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Unethical Behavior of Pharmacists

Most pharmacists who work in retail pharmacies have a serious potential conflict of interest. On the one hand, they are professionals, expected to be knowledgeable about drugs and to dispense them in a responsible and ethical manner. On the other hand, their income depends on the sale of products. Before the FDA's OTC (Over-the-Counter) Drug Review drove most of the ineffective ingredients out of OTC drug products, few pharmacists protested or attempted to protect their customers from wasting money on products that did not work.

Dubious Products

Today nearly all pharmacies carry irrationally formulated dietary supplements, and many stock dubious herbal and homeopathic products in addition to standard drugs. Chain drugstores are more likely to do so than individually owned stores. Pharmacy trade publications, such as Natural Pharmacist, suggest that "natural products" offer opportunities to make up for prescription drug revenues lost as a result of managed care and other cost-containment programs. One pharmacy supplier aligned with this trend is The JAG Group of San Clemente, California, whose comprehensive program features:

• Profit margins greater than those for prescription drugs.
• Product lines that typically produce a 100% markup or more.
• A 3-day seminar covering "the importance of wellness" and how to "use natural products to prevent and/or improve chronic disease states."
• WellStore Software designed as a sales and marketing tool to: (a) capture customer information, including email address, (b) categorize products to market directly to customer needs, (c) provide thank you notes to encourage loyalty, (d) provide product information to print for customers, and (e) track patient health histories to create fee-for-service revenue.
• Pharmacist PlusTMSoftware with causes, signs and symptoms of 223 common ailments and specific dietary, homeopathic and herbal recommendations. [I believe that providing such information to customers would be outside the scope of pharmacy practice and would constitute the illegal practice of medicine and would violate state laws against theft by deception. Furthermore, homeopathic products have no proven effectiveness.]
• Drug Depletion Software telling "what supplements patients need to replace vital nutrients that are depleted by many of the prescription drugs they are taking." [I do not believe there are many situations in which this is important.]
• Nutritional Analysis Software (an electronic nutritionist) to allow the pharmacist to charge a fee for providing consultations to patients -- including assessment of "nutritional needs that best fit your patient's gender, age, lifestyle, analysis of food intake and identification of nutritional deficiencies" and "recommendations for optimum nutrient levels to maintain good health." [I do not believe any software can do this.]
• A TV commercial, radio spots, newspaper and yellow page ads, doctor letters, and a column that can be published under the pharmacist's own name.
• A personalized Internet web page, which adds the pharmacist to a list of "complementary and natural healthcare practitioners worldwide" that so that "when someone searches for a natural healthcare practitioner, they will find you." [I do not believe that pharmacists are qualified or legally permitted to be "natural healthcare practitioners."]
• An in-store display unit designed to let customers see a variety of products, books and services in one place.
• Answers to questions needed "when a customer is standing in front of you" or when "you want to know about a new fad or product your customer just asked you about."
• "The best experts in the fields of pharmacy, natural products and complementary medicine available" by picking up the phone or accessing the internet.

In a recent interview, a JAG's president said that nearly 500 pharmacies were enrolled in her company's program [1].

Delusion-Based Practices

HealthTrust Alliance, of Lawrenceville, Georgia, offers an elaborate system for marketing dietary supplement, herbal, aromatherapy, and homeopathic products to pharmacy customers. The system includes:

• The Life-Span Drug Depletion Program, through which pharmacists inform customers and their physicians that their prescription drugs place the customer at risk for nutrient deficiencies. The program includes sending form letters to patients which state that, "Based on our latest computer search of prescriptions, we have discovered that you are taking certain prescription medications that may be causing a nutritional deficiency. We are writing to inform you that these prescriptions are depleting your body of vital nutrients." Telemarketing is also recommended. The program includes forms to be given to customers who bring prescriptions for any of a large number of drugs, advising them that various supplements are needed. The Life Span Care software system "tracks patient outcomes by integrating the patient's prescription therapy with all supplemental products, herbs, homeopathy, aromatherapy, flower essences, and behavioral lifestyle changes." [2] The 8-person Life-Span medical advisory board includes Jay M. Holder, D.C. (who for years falsely claimed to have a medical degree) and Daniel G. Clark, M.D., whose Florida license was revoked in 1983 for unprofessional practice.

Life-Span seminars suggest many strategies for persuading customers that their current nutrient needs are not being met, even if they are already taking multivitamins containing some of the recommended nutrients. For example:

• You don't get what you need in your food anymore.
• The RDAs really stand for "Really Dumb Allowances," were set 30-40 years ago, and are too low.
• The leading multivitamin brands are incomplete and don't contain therapeutic amounts of some of the ingredients you need. (The sales aids include charts comparing Life-Span products and the three leading multivitamins.)
• Supplements should be taken several times a day because after a few hours, "water-soluble vitamins are excreted out of your body."
• Trust me. Our products are superior. As a professional pharmacists I would not sell them if they were not.
• The vitamins we carry are the ones I take myself and give to my family.

The Drug Depletion Reference Manual advises that every customer should be taking a multivitamin, flax seed oil, an acidophilus product, and calcium (mostly for people over 55). It also contains "quick reference charts" showing which "nutritional support" products, herbals, homeopathic remedies, aromatherapy products and "flower essences" to recommend for over 200 drug products. According to the manual:

Drug depletion is a major revenue source for any pharmacy. It is estimated that approximately 70% of the prescriptions filled deplete the body of some nutrient that needs to be replaced in order to prevent a nutritional deficiency. . . . Pharmacies who implement drug depletion correctly could double their store profitability in six months. [3]

• Pharmacy-Based Lab Testing, through which pharmacists arrange for hair analysis (to test for toxicity), saliva tests (for hormones), stool examinations (for parasites), and various other nonstandard tests that they use as a basis for prescribing products. Company literature estimates that each test will generate $200 to $300 per month in products sales, (half of which represents profit). It also states:

Many pharmacists will average 3 or 4 tests per day. Once your confidence is built, you will order laboratory testing on approximately 30% of your patients. After completing a year of laboratory test training, you will be able to target laboratory tests that will result in approximately a 90% success rate in identifying nutritional deficiency or toxicity you are looking for with your patient.

• Individual consultations, during which pharmacists charge fees for advising patients how to use the company's products. The suggested rate is $100 per hour. HealthTrust literature claims that Life-Span-trained pharmacists can help patients with yeast infections, numbness and tingling of the fingers, mitral valve prolapse, and back pain, and 32 other conditions or symptoms. The products -- more than 150 of which are marketed under the brand name of "Natural Creations" -- include Verma Comp (for strengthening the body's action against intestinal parasites); Tri Folio Comp (for "fortification" of the lymphatic system and spleen); Cardio Circulation (for chest constriction, difficult breathing, ankle swelling); and Carcinosim Miasm (a homeopathic product to provide "system support" to individuals with an inherited "tendency toward cancer"). In October 1999, at a conference on Internet Pharmacies, HealthTrust's chief executive officer reported that more than 300 Life-Span pharmacists were "already selling out-of-pocket consultative services from $50 to $150 per patient." [Note: On March 13, 2001, he told me that the company had switched from "Natural Creations Products" to another product line about a year ago.] On January 11, 2002, I found an online directory that listed about 360 Life-Span pharmacies nationwide.
• Weekly teleconferences and other educational activities for learning how to implement the various programs.

Federal drug laws prohibit the marketing of products for the prevention or treatment of disease that have not been proven effective for their intended use. State laws do not permit pharmacists to engage in "diagnosis" or "prescribing" that constitute the practice of medicine. I believe that (a) many of the products are being marketed illegally; (b) most of the conditions for which participating pharmacists are encouraged to treat are far outside the legitimate scope of pharmacy; (c) pharmacists who offer the recommended testing and consultation procedures are practicing medicine without a license and could jeopardize their own license to practice pharmacy; and (d) their customers are at great risk for misdiagnosis, mistreatment, and financial exploitation. If you have been misdiagnosed or mistreated by a pharmacist using this system, please telephone me at (610) 437-1795.

Dubious Compounding

Compounding is the creation of a drug product by mixing ingredients. Today, only about 1% of new prescriptions are compounded, but compounding appears to be undergoing a resurgence. Compounding has legitimate uses and is most often done honestly at physician request. However, the primary organizations that promote it are aligned with a chelation therapy organization, and a newsletter for compounders has been promoting treatment concepts and ingredients that lack scientific substantiation [4].

Investigative Reports

If asked directly whether an ineffective product is worthwhile, most pharmacists will answer to the best of their ability. However, many are poorly informed.

• In 1985, reporters from Consumer Reports magazine visited 30 drugstores in Pennsylvania, Missouri, and California. The reporters complained of feeling tired or nervous, and asked whether a vitamin product might help. Seventeen were sold a vitamin product and one was sold an amino acid preparation. Only 9 of the 30 pharmacists suggested that a doctor be consulted [5].
• Not long afterward, two dietitians examined the labels of vitamin products at five pharmacies, three groceries, and three health-food stores in New Haven. Products were considered appropriate if they contained between 50% and 200% the U.S. RDA and no more than 100% of others for which Estimated Safe and Adequate Daily Dietary Intakes exist. Only 16 out of 105 (15%) of the multivitamin/mineral products met these criteria [6].
• In 1987, two pharmacy school professors sent a questionnaire to 1000 pharmacists in the Detroit metropolitan area and received 197 responses. Among the 116 who identified their five most-common reasons for recommending vitamins or minerals, 66 (56%) listed fatigue and 57 (49%) listed stress [7]. (Neither reason is valid.) In response to a question about homeopathy, 27.4% said it was "useful," 18.3% judged it "useless," and 54.3% "didn't know." [8]
• A more recent survey found that 47% of pharmacy students at two Philadelphia schools were taking supplements. The study demonstrated that many of them mistakenly believed that supplements could improve energy and relieve stress and that year of school had only a modest influence on these beliefs [9].

What Happened to Ethics?

Merlin Nelson, M.D., Pharm.D., coauthor of the above-mentioned survey, has asked pharmacists why they promote and sell food supplements to healthy individuals who don't need them. He concluded:

The most common reason is greed. Advertising creates a demand that the pharmacist can supply and make a profit. "If I don't sell them, they'll just go to my competition down the street," is a common response. Pharmacists are apparently more interested in a sale than in the patient's welfare. . . .

Rather than just recommending a multivitamin to patients concerned about obtaining enough vitamins in their diet, pharmacists should offer sound nutritional advice or provide referrals to experts in nutrition such as registered dietitians. [10]

Pharmacists are also the only recognized health professionals who sell tobacco products, which cause more death and years of lost life than any other consumer product. Although some pharmacists have stopped, the majority do not consider tobacco sales unethical.

The American Pharmaceutical Association's code of ethics does not state that pharmacists have a duty to prevent dubious products from lining their shelves. Five states have laws declaring it illegal for pharmacists to sell ineffective products, but these laws have never been applied to the sale of OTC products. In 1995, the National Association of Boards of Pharmacy passed a resolution critical of homeopathy. Though commendable, this resolution has had no visible impact on pharmacy practice.

In March 1998, at a symposium sponsored by the Good Housekeeping Institute, former FDA Commissioner David A. Kessler, M.D, J.D., sharply criticized the willingness of a neighborhood chain drugstore to sell supplements whose labels made improper claims. Next to the pharmacy counter, he had counted 26 displays with such claims as: "targeted mind improvement," "advanced memory and concentration formula," memory support complex," helps increase serotonin level," "immune enhancer," "leg health," "cartilage rejuvenation and repair," and "As featured in the book, 'The Arthritis Cure.'" He told the symposium audience:

I wonder whether many pharmacists really have given up their roles as health professionals, as pharmacists. Maybe they're no longer in control of the store. Maybe they're just behind the counter, and anything in front of that counter goes. But it's time for that profession to take responsibility for what it's selling. [11]

I believe that pharmacists have as much of an ethical duty to discourage use of inappropriate products as physicians do to advise against unnecessary surgery or medical care. Very few pharmacists do so. Pharmacy journal editors ignore this problem. Hospital-based pharmacists generally exhibit a higher standard of practice, but very few of them are speaking out about the problems described in this article.

If anything, pharmacy organizations appear to be moving in the opposite direction. In 1999, for example, the Association of Natural Medicine Pharmacists (ANMP) and the Texas Pharmacy Association announced a certificate program to help pharmacists establish "natural medicine sections" in their stores. The program includes 8 hours of home study followed by a 16-hour seminar and some case studies. The seminar has four modules. Module 1 focuses on herbal therapeutics and regulatory issues. Module 2 provides "an overview of vitamins, antioxidants, and essential fatty acids, with a focus on drug-nutrient depletion." Module 3 provides "an overview and description of popular alternative therapies with a focus on the general principles of homeopathy." Module 4 focuses on marketing [12]. The course description and information on the Web site makes it clear that much of the information will be invalid. ANMP's Web site describes it as "a professional association serving pharmacists and those interested in the field of natural medicines."

What You Can Do

If a pharmacy you know refuses to sell tobacco products, herbs, and homeopathic remedies, try to acknowledge this in the letters column in your local paper. Local papers seldom publish antiquackery messages that attack specific products or practitioners. However, they might be willing to print a letter praising ethical behavior. William J. Bennetta, president of The Textbook League, suggests writing something like:

Unscrupulous and irresponsible pharmacies throughout the country are peddling herbal junk, homeopathic water, and other quackish junk to unsuspecting rubes, but the XYZ Pharmacy on Maple Street in Ourtown has declined to engage in such ripoffs. Three cheers for XYZ!

References

1. Garneau J. Interview in Havlick DH. Tomorrow's pharmacy today according to JAG. Natural Pharmacy 3(6):1,20-21, 1999.
2. HealthTrust Alliance advertisement, Natural Pharmacy 3(11):2, 1999.
3. Woodruff RD. Drug depletion. In Drug Depletion Reference Manual. Lawrenceville, GA: HealthTrust Alliance, 1998.
4. Bouts BA. The misuse of compounding by pharmacists. Quackwatch.
5. The vitamin pushers. Consumer Reports 51:170-175, 1986.
6. Bell LS, Fairchild M. Evaluation of commercial multivitamin supplements. Journal of the American Dietetic Association 87:341-343, 1987.
7. Nelson MV and others. A survey of pharmacists' recommendations for food supplements in the U.S.A. and the U.K. Journal of Clinical Pharmacy and Therapeutics 15:131-139, 1990.
8. Nelson MV, Bailie GR. Pharmacists' perceptions of alternative health approaches: A comparison between U.S. and British pharmacists. Journal of Clinical Pharmacy and Therapeutics 15:141-146, 1990.
9. Ranelli PL, Dickerson RN, White KG. Use of vitamin and mineral supplements by pharmacy students. American Journal of Hospital Pharmacy 50:674-678, 1993.
10. Nelson MV. Promotion and selling of unnecessary food supplements: Quackery or ethical pharmacy practice? American Pharmacy NS28(10):34-36, 1988.
11. Kessler DA. Why the FDA does not approve supplements. Speech at Good Housekeeping Institute Consumer Safety Symposium: Dietary Supplements & Herbal Remedies. New York, March 3, 1998.
12. Grauds C. Certified knowledge: Phytomedicinals and alternatuve medicine certificate program. Natural Pharmacy 3(12):6-7, 1999.