Imagine a retail pharmacy where some of the medicines on the shelves have been replaced with similar-looking packages that contain no active ingredients at all. There is no easy way to distinguish between the real and the fake.

Another section of the store offers a number of remedies with fantastic claims, such as “boosting” the immune system, “detoxifying” the body, or “cleansing” you of microscopic Candida. They look sciencey, unless you realize that they treat imaginary medical conditions.

A corner of the store offers unpurified drugs supplied as tinctures and teas. The active ingredients aren’t known, and the batch-to-batch consistency of the product is unclear. The store will suggest products for you based on your symptoms.

Walk past the enormous wall of vitamins and other supplements and you’ll find a nutritionist who will tell you what products you should be taking. You’ll also find a weight loss section. From a science-based perspective, this shouldn’t even exist, given no product has been shown to offer any meaningful benefit. But there are dozens of products for sale.

At the back of the store you’ll finally find the pharmacist. A sign on the counter offers blood- and saliva-based tests for food “intolerance” and adrenal “fatigue”, claiming to test for medical conditions that actually don’t exist or lack an evidence base. The pharmacy also offers a large compounding practice, advertising what it calls “personalized” approaches to hormone replacement with “bioidentical” hormones.

Welcome to the “integrative” pharmacy.

You may not see all of this in your local pharmacy, but they’re coming: claims of a new “integrative” way to provide health care that is changing the face of retail pharmacy. Unfortunately, it’s harkening back to the era of patent medicines and snake oil. It’s not good for the pharmacists and the profession of pharmacy, and it’s even worse for the patients we serve.

The creeping prevalence of pseudoscience and quackery in pharmacies hit home the other day when I found yet another local pharmacy that proudly advertises that it will sell you sugar pills and call it medicine. A twitter discussion ensued, with one pharmacist commenting that his own retail pharmacy looks behind-the-times simply because he puts patient care and ethics ahead of revenue, and refuses to sell products like homeopathy. Pharmacy is a health profession, but retail pharmacy is also a for-profit business. This is a continual conflict, and I fear the professional side may be losing ground in the drive to increase revenue.

While I don’t personally work regularly in retail pharmacy, I think of myself as a strong advocate for the community-based pharmacist’s role – and for their potential to do much more. Not only are pharmacists among the most accessible health professionals, they can also have close, supportive relationships with their patients. And pharmacists are well-positioned to do much more to enhance the safe and appropriate use of drugs – from managing doses and side effects, to simplifying regimens, and by ensuring that prescribed medications are being taken safely and appropriately. If you’re generally healthy and don’t need medication, you may not even know a pharmacist. But those with high medication needs tend to know their pharmacist well, and many rely on their pharmacist as a key member of their health care team. I know the impact a good pharmacist can have on the health of a patient. But I’m increasingly dismayed at retail pharmacy practices that call the credibility and good intentions of the pharmacist into question.

Old whine in a new bottle

Integrative medicine is ascendant. Terms like “alternative” and “complementary” are falling out of favor, in part because it’s increasingly recognized that these terms carry a stigma – they are not part of mainstream medicine. Integrative medicine seeks to explicitly embed complementary and alternative medical practices into conventional, science-based medical care. It purports to take a “best of both worlds” approach, mixing science-based treatments with a variety of unconventional treatments. The fundamental challenge with integrative medicine is that “integrative” products and services don’t have scientific evidence to support them: if they did, they’d simply be called “medicine”. Instead of evidence, promoters of integrative medicine rely on other standards – many are grounded in belief systems, such as the idea of “vitalism“. While ideas like vitalism are long-discarded from science-based medicine, they live on in the philosophies of practices like homeopathy, naturopathy, and chiropractic. And the retail part of the pharmacy profession sees an opportunity, like this advertisement seems to suggest. Never mind the evidence, your pharmacy has sugar pills to sell:

Misleading patients and selling them inert, ineffective products is unethical medical practice. But under an “integrative” framework, pharmacies are simply offering homeopathy – after all, it’s trusted by millions. Basing your medical advice on pre-scientific ideas is incompetence from a conventional, science-based perspective. But integrative medicine seems to mean the freedom to simply make up diseases, and then to sell treatments for them. Scientific evidence is no longer the basis for your practice – it’s become more holistic, embracing “different ways of knowing.” I’ve written before about the harms to hospitals and academic settings from the embrace of “integrative medicine”. In short, there is no medical standard with integrative medicine – and that’s why “integration” is so problematic. The bandwagon is growing, however. On Monday, David Gorski noted that the National Center for Complementary and Alternative Medicine is jumping on board, with a proposal to change its name to the National Center for Research on Complementary and Integrative Health (NCRCI). Change the standard of practice, and what was ethically verboten is now acceptable – and that’s what integrative medicine proponents are explicitly trying to do in health care.

The integrative pharmacy

If you integrate unproven remedies with proven medicine in your pharmacy, it does not improve pharmacy practice or patient care – it makes that care worse. – (paraphrasing Mark Crislip)

A HuffPo column a few years back was a call-to-action to pharmacies to embrace integrative medicine – it was a depressing read to anyone that advocates for science-based principles. Entitled “Who Will Own the Brand of Integrative Medicine? “, the column described integrative medicine as a business opportunity:

There is a revolution happening in North American medicine. If successful, it will educate and empower consumers, introduce us to a world of new cures, and leave most of us wondering, ‘Why didn’t we do this 50 years ago?’

It profiled the Pharmaca chain of pharmacies in the US. The CEO of Pharmaca was quoted:

The common US model is one pharmacist, and a bunch of clerks stocking shelves. In our case, we have the highly trained pharmacist, but also highly skilled practitioners with homeopathic or naturopathic backgrounds. No one expert has the full answer. Instead, we collaborate to offer our customers a more holistic approach to managing their health.

Not surprisingly, Pharmaca advertises a wide array of ineffective treatments, from products that claim to offer adrenal “support” to homeopathy, detox kits and a weight loss selection that Dr. Oz would approve of. To their credit, they also offer important pharmacy services such as vaccines, including the whooping cough vaccine. It’s a shame they’re also actively promoting and profiting from selling pseudoscience.

Another integrative pharmacy that was profiled in the same column was Vancouver’s Pure Integrative Pharmacy:

Up to now, there’s been a polarization between advocates of traditional and conventional pharmacy. We believe the way forward lies in using treatments that are backed by evidence, regardless of their origin.

and the CEO continued:

I want to get rid of the whole east meets west stereotype. This isn’t about east meets west. It’s about getting the best product, or combination of products, for our customers. And those products come with proof of efficacy.

No argument there. Products need to be evaluated on their own merits, instead of a lower bar for products deemed “natural”, “herbal”, “alternative”, “complementary” or “integrative”. For this reason I object to the creation of Health Canada’s Natural Health Products Directorate, which only serves to lower the regulatory standards for anything deemed “natural”. So what kinds of products does Pure Pharmacy believe come with “proof of efficacy”? I didn’t have to search long to find homeopathic remedies, and products to treat adrenal fatigue, suggesting that “proof” seems to be a subjective term when it comes to “integrative” pharmacy practice.

Calls for pharmacy to change

The challenge to the profession and the ethically-troubling issue of “integrative” pharmacy practice hasn’t gone unnoticed. The recent publication of another comprehensive review of homeopathy is renewing questions about what pharmacies sell, and prodding the pharmacy to finally set some standards for what it sells. The Australian National Health and Medical Research Council (NHMRC) report on the effectiveness of homeopathy for treating health conditions was recently published. The NHMRC is the Australian organization that promotes and maintains health standards, both by supporting health research and by creating evidence-based health guidelines. Part of its mandate includes the requirement to “advise the community”. In this case, the review set out to answer the following question:

Is homeopathy an effective treatment for health conditions, compared with no homeopathy, or compared to other treatments?

There were three sources of information assessed to answer this question:

published systematic reviews – a structured approach to filter out low-quality evidence and while analyzing all available published high-quality data

information provided by homeopaths and homeopathy-supporting groups and organizations – from the information submitted, only the highest-quality evidence was subsequently considered.

clinical practice guidelines and government reports published in other countries

To support the credibility of the data evaluation process, the NHMRC asked the Australasian Cochrane Centre to verify the processes used were rigorous, transparent, and consistently applied.

Cutting to the chase, the review concludes the following:

NHMRC concludes that the assessment of the evidence from research in humans does not show that homeopathy is effective for treating the range of health conditions considered.

Case closed, one would hope. Homeopathy has no place in modern pharmacy practice, except perhaps as a case study in history, ethics or perhaps most appropriately, critical thinking. Yet despite the ethical and medical problems that exist with homeopathy, I’m unaware of any pharmacy regulator, worldwide, every taking voluntary action to limit or restrict the sale of homeopathy in pharmacies. The impetus to change only seems to be coming from outside the profession:

Pressure is mounting on pharmacists to stop selling homeopathic products after a major review found there was no credible scientific evidence to support the alternative medicines. Despite scepticism about homeopathy among pharmacists, many pharmacies sell homeopathic products that are marketed for illnesses including migraine headaches, bleeding, persistent nausea and vomiting, coughs and colds, insomnia and arthritic pain. But there are now increasing calls for them to abandon the products after a major National Health and Medical Research Council review of homeopathy concluded there was no reliable evidence it could treat health conditions. The review, released earlier this month, also stated: ”People who choose homeopathy, instead of proven conventional treatment, may put their health at risk if safe and evidence-based treatments are rejected or delayed in favour of homeopathic treatment.” While the review has been criticised by homeopaths who are appealing the finding, some doctors and pharmacists say it should make it unethical for pharmacists to continue stocking and selling homeopathic products. Under the Pharmacy Board of Australia code of conduct, pharmacists are required to practice ”in accordance with the current and accepted evidence base of the health profession, including clinical outcomes” and by ”facilitating the quality use of therapeutic products based on the best available evidence and the patient or client’s needs”.

While the professional bodies of pharmacy seem supportive, the retail arm of the profession is ignoring the advice:

Grant Kardachi, president of the Pharmaceutical Society of Australia, the professional body representing 18,000 pharmacists, said he planned to inform members about the review council’s report because homeopathy did not sit well with their aim for pharmacies to become more professional ”health hubs”.’ ‘I think we’d be saying you should seriously consider, if you are stocking these products in your pharmacy, what that actually means, and you should be looking at other products in your pharmacy to treat patients’ health conditions where you know there is more evidence,” he said. Greg Turnbull, from the Pharmacy Guild of Australia, which represents pharmacy owners, said it did not plan to do anything with the review.

The continued practice of ignoring the ethical responsibilities of the profession reminds me of this classic XKCD cartoon on “alternative literature”:

Alt-text: I just noticed CVS has started stocking homeopathic pills on the same shelves with–and labeled similarly to–their actual medicine. Telling someone who trusts you that you’re giving them medicine, when you know you’re not, because you want their money, isn’t just lying–it’s like an example you’d make up if you had to illustrate for a child why lying is wrong.

Conclusion

The idea that pharmacy practice is at a crossroads is a tired cliché in the profession, but I’m seeing the retail component of the profession deciding between one of two paths: One path will involve retail pharmacists, supported by pharmacy regulators, taking greater responsibility for their own profession and professional standards. In doing so, pharmacists will recommit to a professional service model that puts patient care responsibilities first. On this path, professional ethics trump retail pressures, and the practice of retail pharmacy changes to a new equilibrium, where products and services offered are focused on optimizing health, based on the best scientific evidence. There is no more question about the motivation of pharmacists, or the profession. It has happened before. Canadian pharmacies fought moves to ban cigarette sales. The bans prevailed – and pharmacy practice continued. The same can happen with “alternative” medicine and “integrative” practices, starting with the most egregious practices, like homeopathy.

The alternative path for pharmacy is quite different than the other. It’s the “anything for a buck” model, otherwise known as the “integrative” pharmacy. In this model, the retail practice of pharmacy becomes a loss-leader to get customers into stores, and there is a growing disconnect between the practice of dispensing and selling prescription drugs, and the rest of a pharmacy’s offerings. The pharmacy is a retailer first, and abandons any scientific standards or justification for products and services offered. Customers may be pleased, but they won’t be well-served. Pharmacists and pharmacies may profit in the short-term, but this self-sabotage will effectively and ultimately ostracize the retail pharmacy from science-based medicine.

Personally, I see only one path that is tenable. First, the profession needs to stop embarrassing itself, and get the most egregious quackery, like homeopathy, out of the pharmacy. Second, it needs to stop confusing and misleading customers into the sloppy (and potentially dangerous) thinking that underlies “integrative” care. Finally, it needs to recommit to practice based on scientific standards, while putting the patient at the center of its practice. As a pharmacist I want retail pharmacy to thrive – but in a framework that is grounded in the best science and the best medical care. “Integrative” pharmacy isn’t that path.