CAM and pharmacists: challenge or opportunity?

Use of CAM has increased dramatically over the last 15 years.¹–4 Self-medication with natural health products or dietary supplements, including herbal medicines, vitamins, minerals, essential fatty acids and homoeopathic medicines, makes up the majority of CAM use.¹,² Most pharmacies in North America and Europe sell CAM products, especially herbals, and pharmacists report receiving many questions about them.³,⁵–7 The majority of herbal products sold in Canada and the USA are purchased in pharmacies and surveys suggest that approximately 40% of those who purchase a herb in a pharmacy ask the pharmacist questions about the herb they select.⁸–10 So does this mean that pharmacists see this situation as an opportunity to help patients make informed choices about CAM products and as a way to improve their businesses? Yes and no.

For a number of reasons, pharmacists appear to be in a good position to provide patients with evidence-based information about CAM products, especially regarding potential interactions with conventional medications. Pharmacists are readily accessible to patients at the point where they are making decisions about purchasing CAM products. Pharmacists also have the knowledge and experience to help patients determine when self-medication is appropriate and when the expertise of another healthcare provider is needed. Training in pathophysiology and pharmacology gives them the background necessary to interpret and evaluate studies of CAM products and theoretically places pharmacists in an excellent position to determine if a CAM product is a safe and appropriate option, given any other medication(s) a patient may be taking.⁷,¹¹–17

Pharmacists could potentially be instrumental in helping patients make safe and informed choices about CAM products, but the ability of many pharmacists to take on this professional responsibility is limited. Practising pharmacists have variable (and often very little) knowledge of the medicinal use of CAM products.⁷,¹¹,¹⁴,¹⁸–20 Although many pharmacy schools have some instruction about CAM products built into their programmes, the content and depth of discussion varies dramatically from university to university.¹¹,¹⁸,²¹ The lack of education and practice standards in this area means that not all pharmacists have the same level of competency with respect to providing advice about CAM products to consumers and other healthcare practitioners.

Pharmacists are an integral part of the conventional healthcare team within the context of healthcare systems around the world. Although the specific scope of practice of pharmacists is defined by country- or district-specific legislation, it generally includes ‘the custody, compounding and dispensing of drugs, the provision of non-prescription drugs, healthcare aids and devices, and the provision of information related to drug use’.²² Whether CAM products are legally regulated as ‘drugs’ varies from country to country, but pharmacists’ responsibility to detect and prevent interactions between CAM products and conventional medications has consistently been identified as important in the literature.⁷,¹¹,²³–25 A recent North American study suggested that use of prescription drugs in conjunction with CAM products is high enough (16%) to raise concerns about unintended interactions.²⁶

Several recent reports call for pharmacists to increase their knowledge of CAM products, especially any sold in their stores. An information paper, The Role of the Pharmacist with Respect to Complementary/Alternative Medicine,¹² completed by the Alternative Medicine Task Force of the Canadian Society of Hospital Pharmacists suggests: ‘Our role as pharmacists is to help educate patients about these [CAM] products and guide them to make informed choices. Our goal should be to ensure that patients who choose to use [CAM products] do so safely’(p. 183).¹² Similarly, the authors of the American College of Clinical Pharmacy’s (ACCP’s) White Paper on Herbal Products argue that ‘the basis for pharmacist involvement with herbal products is an extension of their established roles in pharmaceutical care, clinical pharmacy practices, and collaborative health care teams’(p. 883).¹⁴ This document suggests that providing care to patients (many of whom are considering the use of CAM products) means that the pharmacist must assume an active role in this area of practice. The report also recommends formal education or instruction on herbs in both the undergraduate pharmacy curriculum as well as in continuing education forums.¹⁴

These reports seem to imply that there is relative agreement within the profession of pharmacy; however, there is evidence that this is not an accurate portrayal of the profession. For example, a study of US pharmacists reported that although almost three-quarters of the pharmacists surveyed worked in a retail setting where herbal medicines were sold, almost half 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.’¹⁶ A Canadian study reported that only 2% of pharmacists felt they had adequate information about complementary and alternative health care.²⁷ This finding is supported by other recent surveys in the USA, Korea and the UK that reflect pharmacists’ views that they need more education about CAM products.⁵,⁶,²⁰,²⁸,²⁹

Perhaps the most controversial type of CAM products are homoeopathic medicines. A study of US pharmacists found only a quarter considered homoeopathy to be a legitimate medical practice.³⁰ An issue of the American Journal of Health-System Pharmacy that explored the controversy began with an editorial describing the articles in the issue as ‘ranging from appeals for tolerance to outright rejection of the therapy’ (p. 2411), echoing the range of opinions within the pharmacy profession.³¹ In addition, a recent article in The Pharmaceutical Journal,³² arguing that homoeopathy has no place in pharmacy practice resulted in numerous letters vigorously defending it.³³–35 The debate is summarised particularly well in Pray’s article entitled ‘The challenge to professionalism presented by homeopathy.’³⁶

CAM products are both a challenge and an opportunity for the profession of pharmacy. It is no longer possible to ignore the widespread use of CAM products by patients. If pharmacies continue to sell CAM products, then pharmacists must have sufficient evidence-based knowledge of CAM products to be able to effectively counsel patients about these products. This means actively educating pharmacy undergraduate students, and providing additional training for practising pharmacists, about the safety and efficacy of CAM products. The profession of pharmacy now has the opportunity to rise to this challenge.

References

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