Part Two of Upselling Drugs

 I decided to approach one more official body, Otago & Southland District Health Boards. Here is the reply:

  

“The DHB has a contractual relationship with pharmacies and requires ethical standards to be upheld at all times. The DHB is not the correct or appropriate organisation to make judgement on a pharmacist's ethics or actions. I can however provide you my personal views as a pharmacist which hopefully you will find helpful. Your experience of being offered another product with your antibiotic prescription is common practice in New Zealand and around the world.  I ask you the question ... if it had been a different product such as a cough medicine or pain relief, then would your response have been the same?  The pharmacist was offering a product, which in their professional opinion, would have had benefit to the patient.  The product you would have been offered would have been some form of pro-biotic which does have a solid evidence basis for being beneficial when taken with antibiotics.  Ultimately you were provided advice and given a choice.”

In my view this argument still emphasised option above ethics. I remained unconvinced. However, with so much high-powered opposition my conviction was faltering. At this point the practice manager returned to work and restored my faith, at least in one corner of the medical field. 

      

The doctor given the task on behalf of the practice to take up my concerns wrote the following, “which reflect the position of the practice:”  

 

“Offering of probiotics suggests that everyone gets side effects from antibiotics, when this is clearly not the case.

 Offering of probiotics is at best confusing for patients and at worst undermines the credibility of the doctor, by suggesting that the prescribed medicine is somehow ‘bad’ for them.

There is an ethical conflict which arises from the fact that the pharmacy is making money out of selling the product being recommended.

There is a big difference between patients actively seeking pharmacist advice and being offered unsolicited advice.

There are tensions arising from the fact that pharmacists dispense both evidence based medicine and alternative treatments.”  (Though not concerned about pharmacists giving advice about alternative treatments per se, it is important that they make the distinction that it is not an evidence-based treatment).

 

The pharmacy manager’s response is summarised as follows: 

 “Providing advice to patients about the taking of medication is considered an integral part of the pharmacist’s role, including what possible side-effects to expect and in what circumstances they should go back and see their doctor.

Making recommendations about treatments with general health benefits is also part of the pharmacist’s role. This is not intended to be ‘hard sell’ and it is the patient’s decision whether they follow the advice or not.

It is never intended to undermine the advice or treatment made by prescribers.”

Nevertheless, the manager noted that she would be working with the pharmacist involved to address his understanding of how advice should be communicated to customers.

This division of opinion between front-line doctors and patients on one side and everyone else on the other side is surprising and a bit of a worry. Particularly when poor, inarticulate people front up to pharmacists with a prescription for themselves or their children. The “decision” the patient has to make is to waste money on drugs they don’t need or feel guilty for being confused and stingy.  There are clinical and ethical views here, and the real worry is that they may in time be swamped by the clout of a billion dollar industry.

    

Christopher Horan

 

UPSELLING DRUGS. PART ONE.

I caught a virus and a touch of pneumonia. Nothing serious. Nothing to worry about. My doctor prescribed antibiotics and off I went to the pharmacist feeling confident I was being well cared for. After the usual wait the pharmacist gave me a little bottle of antibiotics for $3.00. But at the same time he produced another bottle of pills called Probiotcs, saying, “I always advise patients to take these too because antibiotics kill the good as well as the bad bacteria.” These pills were over $30.00  

I was lost for words for a moment. I didn’t have extra money on me. But that was not my major concern. Whenever I have sought advice from pharmacists I have found them unfailingly helpful, but this was a first; unsolicited advice inconsistent with advice given by my doctor. I found the experience disturbing. How would a person who is hard-up as well as sick respond to this dilemma? The feeling of unease stayed with me.  How much was this a commercial intrusion into the world of medicine? I set out to find out.

First stop: The practice manager of the medical centre I attend. I sent the  following (abbreviated) email entitled "Ethical Issue."

“1. I  did not go to the pharmacist for advice. 
2. The advice he gave me made me question the value of the advice given by the doctor.
3. I have never experienced this kind of unsolicited advice from a chemist before when asked simply to provide prescribed  medicine.
4. I think this indicates that the chemist is abusing the special relationship with your practice for commercial gain. I found the man friendly. Perhaps he was unaware of the ethical issue here. You may not agree. I would appreciate your opinion.” Back came the reply:

“You are correct in pointing out that the situation you experienced raises a number of issues which need to be clarified.”  

So, the matter was now between the pharmacy owner and the practice manager.  But getting a response from the owner of the pharmacy proved difficult partly because the practice manager went on leave and there was some miscommunication. Weeks dragged on until I decided to phone the pharmacy.

I raised my concerns with the manager. She repeated what the pharmacist had said: Antibiotics attack good and bad bacteria and it was common practice to sell Probiotic. "We sell a lot." She was polite but could not see my point of view about the practice being unethical. And so I wrote to the Pharmacy Council of New Zealand. They  replied: 

“The product that you were offered when collecting your prescription for an antibiotic is a service offered by many pharmacists to counter harmful side effects of antibiotics.  The pharmacist is within his/her rights to offer or recommend such a product as long as the patient is given the choice to decline the purchase.”

I wrote to Pharmac and got this reply: “It sounds like your pharmacist was offering you some probiotics.  These are an optional extra to, as your pharmacist explained, keep up the healthy flora in your stomach to reduce the likelihood of stomach upsets as a result of the antibiotics.”

“You can either consider this to be 'upselling' or the pharmacist 'doing his best for his patient' by offering you this option, albeit unsubsidised. Either way, it is allowed for your pharmacist to offer you additional products if they feel they may help your situation.  And you have the right to decline them if you wish.”

 All this was  fine  but  none of it  answered the issue (or the word) I was concerned about. I had asked for a judgement on ethical practice and I was still looking for an answer.

 

 

 

UNDRESSING THE BULLIES.

Given that New Zealand respects civil rights, Wanganui’s banning of gang patches was bound to bring on a protest. But is the argument about the erosion of civil liberties or anarchy versus democracy?

The gangs have clearly not been denied free speech. Their ability to engage in the political, religious and social life enjoyed by other citizens has not been curtailed. In other words, all those democratic rights that we hold dear, rights that are virtually unquestioned in our society, are available to members of gangs.

Gangs are criminal organizations that have set themselves against society and created their own rules. Their customs include grooming ‘prospects’ to commit crimes to earn membership. And the cultural and moral relativity that educated apologists talk about includes gang rape.

But the most disquieting news I gleaned the day after the banning was a 'Morning Report’ item on National Radio. Apparently a handful of mayors had been canvassed for their views. One of them insisted his identity be kept confidential. That, in a nutshell, is why gang patches and democracy are at odds.