Skepticism in Pharmacy

Matt Crowley

I graduated from pharmacy school with a Bachelor of Science degree in 1987. Much of what one does on the job is actually learned on the job, not necessarily via one’s academic education. I experienced this myself, in many ways, including the shortcomings of education when dealing with customer questions. Years of pharmacy practice introduced me to many opportunities for skeptical outreach with customers.

Pharmacists are asked questions about over the counter (OTC) products as much as about Rx (pharmaceutical) products. In addition to conventional university education, medical professionals engage in continuing education throughout their careers. If these forms of formal education fail to include OTC products, it falls to the pharmacist to learn on their own.

Nutrition, for example, can be given short shrift in conventional education. This is unfortunate, as there are a huge number of nutritional supplements sold in most pharmacies. In addition to vitamins and minerals, there is a blinding array of herbal products and “fitness” related supplements available. Each of these products is a different chemical, or set of chemicals, so all require individual attention. In many cases, products can bridge the gap between food supplements and drugs, such as “energy drinks” and “pre-workout” supplements. These products often contain sugars, other carbohydrates such as maltodextrin, and caffeine. In addition, they may contain amino acids such as taurine or phenylalanine, which in large enough doses may act as stimulants.  Many customer questions are about nutritional supplements.

Skeptics are likely already familiar with homeopathic products being sold in pharmacies. Thankfully, some progress has already been made to abandon this practice. In September 2016, CVS pharmacy announced their decision to discontinue sales of some homeopathic products in their retail stores and online.

The presence of clearly worthless homeopathic products illustrates a conflict of interest at the root of all OTC counseling by pharmacists. For the bulk of retail history, pharmacies were independently owned—usually by the pharmacist. That suggests a tacit approval of anything stocked on the shelves, as why would an ethical pharmacist choose to sell a product they knew to be ineffective or possibly even dangerous? Yet this high standard was routinely ignored, as many pharmacies to this day choose to sell homeopathic products and even cigarettes.

Another ethical conundrum arises if a customer asks a pharmacist for advice about a particular product. Should the recommendation be based on the best medical knowledge we have or on the profit motive of a small business? Thankfully a deeper sort of ethical response is enabled in this circumstance, namely the ability to build trust with customers based on honest and forthright answers.

People who work in retail settings usually gain psychological insight based on innumerable encounters with customers. Retail pharmacists are no different. In my experience, a subtle pattern began to emerge when people asked me questions about OTC products: They often have a preconceived idea that they want the pharmacist to reinforce. Since the pharmacist is coming into the transaction “cold,” they will not know what preconceived idea the person has until it’s articulated by the customer. By that time, a question ostensibly looking for advice becomes a borderline argument if the pharmacist doesn’t give the expected answer.

A good example of a broadly held preconceived idea is that there are nutritional supplements that can give someone “energy.” Customers often zero in on vitamin supplements for this. Questions about vitamin and mineral supplements are instructive, as there can’t be a simple, broad-based answer. While vitamins and minerals won’t provide a person with “energy” there are evidence-based reasons to supplement diet in certain circumstances. It’s entirely rational for women to take iron supplements, and it behooves all pharmacists to learn about this issue, as there are multiple sorts of iron compounds available. The growth of vegetarianism and veganism creates the need for supplementation of vitamin B12 and perhaps other nutrients.

For many years, the “health food” industry focused on alleged “deficiencies” in the modern Western diet. Today there is something of a shift in focus, as there is an entire class of nutritional supplements being promoted to enhance one’s functional state from normal to superior. This would be the “sports nutrition” class of products. The cornerstone of this class is powdered protein supplements. Again, this is an area where pharmacists owe it to themselves and their customers to stay abreast of evidence-based research, as these nutritional supplements are very popular. At the very least, those engaged in bodybuilding and those on some vegan diets may benefit from these products. Protein powder is just the tip of the iceberg with regards to “performance” supplements. In many cases, the evidence for benefit from this class of products is only weakly positive. Some “pre-workout” supplements contain stimulants such as caffeine and should be treated with caution.

Customers turn to pharmacists for advice on OTC products that are not consumed. In some cases the questions are unusual, and the conventional pharmacy curriculum may not even mention them. I would occasionally receive questions about ear candles. For those not familiar, they are ostensibly used to remove ear wax. While this seems like the perfect counselling opportunity to direct someone towards an evidence-based product such as a rubber bulb ear syringe, we should consider the factor mentioned above: people often come to the pharmacist with preconceived ideas and are in fact looking not for information but instead reinforcement by the pharmacist of these ideas. Imagine if you were the customer; if you already knew that ear candles were bogus, why would you even ask a pharmacist about it? On the upside, a person in that situation may not even know there are genuinely effective ear wax removal products available. The first response to the question “do you sell ear candles” therefore might be “for ear wax removal?” Obviously the answer is “yes.” At that point it becomes easy to segue from “no, we don’t sell ear candles, but we do sell rubber ear syringe bulbs. Those are definitely effective.” To persuade a person to choose a rational therapy often requires an understanding of the claims of the irrational therapy. Comparing how ear candles are supposed to work with how an ear syringe actually works may be enough to persuade a customer to choose the rational therapy.

Slightly more far-out are questions about pH paper. There are various diets such as the “alkaline diet” that call for testing one’s urine for its alkalinity using pH paper. Again, this calls for a subtle, non-confrontational, evidence-based response.

Pharmacists sometimes receive questions that are so far-out it may take time to figure out what the real intent of the question actually is. On more than one occasion I was asked if the pharmacy sold something to “clean them out” or to “clean out their system.” At first I believed these were questions about laxatives from people who were too shy to use the word “laxative.” Eventually I realized they were questions about how to beat drug tests! I can assure you this is a subject that a pharmacy curriculum will not address. While it’s an honest answer to say “I don’t know” in my opinion, it’s better to have actually investigated the situation beforehand, as it helps maintain rapport. There’s no honest answer that would compel a pharmacist to recommend illegal or unethical products or behaviors in that situation, thankfully.

These days, a pharmacist may be asked questions about “gray area” drugs, commonly available on the internet. Two classes of drugs come to mind, namely SARMs and nootropics.

SARM is an acronym for selective androgen receptor modulator. These drugs mimic the action of anabolic steroids for building muscle but appear to have a much better side effect profile. Nootropics are drugs that claim to enhance cognitive functioning. There are already Rx drugs for the treatment of Alzheimer’s disease, so it’s a valid therapeutic modality. Not surprisingly, it’s easy to find hyperbolic claims about these drugs on the internet. It behooves a pharmacist to study and be aware of these claims, even if the substances are not sold in pharmacies. An honest appraisal must be nuanced, as there is legitimate evidence of benefit, coupled with unknown side effects, drug interactions, and long term toxicities.

There are numerous opportunities for ethical skepticism within pharmacy. Capitalism assures us that there will be more products available on pharmacy shelves, and the internet guarantees that there will be unusual products for sale online. Adopting an evidence-based skepticism in assessing these products enables pharmacists to benefit customers with questions. One’s university education on these subjects is necessarily limited, and it benefits the pharmacist as an individual to maintain their own continuing education on these topics.

Matt Crowley

Matt Crowley is a retired pharmacist who lives in Seattle. A stint as a sideshow performer in the early 1990s led to his creation of a stunt later known as the “condom challenge.”