The front store of the pharmacy has traditionally been where the pharmacist and patient relationship grows to a level beyond where it would be with just prescription counseling alone. It affords to pharmacists a selection of products that empowers the lay public to take some sort control of their health in almost any way they choose. With certain selective issues (or perhaps a wider selection in their minds), they can bypass the waiting room of the physician, the poking and prodding, the embarrassing questions, the waiting at the pharmacy counter – all gone with just a wave of the hand from the OTC aisle to the pharmacist peering down to you from his or her stoop in the dispensary.
The general public questions this type of medical treatment very little, partially because of the level of trust that is consistently demonstrated towards pharmacists, or perhaps because most of what is available to choose from in this realm has been virtually unchanged in its ingredient list for decades. In fact I am willing to bet that if I were to walk through the aisles of my neighborhood pharmacy on the day I was born nearly 50 years ago, aside from a few struggles with brand names and a few recognized products that have been discontinued, the ingredient list on most items in the entire store would be much the same as my store today. This brings with it a level of trust in these products by the public, sometimes a false sense.
Back then many of these products were put there in the front store without a whole lot of randomized placebo controlled double blinded/crossover trials (RCT’s) that brought most of the prescription medications to market and back 50 years ago there was little debate as to their effectiveness. The pharmacist recommended it and you took it and it worked. That was that. The path that each product took to land on the shelves of your pharmacy each has a story and history of their own.
There is a growing concern that pharmacists are now selecting items for patients that have little backing scientifically. For example, one of these families of products, known as homeopathic, is one of them. Back 50 years ago you may have even spotted one of these in your neighborhood pharmacy. Now before I go any further I’ll end your guessing of my views of homeopathy: I don’t think it really does much of anything for anybody. For those of you still reading, because you’re in agreement of that last statement, just hold on a second. If we are slamming this mode of treatment because we feel the studies don’t back it or because there is nothing in the actual dosage form, that is fair enough. The supplement aisle is another category that brings about much criticism, and for the record, I have a different belief in this category (just not fanatical in like everyone should have all of them). But as “evidence based” practitioners, in all fairness we need to apply this to the entire store.
Applying our strong standard of evidence to everything else, we look with our magnifying glass at all other products: cough medicines, constipation relief, lice remedies, pain relief selections, antacids and reflux relief meds, skin creams, acne relief, teeth whitening (ok maybe not available in the 60’s), hemorrhoid relief, bug spray, lozenges, lip balm, and lots more. Can you quote or summarize the randomized controlled history for these categories? Perhaps can you find evidence against what you are recommending that product for? Acetaminophen for lower back pain? Cough syrup for someone with a common cold. You can check out a fuller explanation of these categories here .
So getting back to our original claim slammed against us: Why do we sell these items that obviously have some doubt as to their effectiveness? As a pharmacist I am always striving to supply what people want to use for their health as long as it does not harm their health in taking it. Secondly it should be effective. The order of these two is important. My community wanted organic food so that’s what I got in to sell at the pharmacy. Removed 12 feet of magazines and replaced it with organic, gluten free, non gmo. Does it harm them? No. Is it effective for what they are taking it for? Maybe. Maybe not. But it does not harm them.
When Cold FX was going through it’s court case on the claims it was making I voluntarily removed it from my shelves. When the case ruled in their favor I brought it back – much to the delight of my customers who had been asking for it for weeks and months. Is it safe – yes, and is it effective – who the hec knows. I push vaccines, but I also sell Muco Coccinum and stress that you cannot rely on that to prevent the flu or much of anything else. I sell probiotics but screen those with suppressed immune system who cannot safely take them. I ensure that it is used safely first and if it is effective for their gut health, immune health, skin health or mental health then so be it. I try to guide them with the studies I have available to me but first and foremost it must be used safely. That means the product won’t interact with their medication or medical condition or result in them omitting proper established treatment for their condition especially should it be serious or life threatening. No one should be curing cancer or treating their heart disease in this part of the store, but if they have a drug induced lowering of vitamin B12 then I’m their guy. If they are looking to prevent a cold they feel might be coming on with Zinc tablets then great (something I take).
The point of all this is most if not all of new drug research is targeted towards bringing new prescription medication to market, not OTC drugs. While it’s true that some prescription medication may trickle down to OTC status (and thankfully this should have RCT’s to back them up, which is great) not much groundbreaking in the OTC field happens for the most part. Recently I have seen a new product come out for varicose veins and one for vaginal dryness, but for the most part we are stuck with what we have out there, and it’s not an area where we test existing products on new indications, nor do we really go testing a lot of the current indications for existing products that they are sold for (perhaps with a few exceptions). Unfortunately the vitamin/supplement and herbal market is always pushing the boundaries of what science thinks will happen if you take pill A and what an RCT says. What this means is going forward we will be left with an aging pool of products, a number of which have questionable efficacy for the indication they are being sold for and a growing list of products that have the same backup. This pool may have some new additions here and there but the old standards stay around.
Complaining about a select group of these items such as homeopathy is noble, but is kind of two faced when we don’t slam other pharmacists that sell all the other products that have similar lack of actual evidence to back them up. Particularly when the pharmacist is following the law. Being a pharmacist is not being a doctor. We can now prescribe for minor ailments in my area, but the pharmacists today didn’t invent this front store they have available to them. A pharmacist’s recommendation may not always be the same as a doctor’s recommendation, or the same as another’s recommendation, but it should be as safe.