offering advice. If they don’t want that, the medicines are regulated in such a way that they’re safe and we should respect that, but if they do take it up we have some obligations about how we then give that advice.”
This includes talking about CMs in conversations about prescription and OTC medicines, and vice versa.
“The model we’re talking about is pretty much the model we have with OTC medicines,” Dr La Caze says.
“Part of it is recognising the commercial pressures pharmacies have, but as much as possible, trying to be proactive with CMs and being a place where we can help people.”
View the framework here.