Research Profile - A natural need to know
Dr. Heather Boon
As more Canadians embrace the use of over-the-counter, natural products, pharmacists face new challenges
More than 70% of Canadians have used natural health products (NHPs), such as herbal remedies, vitamins and dietary supplements. But how much do pharmacists know about the NHPs sold over the counter in their pharmacies? How much should they know? Dr. Heather Boon, an associate professor in the Leslie Dan Faculty of Pharmacy at the University of Toronto, has led a four-year study, funded by the Canadian Institutes of Health Research (CIHR), on NHPs and pharmacy practices. She shares her thoughts on the growing phenomenon and how pharmacists are responding to it.
At a Glance
Who – Dr. Heather Boon, University of Toronto. Current Chair of Health Canada’s Expert Advisory Committee for Natural Health Products and co-author of A Complete Natural Medicine Guide to the 55 Most Common Herbs.
Issue – While pharmacists are in a key position to provide evidence-based information about natural health products sold over the counter in their stores, knowledge levels vary dramatically.
Approach – Dr. Boon’s team interviewed representatives from pharmacy associations, pharmacies and health food stores, the pharmaceutical and NHP industry, policy makers and health practitioners. They also conducted focus groups across Canada to get a better understanding of consumers’ expectations and pharmacists’ concerns.
Impact – Guidelines for establishing core competencies in complementary and alternative medicine are in the process of being disseminated to Canadian pharmacy schools for integration into curricula.
Question (Q): Pharmacists are well-positioned to help people when it comes to using NHPs, but their knowledge varies quite dramatically, doesn't it?
Dr. Heather Boon (HB): It ranges from, "I don't know anything" and, "We didn't learn about that in school", all the way to those who have taken an interest in it and become quite expert. That's one of the reasons we wanted to do this study: we needed to know where to set the bar.
Q: You conducted focus groups across the country with both consumers and pharmacists. Why consumers?
HB: It's one thing for us as pharmacists to decide what we think we should be able to tell the public, but we also wanted to know what patients' expectations were.
Q: What were those expectations?
HB: They were most interested in being able to go to the pharmacist and find out whether an herbal product they were considering would be safe to take with their other medications. Consumers felt strongly that that was where the pharmacists could help out.
Q: Can you give an example?
HB: Lots of people take warfarin if they've had heart problems. It keeps their blood from clotting too much. There are a lot of herbal medicines that can either affect the way the body metabolizes warfarin or directly affect the blood's ability to clot. People told us it would be helpful to be able to go to your pharmacist and say, "Hey, can I take this while I'm taking warfarin?" We also tell pharmacists this is the kind of thing they should be picking up on with their patients because patients may not know to ask about herb-drug interactions.
How often do people ask their pharmacists about natural health products (NHPs)?
“All the time” says Jaklin Boulos, a pharmacist at an HBC Zellers store in Toronto. “I would honestly have to say that it is quite amazing how interested people are in NHPs. These are very common questions.”
Ms. Boulos graduated from pharmacy studies at the University of Toronto in 2007, where she worked with Dr. Heather Boon in preparing patient information pages for camline.ca, an online source for pharmacists and patients seeking news and information about complementary and alternative medicine (CAM). It’s a resource she uses frequently now – printing off information sheets for her customers.
“People ask a lot about arthritis medications like glucosamine and chondroitin,” says Ms. Boulos. “They ask about various NHPs for weight loss and about products that promote good health, such as Echinacea for the common cold.”
While she has only been a pharmacist for two-and-a-half years, Ms. Boulos has seen NHP interest grow considerably in that time.
“There has definitely been an increase.”
Q: People often purchase over-the-counter herbal remedies without talking to a pharmacist. Can that be a problem?
HB: Absolutely. That's why we need to do some education for the consumers to let them know that just because these products are "natural" it doesn't mean they are perfectly safe for everyone. The problem is, if we're going to tell them, "Go ask your pharmacist," then we better make sure that the pharmacist is ready for those questions.
Q: Are pharmacists ready?
HB: We're getting there. More stores have at least one pharmacist who is quite comfortable answering these questions. There is continuing education for people who are already out there practising. I was speaking to the Ontario Pharmacists Association and they are doing a whole series of "webinars" (online seminars) so their members can learn more about complementary and alternative medicine.
Q: A recent Ipsos Reid survey indicated 71% of Canadians now use natural products – so pharmacists have to adjust to that reality, don't they?
HB: Now that NHPs are regulated by Health Canada as a subcategory of drugs, that makes it a much easier to sell the pharmacy community on how important they are. Before, many of these products were sold as foods, so it wasn't clear where our role began. Now, they're considered a class of drugs, so in my opinion they are definitely, squarely within our scope of practice.
Q: What do the pharmacists want?
HB: They would like more knowledge. These are people who have gone into a health care profession because they want to be able to help people. They told us over and over again that they wished they had learned more about complementary and alternative medicine at school. I don't think it will be too hard a sell to make these changes in school curricula. It starts there.
Q: How is that progressing?
HB: We'll soon publish a final paper listing recommendations of core competencies in NHPs for pharmacists. There are 10 pharmacy schools in Canada and we had (representatives from) four of them as co-investigators on our project. They agreed – and their deans agreed – that they would implement the core competencies. In fact, our co-investigators are basically already teaching those core competencies in those schools.
What should pharmacists know?
As part of their research, Dr. Boon and her team of investigators conducted 16 focus groups with pharmacists and consumers, tested fourth year pharmacy students' herbal knowledge and conducted a survey of 3,356 licensed Canadian pharmacists. As a final step, experts involved in teaching about NHPs or setting/enforcing related pharmacy policies were asked what should be considered core competencies for newly graduated pharmacists. Guidelines have been accepted for publication in the American Journal of Pharmacy Education and will be published soon. Meanwhile, here is a simplified summary of draft statements produced in 2008:
Pharmacy graduates should be able to:
- Create the opportunity for an open dialogue with patients about NHPs. This includes inquiring about NHP use; considering NHP use when identifying potential or actual drug therapy problems; integrating knowledge of NHPs into individualized care plans; and, when appropriate, documenting patients' NHP usage.
- Access and appraise sources of information related to NHPs. This includes finding credible NHP references; identifying evidence-based indications for use and expected outcomes; and identifying potential or actual interactions with drugs or diseases.
- Provide appropriate education to patients and other health care providers on the effectiveness, potential adverse effects and drug interactions of NHPs.
By the book
Under Canadian law, NHPs are defined as any substance found in nature "...that is manufactured, sold or represented for use in: (a) the diagnosis, treatment, mitigation or prevention of a disease, disorder or abnormal physical state or its symptoms in humans; (b) restoring or correcting organic functions in humans; or (c) modifying organic functions in humans, such as modifying those functions in a manner that maintains or promotes health." *
Health Canada regulates NHPs, which includes: vitamins and minerals, herbal remedies, homeopathic medicines, traditional medicines, probiotics, amino acids, and essential fatty acids sold over the counter to consumers. **
By the numbers
71% of adult Canadians surveyed in 2005 said they had used an NHP. Of them, 38% said that they did so on a daily basis, 37% said "only during certain seasons," while 11% did so weekly. Vitamins (57%), Echinacea (15%), herbal remedies and algal and fungal products (11%) were most popular. ***
Canadians spent an estimated $7.84 billion on alternative medicine products and services in the latter half of 2005 and first half of 2006. ****
NHPs ranked 6th and herbal remedies were 8th in a 2004 report by the Nonprescription Drug Manufacturers Association of Canada on its list of the top 20 self-care products sold in Canada. (Headache remedies and over-the-counter analgesics ranked 1st.) *****
Sources
* Government of Canada. Natural Health Product Regulations. 2003
*** Ipsos Reid for Health Canada. Baseline Natural Health Products Survey Among Consumers.
***** NDMAC