Ask your pharmacist? I don't think so! (part 1)


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Pharmacists have always been thought of as reliable health care providers – someone you can go and have a chat to when you don't have time to line up to see a G.P. Given the enormous amount of money that Australians spent on Complementary and Alternative Medicines (CAM) now days however (more than double what we spend on prescription medicines [1]) many pharmacy proprietors are taking advantage of this recent trend in the market and practically doubling as health food stores. Considering the questionable efficacy (and safety) and little or no science that such products are often based on, their sale among more scientifically validated medicines in the pharmacy setting has raised questions about the reliability of the pharmacists advice, and saw the 2006 Australian Skeptics ‘Bent Spoon Awards', given to “the pharmacists of Australia who manage to forget their scientific training long enough to sell quackery and snake oil in places where consumers should expect to get real medical supplies and advice.”

Legitimate Use?

Not all supplements and other complementary medicines sold on the pharmacy shelves are worthless of course – some certainly have a legitimate use (as I mentioned briefly in my article in the Autumn 2006 issue of the Skeptic). Given the enormous number of mega dose vitamins supplements, herbal products and other complementary products (not to mention homeopathic products) that are routinely sold on pharmacy shelves, it's tough to imagine that pharmacists out there are always giving honest, reliable advice about them. After all, if they weren't going to recommend them, why would they sell them?

If for example someone were to pick up a bottle of 1000mg vitamin C tablets, or a bottle of 500 IU vitamin E capsules (two of the most popular purchases), and ask the pharmacist if they were any good, what are the chances they would be told:

“No – your body can only deal with around 200mg of vitamin C at a time [2], and the average intake among Australian adults far exceeds that anyway [3], with additional doses being contraindicated in several common medical conditions [4] and may potentially interfere with sex hormone regulation, capable of inducing preterm birth in pregnant women [5] and has been shown to induce abortions in rodents [6,7 ](even though it says none of this on the label of course). As for the vitamin E, although the label may say “for heart health”, it does not say that it will actually prevent heart disease, because this would be an illegal claim. In reality, although it is the subject of considerable debate, [8] there is at least some evidence that a dose in excess of 400IU daily may actually increase the risk of death. [9]”

Although the odds of hearing that from pharmacy staff would be next to zero, once upon a time, there were a couple of pharmacies where you may have been likely to be given a response similar to that; the ones which I worked in! Pharmacy Nutrition Warehouse & Shopsmart Pharmacy

Confessions of a former pharmacy assistant

After completing a nutrition degree a while back, my first position was in a pharmacy which advertised itself as specializing in nutrition. The major strategy was for the pharmacist on duty to ascertain the patient's medical conditions(s) upon receiving their prescription, and then send them over to me where I was meant to advice them that they needed to fill their baskets up with additional ‘natural' goodies in order for them to get the best for their treatment. I was even given a white pharmacists coat to wear to give myself a more ‘clinical appearance” so that customers would be more inclined to trust me, (and they did).

As training, I had to witness and take notes as the proprietor / head pharmacist gave advice to different customers regarding a variety of health complaints, to which he would recommend a plethora of supplements, herbs and even homeopathic remedies. I simply don't have room to mention all the many weird and wonderful product recommendations he made to patients, though suffice it to say; they were based on little or no supporting evidence. In fact, I was instructed that peer reviewed literature was not appropriate for me to be looking at for additional information, and that better sources included supplement companies literature and other pro-CAM websites. In fact, I learnt that many pharmacy staff receive product training directly from supplement companies such as Blackmores, in order to ‘enhance' their knowledge of the products uses in order to help boost sales.

Any safety issues I ever raised with the boss were quickly dismissed, as apparently it was unnecessary to worry the customers about any safety concerns unless it specifically stated them on the label. For example, according to him, there was no need to worry about past history of intracranial bleeding or warfarin use before recommending anti-coagulant (blood thinning) supplements such as fish oil, vitamin E, garlic, Ginkgo biloba and other herbs (despite the documented though not-so well known contraindications [4,10,11]). There was no need to worry customers about whether or not they were on the contraceptive pill (let alone other medications) before suggesting St Johns Wort (despite the potential risk [12]) and there was certainly no need to tell a customer to go and ask their doctor first before taking any complementary medicines – that was something he was especially adamant about. Apparently, this was because the patients had come to us for help because they wanted something quick that they could buy over the counter because they did not have time to go and see their doctor, who may well advise them not to go and buy ‘natural stuff'.

Essentially, I was not employed to give honest advice. I did anyway of course, so obviously the job didn't last too long, which, given the constant need for dishonesty and deception, was not terribly upsetting to me. What was upsetting however was to see so many vulnerable customers (often elderly pensioners) being ripped off, as trusting their pharmacist as a reliable source of health related information of course (or anyone else wearing a white coat) they simply did whatever they were told.

I figured that this must have been a one-off, and that surely, the kind of corruption going on in this pharmacy was an isolated problem. However, on the first day of my next pharmacy job, I was told quite clearly, that I was there to “push the vitamins”, and that if I “pushed” a particularly larger amount of them in a month than usual, I would be offered a proportion of the additional profit. Once again, I witnessed this pharmacy proprietor telling their customers all sorts of nonsense (some of which was even potentially dangerous) in order to get them to buy supplements, and it was made abundantly clear to me that I was not there to give any professional or honest advice to customers unless it meant recommending a product that we were selling.

I generally had to make sure I looked over my shoulder every time to make sure that the boss wasn't watching before offering anything even remotely resembling honesty. To give another couple of examples – two of the most common products I was asked about there were both Centrum multivitamins as well as various herbal weight loss pills such as Fat Blaster, Blackmores Metabolism Advantage and of course, Xantrax (which conveniently sounds very similar to a different weight loss pill which, although is not without deceptive marketing issues of it's own, actually works [13]). My responses were generally as follows:

“As the label says, vitamins may only be of assistance if your dietary intake is inadequate, which, although the label doesn't mention, is very unlikely, [3] so no – this product will not give you “energy” or make you “feel 100%.” When they say “unlock energy” they mean chemical energy (Calories / kilojoules) not feeling energetic, though given their clever wording and athletic spokespeople, you could be forgiven for being confused. If you are feeling fatigued all the time, you may not be sleeping well, and should see your doctor to rule out anything more serious. As for the other product, this combination of herbs and nutrients has never been studied, though given all the available evidence [14-18] it is not likely that you would lose any more than about 1 kg every 4 months (best case scenario), and even then it would only occur if on a hypocaloric diet (in which case you would be loosing weight anyway). Given that it will cost you over $100 a month, you would be better of learning how to improve your diet and getting more exercise, or even going with a product that actually works.”

Funnily enough, the vitamins weren't being ‘pushed' as much as they had expected. I can't imagine why ;-D

Isolated Incidents or Widespread Dilemma

If it were a health food store worker, a Multilevel Marketing (MLM) distributor or even a naturopath, then at least the public would be more aware that the advice being offered may not be in sync with official mainstream medicine and instead stem from ‘alternative' philosophies. Pharmacists however are, presumably, supposed to be recognized as reliable health care providers you can trust, and when you're a vulnerable pensioner with no medical training, all you have to go on is trust. So should we be putting our trust in the hands of a pharmacist as a reliable source of mainstream medical advice, or are they becoming nothing more than a glorified health food store clerk?

In September 2005, researchers from Charles Sturt University published the results of a survey that more than four hundred pharmacists across NSW had taken part in.[19] The large majority of pharmacists surveyed reported that CAM products “enhanced the customers' image of pharmacy”, believed that they could “increased customer numbers” and “could increase annual sales”. According to this survey, the main reasons these pharmacists gave for recommending CAM products was based on “evidence of efficacy and to maintain general health” (though I doubt that “purely to increase sales” was an option).

These pharmacists knew that their responses were being surveyed as part of a study however, so we can't know precisely what they would be telling their customers. The only way to do this would be for researchers to pose as a customer, ask a bunch of questions about CAM products and record the pharmacist's response. Although it was not published as an official ‘study' as such, the Australian Consumers Association's “Choice” magazine did just that, and found that advice given in 58 out of 87 pharmacies was rated “poor” by their experts. [20]

Not all pharmacists are bad

In pharmacists defense however, I must admit that a lot of employed pharmacists I have known and worked with are not in the habit of lying to their customers, and do recognize the problems and conflict of interest associated with selling complementary medicines in the pharmacy setting. In fact, after writing an article very similar to this on a hobby blog, I assumed that any pharmacists who would come across it would consider it ‘pharmacist bashing' and instantly disagree with me. As it turns out, several pharmacists wrote to me telling me that they could not agree more, and I was even asked to contribute a regular column to an electronic journal (run by pharmacists) called ‘Information 2 Pharmacists' (

One problem seems to be the lack of formal training that pharmacists receive (or rather, don't receive) when it comes to CAM 's. A recent survey of Australian pharmacists found that whilst 95% reported that they frequently received patient enquiries about CAM's, less than 15% could say that they were ‘very confident' when it came to giving advice about their safety and efficacy.[21] Whilst some pharmacists reported using peer-reviewed journal publications as a source of information, a lot of their information appears to stem from less-reliable sources such as that provided by the supplement companies themselves (who have no real incentive to provide non-biased information anyway). I really don't think that this is a valid excuse however, as the real research certainly is out there. I'm sure that pharmacists could access it if they really wanted to.

The major determining factor however that I perceive to be, (and which none of these studies have taken into account) would be whether or not the pharmacist on duty is the proprietor. If they are an employee, then they would have less incentive to give dishonest advice (as they are paid a flat, hourly wage), but when the pharmacist on duty is the boss, then honest advice may mean missing out on additional income.

I don't believe that pharmacy proprietors are necessarily bad people – they are simply trying to run a business. The question is, should employee pharmacists have to compromise their professional integrity for the sake of boosting the boss's income, and more importantly, should the publics' trust be exploited or their health be jeopardized as a result?

What are the alternatives?

One might reasonably argue that pharmacists should not be allowed to sell any unproven medicines at. Unfortunately though this could mean a disaster from public health perspective, as it would mean that people seeking complementary medicines would instead have to go to the health food stores; the advice of which has been shown to be disastrously unreliable. [22]

Another suggestion may be to allow pharmacies to sell CAM's if they have a qualified naturopath working there. After all, many naturopaths have university science degrees these days, and I'm sure than many naturopathic associations would be equally concerned about people receiving CAM advice from inadequately qualified people such as MLMers and health food store clerks. Unfortunately however, I would have to disagree that a naturopathic university education does much to protect consumers.

Back when I was going my nutrition degree, I decided to do ‘Herbal Medicine' as an elective (a unit compulsory for naturopathy students). To give a few examples of what naturopathy students are taught, click here to see a handful of the ‘immune modulating herbs' with the appropriate uses, as laid out in our study guide.

Perhaps with the exception of Hypericum (St Johns Wort) for depression, many of these purported indications range from the plausible yet unproven, to the dangerously inaccurate. After sitting through an entire semester of this stuff as well as discussing it with the other students (including a focus group study I conducted (using some of them as subjects) later on in my degree to canvass their opinions about CAM use in Australia ) several things were clear (none of which were at all surprising).

•  Naturopaths (at least these ones) do not like real doctors or orthodox medicine, and gave the impression that they would not agree with most orthodox medical treatments. (Not very comforting given the high level of people who seek treatment from naturopaths and other CAM therapists, especially cancer patients (given the potential for CAM's to interact with chemotherapy [23,24]) many of which do not inform their doctors they are taking CAM treatments.[25,26])

•  Even at a university level, naturopathy students are taught that modalities such as homeopathy and iridology are not unproven (let alone implausible) hypotheses, but instead that iridology is an effective means of assessing a patients health status and that homeopathy is an incredibly effective means of treating almost every disease in the book. (Suffice it to say, neither is true.[27,28]) So much for university training ensuring a high standard of healthcare education.

Given the unreliable sources of information Australian naturopaths report using [29] (which include ‘professional' newsletters, seminars run by manufacturers, patient feedback and personal observation of patients, though do not include peer reviewed publish research) together with their unscientific training, I don't think that placing naturopaths in pharmacies is an appropriate solution – it may even make the situation worse.




Better Regulation

When it comes to protecting the public against useless or potentially harmful listed therapeutic goods, (and the potential for retailers to give misleading advice about them) I think that TGA regulation, especially in regards to labeling, is the most important step in the right direction.

Unlike ‘registered therapeutic goods' (pharmacy only medicines) which need to be proven efficacious and tested for any potential adverse reactions, all you need to say is that something has been used by three generation of people for the TGA to consider it safe enough to be sold as a ‘listed therapeutic good' (which most CAM's fall under).

Perhaps most disturbing is that with the exception of supplements containing Retinol (vitamin A) or selenium, no listed therapeutic good must mention any potential side effects or contraindications on its label. Having dealt with hundreds of pharmacy customers, it is clear that the inadequate labeling regulation and absence of label warnings is responsible for giving many consumers the impression that these products must be ‘natural', safe and harmless. Many customers think that the worst case scenario is simply that the product ‘doesn't help' and assume that the labels would warn them about any potential adverse reactions

I don't think it's too unreasonable to suggest that the absence of label warnings (especially when registered therapeutic goods are often riddled with them) is largely responsible for the widespread misconception that CAM 's must be completely without potential harm. I also don't think it's too far fetched to suggest that the dietary supplement industry is largely dependant on this widespread false sense of security, and consequently remain adamant that things stay the way they are, as warnings might start scaring off customers.

Many CAM proponents argue that concern over the safety of these medicines is unnecessary, as few if any people die or are harmed from their use, as apposed to those who die or are harmed from inappropriate use of prescription medications. My response is that the only reason that we are aware of the harm associated with certain registered therapeutic goods is because they are constantly studied (though some would argue that they are still not studied enough to identify potential harm, especially in regards to prolonged use). Just imagine if tobacco (which is also ‘natural' and stems from many generations of traditional use) had not been studied so extensively.

My suggestion would be not to allow any therapeutic goods to be sold at all without adequate clinical trials to identify any potential adverse effects. Once any potentially harmful effects have been identified, surely it's not too much to ask that consumers be warned about them by listing them on the labels.

But who would foot the bill?

Proponents of CAM constantly argue that because ‘natural' medicines can not be patented, there is no financial interest in studying them. Although this is true to some extent (though many supplement companies patent their own unique combinations of them, even though most in Australia rarely pay for clinical testing), it doesn't somehow automatically make them safe and effective.

Australians spend an estimated two billion dollars on CAM each year. [1] How wonderful it must be for major supplement companies such as Blackmore's and Natures Own (not to mention retailers including pharmacies) to be able to take such an enormous piece of this complimentary pie, without (unlike makers of registered goods) having to spend a cent on research to assure safety and efficacy. (Even rigorous testing does not guarantee the safety and efficacy of a medicine, but surely it's better than the alternative).

It's a win win situation for them. Unlike makers of registered therapeutic goods, if a listed therapeutic good ends up being safe and effective, then the supplement companies (and retailers, including pharmacies) win. If they aren't safe and effective, then they win anyway, because it really doesn't matter – they will continue to be sold and will never have to bare any warnings on their labels.

Although I know this is a relatively far stretch, the only possible suggestion I could think of would be for the federal government to fund independent testing of supplement product sold in Australia (as the NIH's National Centre for Complementary and Altenrtive Medicine has done in the United States) only charge anyone selling them (both manufacturers and retailers) some kind of tax or levy to cover the cost. It's only fair that the more supplement companies and retailers make by selling these things, the more they should be taxed to help foot the bill for studying them.

Given the enormous fight that anyone associated with the CAM industry puts up when anyone else comes close to infringing on their rights to sell untested medicines without having any objection to it, (including the Complementary Healthcare Council, who I think should replace the word ‘Council' with ‘Union' as all they really do is vigorously promote anything CAM related and emphatically reject any criticism of anything CAM related) I doubt that this will ever happen.

Labeling - Safety

Other than mandatory listing of any potential adverse effect, I would suggest that all listed therapeutic goods bare warnings that consumers should inform their DOCTOR that they are taking it. I once had a chat with the marketing director of a major supplement company who told me how delighted he was that the TGA had allowed them to write ‘health care professional' instead of ‘doctor' because ‘health care professional' could mean a naturopath (or pharmacist) or someone else who would be more likely to recommend the product than a doctor. (Funnily enough, even though they can't to manage to list any potential adverse effects, Blackmores products do manage to list a 1800 number which you can call to get free advice from one of their naturopaths. How convenient.)

Labeling – Efficacy

The other major change I would propose is that the TGA crack down on loopholes in current legislation which allow supplement companies to make certain health claims on the labels of their products. Although they can not technically state that their products can treat or cure a specific medical disease, a frequent method of getting around this is to take a physiological process that a particular nutrient or herb may affect, and carefully word the description to suggest that it may somehow be effective for treating conditions which affect that physiological process. For example, vitamin C is needed for wound healing, though given that it is extremely unlikely that anyone is going to be so deficient in vitamin C that their wound healing abilities would be impaired, it is misleading for supplement companies to mention this physiological function on their labels. The question we want to know is not what this nutrients (or any others) function is, but whether taking this product is going to make our wounds heal any better or any faster than it would if we didn't take it. Zinc may be involved in “maintaining a healthy immune system” and is “essential to maintain healthy skin” but is taking additional amounts of it going to make our immune system work any better or our skin any healthier than if we didn't take it? And even if the answer is yes, then is it going to make it work that much better that it will actually have any measurable effect on any specific disease state?

Vitamin E might be involved in “healthy heart function” by “reducing oxidation of LDL cholesterol” and helping to “protect capillary function”, but does it treat or decrease the risk of getting heart disease? The B complex vitamins may indeed “aid the body during times of stress”, and vitamin B6 may be “necessary for the formation of hemoglobin”, but is taking additional doses of them going to help decrease your stress levels and treat anemia, or will it just change the colour of your urine? Whilst Milk Thistle may have “traditionally been used in European medicine to enhance liver function, assisting as a natural liver tonic,” will it help effectively treat or prevent any actual disease of the liver? Although Astragalus may have been “traditionally used to help support a healthy immune system”, will it help prevent or treat any actual medical condition affecting the immune system (let alone HIV and cancer, which university educated naturopaths will be using it to treat).

If the answer to these questions is yes, then they should be saying that they will actually treat or prevent those disease states instead of making vague, non-specific statements about what role they play in the body, or what their ‘traditional; uses are. If the answer is no (and it generally is) then although these statements may be technically true, they are unnecessary and are deliberately deceptive to the average lay consumer.

The TGA needs to tighten the loopholes they currently have which allow supplement companies to mislead the public with vague and deceptive wording, whilst avoiding the necessity to mention any potential adverse affects they might have.

Clinically proven?

Perhaps the most mind boggling examples are where the labels do not use vague wording at all, but instead make very specific claims about the ‘clinically proven' efficacy of their product when no such clinical proof exists at all. The most common examples are where supplement companies will not use systematically reviewed data, but instead selectively cite only supporting studies and ignore the rest (as they did when Choice magazine approached companies selling herbal weight loss supplements some time ago.[18])

For example, despite several reviews (including a recent one published in the December 2006 issue of the Journal of the American Dietetic Association [17]) listing hydroxycitric acid (from the herb Garcinia cambogia, ) as being ineffective for weight loss, why is it that Blackmores can claim on the label of their Weightloss Accelerate™ product (which contains only hydroxicytric acid) that its “Clinically proven ingredient” produces “3 times greater weight loss than diet and exercise alone” and that “results [are] usually expected after 4 weeks”? (I'm sure that it's just a coincidence that they are sold in 4 week packs, and not a marketing ploy to increase the chances of consumers purchasing a second pack even after the first month of disappointment). Their website cites not a review paper, but only a single small study as justification for this claim.[30]

The most significant example of recent times was the Tebonin fiasco where Schwabe Pharma Australia Pty Ltd made very explicit claims about the clinically proven efficacy of their Ginkgo biloba product (Tebonin) for the treatment of tinnitus. Despite a Conchrane review finding that Ginkgo was an ineffective treatment for tinnitus,[31] one judge decided that apparently, the public should not be afforded the right to know this, and stopped self appointed consumer watch dogs ‘AusPharm Consumer Health Watch' (who simply couldn't afford to fight them any further) from making it publicly known.[32]

Pharmacist Mark Dunn from AusPharm also sent their report as a complaint to the Therapeutic Goods Advertising Code Council (TGACC) who, only after all the rigmarole, finally decided to change the wording that the Tebonin claims were allowed to make. [33]

My only suggestion would be that if makers of listed therapeutic goods really do have the hard core scientific data to back up claims of ‘clinically proven' efficacy, then why not just sell the product as a registered therapeutic good? As it turns out, makers of listed goods do not need to present supporting evidence before they make claims on their labels. All they need to do is have the evidence available if by some chance the TGA wants to challenge is, which is probably only likely if someone complains.

What can you do?

Speaking of which, I was pleased to read in last summers issue of the Skeptic, that Loretta Marron (‘The Jelly Bean Lady') has managed to draw enough media attention to these problems (including a regular radio show on which she invited me on as a guest 3 times as well as an article in Australian Doctor) that she inspired Professor Lesley Campbell to write a letter of concern to Tony Abbot, which consequently resulted in a $5 million grant to investigate the use and effectiveness of complementary and alternative medicine in Australia. Whilst most of us are not professors that government ministers will listen to directly, I would say that the next best thing for the rest of us to do is to submit complaints to the TGACC. It may be a more economically sensible way to help contribute to consumer protection than by direct public education, which, as we have seen with AusPharm Consumer Watch, can result in costly litigation.

The bottom line

There is no perfect solution to these complex problems. If however utterly useless products were not available, and those which had at least some use possessed no cleverly yet deceptively worded misleading claims (and this includes their websites and promotional literature as well as the label) and were required to list warnings of any potential side effects or interactions, (as apposed to leaving the customer to discuss it with a ‘health care professional' of their choice) then I would suspect there would be less potential for pharmacists and pharmacy staff to abuse their position and sell unsuspecting customers products based on false premises.

Until this happens however, from a public health perspective I would strongly object to promoting a message to the public to “ask your pharmacist,” at least when it comes to CAM 's. Whilst I'm sure there are many pharmacists out there providing honest, reliable advice, currently, there is little necessity for them to do so, and just too much room for them to exercise dishonesty and let their critical thinking caps lapse. Restricting the ability for manufacturers to deceive the public is, in my opinion, the best way to limit the retailer from doing the same.

I'm sure that both supplement companies and their retailers would fiercely object to tighter regulation on the grounds that it may hurt the CAM industries (which include pharmacies), though I really don't think that protecting the financial status or reputation of any industry should be considered more of a priority than protecting the vulnerable lay public from being mislead and potentially harmed. I'm all for people using dietary supplements and perhaps even various other CAM's so long as they do so appropriately, make an informed decision about their use and are not mislead, exploited or unnecessarily harmed. Surely that's not too much to ask.


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