Is pharmacy a business or a profession? It’s a question that comes up when when pharmacists put financial interests ahead of patient interests. And that’s the question that’s being asked of the Pharmacy Guild of Australia, the national advocacy organization for Australian retail pharmacies. The Guild recently announced a partnership with Blackmores, a large Australian supplement manufacturer. The partnership means that the Guild’s pharmacy computer system will prompt pharmacists to recommend Blackmores-branded supplements alongside specific prescription drugs. The announcement has exploded in the Guilds’ face (see the advertisement above, for example), and brought widespread criticism to pharmacists, and pharmacy practice. Is this co-marketing science-based or profit-based? And is it ethical? Let’s look at the details.
Pharmacists can be found everywhere, but each country regulates the profession of pharmacy a bit differently. Compared to North America, Australia doesn’t have pharmacies owned by public companies, or located within supermarkets or grocery stores. Only pharmacists can own pharmacies. And only these pharmacists can be members of the Guild. What does the Guild do? Section 5 of their constitution states it clearly [PDF]:
The objects of the Guild shall be:
(a) to represent the interests of members in industrial matters,
(b) to further and protect the interests of and generally to do anything which may be considered beneficial for its members.
Sounds pretty clear. The Guild advocates for its members. Not for all pharmacists, just those pharmacists that own pharmacies. Full stop. I reviewed the organization’s strategic plan for pharmacies and there’s actually a lot to like. It sets out a vision for community pharmacy practice that recognizes the transition from a product focus to a service focus, with implementation plans for a variety of patient-oriented, professional pharmacy services, delivered by properly trained pharmacists.
But the entire foundation for the Guild’s plan is based on a single, critical parameter: The credibility of the pharmacist as a health professional. If the pharmacist is simply a retailer, the rest is irrelevant. Retailers don’t deliver health care. Health professionals do. Australia or anywhere else, the pharmacist’s responsibility is to the patient. Not to the physician, not to any pharmaceutical company, and not to any supplement maker. It’s patient care – putting the patient first. Would the Guild really risk its entire strategic plan with this new partnership?
The partnership was announced on September 22 in Pharmacy News magazine:
For the first time, GuildCare will incorporate a complementary product – the new Blackmores Companions range of specially formulated dietary supplements – into their professional service software suite. Endorsed by the Pharmacy Guild of Australia, the products, which support the use of prescription medicines, will carry the Gold Cross logo, and will be available in pharmacies from October. The range includes the ANTI-HT Companion, containing zinc gluconate to complement use of antihypertensives, and the STAT Companion, containing Coenzyme Q10 and vitamin D3 to support statin use. The PPI Companion contains a highly bio-available form of magnesium to aid use of proton pump inhibitors, and the BIOTIC Companion provides the probiotic strain Lactobacillus reuteri to reduce antibiotic-associated bloating, flatulence and diarrhoea.
Christine Holgate, CEO and managing director of Blackmores, said the range also gave Blackmores the opportunity to provide the “coke and fries” for these pharmaceutical medicines for pharmacists. “Apart from all the therapeutic benefits that it gives to consumers it is also providing a new and important revenue stream for community pharmacy,” she concluded.
Which pretty much says all you need to know about the relationship. Blackmores manufacturers the supplements and supplies them to pharmacies. The Guild offers a pharmacy software system to its members. These systems are essential to processing prescriptions: The capture patient data, bill insurance, check for drug interactions, generate patient prescription handouts, and generate labels for dispensed products. The system will now prompt pharmacists to recommend a Blackmores supplement when specific prescriptions are dispensed. The Guild explicitly endorses these four products.
As I noted above, the pharmacist’s ethical responsibility is to the patient – no one else. The Pharmaceutical Society of Australia is the national organization for Australian pharmacists. Its code of conduct makes this clear, in its first principle:
The primary concern of the pharmacist must be the health and wellbeing of both clients and the community.
With respect to product promotion, there’s a key phrase under principle five, describing practice standards:
A pharmacist must avoid situations likely to present a conflict of interest or compromise the objectivity of their professional practice.
If a pharmacist is going to recommend that a patient purchase a specific product, it must be unequivocally in patient’s best interest. And given the pharmacist (or pharmacy, depending on the setting) will profit from the sale of every product, there needs to be a demonstrable need for a product – it must be an important component of patient care. For example, it’s appropriate for pharmacists to recommend that women contemplating pregnancy, or already pregnant, take a folic acid supplement, to reduce the risk of neural tube defects. That recommendation is backed by good scientific evidence. The same exists for women being treated for osteoporosis – calcium and vitamin D are usually required – but not always. Some chemotherapy requires the concurrent use of folic acid and vitamin B12. All recommendations require an evaluation of the evidence, as well as patient-specific factors.
Recommending a supplement alongside a prescription drug as a matter of routine is problematic, particularly when a specific brand is being recommended above any other. There are multiple conflicts of interest present. So in order for this partnership to be professionally and ethically acceptable, there needs to be some very convincing evidence to justify the recommendation of a Blackmores supplement to accompany the millions of related prescriptions pharmacists process each year. Do the claims stand up?
Nicely, the Australian National Prescribing Service has already reviewed the evidence base supporting the concurrent use of these supplements and prescriptions. Here are their bottom lines on routine supplementation:
On the Blackmores Anti-HT Companion, which is a zinc supplement to accompany antihypertensives:
Routine use of zinc supplements is unnecessary for people taking blood pressure lowering medicines (or ‘antihypertensives’).
On the Blackmores STAT Companion, which is Coenzyme Q10 and Vitamin D3 for consumption with “statin” lipid lowering drugs:
Evidence does not support the use of Co-enzyme Q10 to prevent myalgia (muscle pain) during treatment with a statin.
On the Blackmores PPI Companion, which is a magnesium supplement for use with proton pump inhibitors, used to protect and repair the gastrointestinal lining:
No studies have investigated the use of a magnesium supplement to prevent magnesium deficiency during PPI therapy. A magnesium supplement should only be considered if a PPI has caused a deficiency in magnesium that requires treatment. Evidence for using a supplement with a PPI to treat magnesium deficiency is based on case reports.
And on the Blackmores BIOTIC Companion, which is a lactobacillus supplement, targeted for use with antibiotics:
There is some evidence from trials that probiotics may prevent antibiotic-associated diarrhoea in some adults and children. But limitations with the trials mean that the true effect of probiotics is uncertain, as is the most effective product or dose.
On balance, there’s no persuasive evidence to suggest that routine supplementation with any of these products is warranted. Nor is there any published evidence to demonstrate that any of these Blackmores supplements have actually been evaluated in clinical trials to determine if they are actually effective at addressing the specific reason for use. Blackmores, not surprisingly, disagrees about the scientific evidence base:
The Companions range is four products that are backed by scientific evidence and they have been developed in response to specific consumer needs. Any criticism of their potential benefit highlights the need for further healthcare professional education on medicine-related nutrient deficiencies. There’s no intention for these products to interfere with the doctor’s prescription. The drugs will treat the disease, the supplements will address the nutrient deficiencies.
So the issue is simply a pharmacist’s lack of education, according to Blackmores. To date, Blackmores hasn’t produced any evidence to substantiate their claims.
The feedback has been near-unanimous and generally very critical:
Steve Hambleton, president of the Australian Medical Association, in an interview:
You know, the pharmacy- the standing of pharmacists in the community is almost, well, it is almost at the top in terms of trust, and I think anything that undermines that is going to be bad for pharmacists across the board. The suggestion they are going to sell these products in something like 58 million claims for PBS prescriptions. Now this is a big financial deal. We can’t put finances ahead of the health of a patient. [emphasis added]
The National Prescribing Service [PDF]:
NPS is urging pharmacists to continue to tailor advice to individual patients based on their need and the evidence available, following the announcement of a partnership between Blackmores and the Pharmacy Guild of Australia that will see four complementary medicines recommended alongside prescription medicines. NPS CEO Dr Lynn Weekes says that for health professionals to adhere to quality use of medicines principles, every patient should be assessed on an individual basis. “Pharmacists are trusted by the community to work independently and in the best interest of the individual patient and it is important that professional standards are met,” says Dr Weekes.
“Companion selling as a routine practice is not an appropriate way for pharmacists to provide individual patients with what they need, and it may cause more confusion about medicines and possibly adverse effects. [emphasis added]
The Pharmacist Coalition for Health Reform, which represents pharmacists, not pharmacy owners:
The reputation of community pharmacists should not be brought into disrepute because of an ill-thought out decision. Pharmacists are among the most trusted health professionals in Australia for a good reason and the Pharmacist Coalition are outraged that a cash-driven deal has tarnished their high standing.
The comments made by Blackmores’ Chief Executive Christine Holgate, likening the deal to “coke and fries” for pharmacists is disrespectful to the pharmacy profession and illustrates a lack of understanding and appreciation for Australian pharmacists.
The Association of Professional Engineers, Scientists, and Managers, Australia:
CEO of APESMA, Chris Walton, said the Australian public had taken to social media to express their disgust in the move and the Guild’s deal with Blackmores is now damaging the reputation of pharmacists across the country. “We should be clear – this is not a decision taken by pharmacists, it is a grubby deal done by the Pharmacy owners Guild,” Mr Walton said. “It is unfortunate that professional Australian pharmacists are copping abuse for a decision they have had no say about.”
The Pharmaceutical Society of Australia [PDF]:
As the professional body, PSA has not been involved in this commercial agreement struck by the Guild and Blackmores, and are aware only of the details made public. However, PSA believes medicines and services are not ordinary items of commerce and cannot be treated as such. PSA does not support the Guild-Blackmores program. We are the custodians of the professional interests of pharmacists and as such, are responsible for ensuring the integrity and professional conduct of pharmacists who we are confident that being the professionals they are will continue to put the consumer first.We believe that pharmacists at all times act in the best interests of consumers and do not act with commercial gain as the primary motive. Our Code of Ethics makes this clear.
Dr Louis Roller, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University:
To suggest that pharmacists should be recommending add-on vitamins, minerals and/or other substances of dubious (unproven) worth in response to a prescription for a medicine is aversive to any good professional.
Not everyone has a negative view. Commonwealth Bank Associates thinks it’s a great partnership for both Guild pharmacies and Blackmores:
CBA analyst Natalie Kelly said the initiative would help pharmacists “put increased commercial focus on their non-dispensary offering, given ongoing financial pressures to the dispensary side from recent Pharmaceutical Benefits Scheme reforms, upcoming fee cuts, price disclosures and tighter trading terms from wholesalers. “In addition, the weak retail environment was also cutting into front-of-store sales.” For Blackmores, the deal could push sales up by 2.4-12 per cent a year.
For pharmacy practice to maintain any credibility in the health care system, pharmacists must be seen as providers of science-based information – not purveyors of unproven, unnecessary supplements. Blackmores, the supplement manufacturer, seeks to leverage the trust placed in a pharmacist’s professional recommendation to give their supplements the patina of scientific credibility. They have none.
But I don’t blame Blackmores. They are a supplement manufacturer with a single goal – sell supplements. They have no responsibility to the health and safety of patients – unlike pharmacists. They have no ethical responsibility to put patient care ahead of personal financial interests – unlike pharmacists. The reference to their product as the “coke and fries” to accompany a prescription is apt, and reflects their philosophy. It’s a product they want to sell- evidence is irrelevant, as is appropriate patient care. This is strictly a sales opportunity, and the pharmacist’s professional reputation, and their ethical responsibility, is clearly of little importance to Blackmores.
The sole responsibility for this debacle lies with the Pharmacy Guild of Australia. By entering into a financial relationship to sell Blackmores supplements alongside prescription drugs, they have put profits before patients, doing significant damage to the credibility of pharmacists, and the entire profession of pharmacy. Again: Are pharmacists retailers or health professionals? If you ask the Pharmacy Guild of Australia, their perspective is clear.
For the latest updates on this story, interested readers can follow the #cokeandfriesgate hashtag on Twitter.