Monday, November 12, 2007

Corpo-Pharma's Silent Assault on Pharmacist Ethics

I work for a major pharmacy retail outlet, and by and large, they've been good to me. It pays the bills, and I've had the opportunity to work with some amazing pharmacists and technicians who have had a profound impact in shaping the kind of pharmacist I want to be.

Pharmacists have a pretty good reputation with the general public. If opinion polls are any indiciation, the public trusts their pharmacists. Voted second most honest profession in America, in fact. Commercials by all the major chains want to portray pharmacists as reliable, accessible, knowledgeable, and friendly. Many of the pharmacists that I've worked with have been all of these things, and they've given me a model for my future.

This is why nothing makes me hot under the collar like an unethical pharmacist. Or, perhaps, to state things a little more broadly, like unethical pharmacy. You don't really hear about it as often as you hear about the transgressions of other medical professions. Most physicians and surgeons carry malpractice insurance for a reason; they have high-profile positions, and negligence and maleficence are not tolerated. And those paying attention to the practice of quackery are quick to sting any physician who would overpromote services like chelation therapy for autism or DCA for cancer. So when I flip through pharmacy's professional magazines and spot advertisements for unproven therapies, I think I have a right to be disgusted. What respectable pharmacist's publication is going to run ads for homeopathic products? But DrugTopics has done it. So has Drug Store News, and they do it regularly; at the time of my visiting their website, the front page proudly displays an ad for cranberry supplements suggesting pharmacists "tap into the number-one selling herbal product." A magazine aimed at technicians I was looking at the other day actually mentioned Similasan, a line of homeopathic eye and ear drops, as a legitimate therapeutic option for infections that didn't require a doctor's prescription or contribute to the dreaded antibiotic resistance epidemic. Their heart is in the right place, if they're hoping that promoting homeopathy to treat self-limiting infections will cut down on the development of strains like MRSA, but it's an established convention in medicine that use of placebos is unethical because of little things like "patient consent."

The rare pharmacists who run independents these days have no excuse, but we in the chain world are stuck under the oppressive thumb of corporate masters who have no apparent concern for things like "ethics" or "honesty" when "the dollar" is concerned. It's true that Corner Drugstore Inc. is watching out for their patients in the big ways. They've implemented all kinds of safety features to cut down on misfills and mix-ups, because these are the kinds of things that they imagine might actually hurt someone.

(Read: These are the kinds of things that Corner Drugstore, Inc. might be held personally accountable for.)

No one is going to hold Corner Drugstore accountable if the latest "wonder diet drug" turns out to be unsafe or a child dies because the drugstore sold the parents homepathic remedies when the child needed real medicine. Or at least, I can't find any evidence that Corner Drugstore has ever been held accountable.

I am approached by patients with great frequency who are trying to find HeadOn, zinc, selenium, vitamins for every body system imaginable, untested probiotics, Emergen-C, you name it. Our shelves are stocked with homeopathic "anti-snore" tablets and throat spray somewhere underneath the Breathe-Right strips, leg cramp medicine supposedly containing quinine that would be lucky to contain one molecule of the stuff, and at least one "stress tonic" herbal formulation promoted for sleep that costs at least ten times as much as generic diphenhydramine tablets. "Which of these will help me with my cold?" a man asked me one day, dropping a plethora of boxes on my pharmacy counter. Two boxes of zinc lozenges, different brands, accompanied by Airborne and a store generic version of the same. As the Drugmonkey once quipped, I could've told him to eat the box containing the Airborne and he would've gotten the same therapeutic value out of stuffing his mouth with the corrugated paper as he would consuming the contents. Probably. Come to think of which, that fiber would be good for the colon. Maybe eating the box would've been better in the long run.

Here's what bothers me. These patients usually aren't woo-meisters. They're not dedicated worshippers at the altar of altmed. They're confused and lost souls, bewildered by the array of products available on the pharmacy shelves. Maybe they saw an ad on television for the product they're looking at; that's the kind of thing that motivates patient choices about self-medication above all else, pharmacist input included, if my anecdotal experience is worth anything on the matter. And Corner Drugstore Inc. is throwing a huge monkey wrench into the whole "counseling and patient education" pharmacists are supposed to do by having these products on their shelves, because this is the pharmacy, and patients go to the pharmacy to get medicine (or light bulbs, or batteries, or toilet paper) and by God, if it's for sale in the pharmacy right next to the Tylenol, of course it works! Why would the pharmacy sell medicine if it didn't work? This concept is so foreign to patients that most of them tend to give us blank stares. It totally flies in the face of the "you can trust your pharmacist" mantra.

At Corner Drugstore, We're not the ones stocking the shelves. But the average consumer links everything even vaguely medicinal in a drugstore with the pharmacy. It's this tacit endorsement of altmed--cough, "health freedom"--that drives me into a vial-throwing frenzy. Those 40-dram vials are pretty big. If I fill them with expired ibuprofen they make decent projectiles. Duck and cover!

My store's manager asked me once what I liked and didn't like about my work environment. "If you could change one thing about the store, what would it be?" Most of the responses from coworkers were things like "please turn down the awful Muzak." I told my boss that nothing would make me happier than to see our store stop stocking unproven medical or drug products of all varieties, including untested herbals and homeopathic remedies. I don't think I've ever gotten such a strange look in response to something I've said.

The thing is that the pharmacists I work with agree with me. They complain all the time about the "junk" on our pharmacy shelves and get tired of trying to explain to people why we stock "fake medicine." Here's why we stock fake medicine: Because people keep buying it, and Corner Drugstore doesn't care how that reflects on pharmacist ethics. And Corner Drugstore's biggest committment is ultimately to making mone--er, I mean, upholding health freedom and patient choice.

Pharmacists are supposed to be scientists. And most of the pharmacists I've known have been very good when it comes to their ethical and scientific integrity. I think it might be worse when pharmacists turn to woo than when physicians do it, somehow, especially things like homeopathy and herbal products; they're supposed to be drug experts! How could anyone with four to six years of chemistry, biology, biochemistry, pharmacology, and physiology be sucked into promoting quackery? The answer, of course, is that most of them aren't. But I have worked with pharmacists who felt it was easier to say "well, go ahead and try it" than try to educate patients about altmed. Part of this is because Corner Drugstore pharmacists, no matter what anyone tells you (or what you're told in pharmacy school) do not generally have time to do serious patient education. When a store is busy, your pharmacist barely has time to go to the bathroom, much less explain the fact that dietary supplements are on the shelves because of legal-political lobbying and not stellar drug design and research. Patient education is a service that gets thrown by the wayside in busy stores where all that matters is prescription volume, sales statistics, and the results of customer surveys. Is this really an environment conducive to education or science?

Pharmacists have the opportunity to be the cornerstone of anti-woo among outpatients. We have to convince Corner Drugstore to let them.


JD said...

My personal favorite is seeing customers go up to the pharmacist and ask, "Which of these diet products will get the best results?" The answer is inevitably, "Diet and exercise," at which point the customer becomes downhearted and somewhat offended. Always gets a chuckle out of me.

N.B. said...

Diet products, like conspiracy theories, represent a fundamental flaw in human reasoning. After all, if all you had to do to be thin and beautiful was buy supplements, wouldn't everyone look like a supermodel by now?