evidence based medicine

Self Selecting P-meds: searching for the evidence

The other week, the lovely folks at The Pharmacy Show Community (they are really lovely, my flattery of them is nothing whatsoever to do with the fact that they are linking to and publishing bits of my blog) held a tweet chat all about the self-selection of P meds, led by the mysterious and always entertaining @MrDispenser.

There are a few concerns that I- and it seems many other pharmacists share about the self-selection of P-meds. I've covered some of my concerns here, but the tweet chat threw up many others too. Other pharmacists have also shared their concerns, and you can find some of them in the links below:

Right now I want to look at the evidence that self-selection works. The theory is that allowing patients to choose their own medicines leads to greater adherence. As the patient feels they have more ownership over their healthcare decisions, they might use the drugs more effectively for a better outcome. But is there any cold, hard evidence that this is the case when it comes to over the counter medicines? 

As a skeptic, the words "Where's the evidence?" are often found escaping from my mouth. Sometimes the need for evidence is countered by the risk averse pharmacist side of me, where the theoretical likelihood of a risk outweighs the need for evidence. As with all things in healthcare, a balance needs to be taken into account: what are the risks vs what are the benefits?  In this case of self selection, I can see there being a real risk of fatalities. Any evidence of benefit to patients needs to be robust in order to outweigh the risks, in my opinion.

So I've made a start by looking at Embase and Medline. I've also had a look at NHS Evidence and have even googled. And I've been able to find very, very little on the subject. I found one Dutch paper about self-selection in the pharmacy, but that has no abstract.

I found this World Self-Medication Industry website which states:

"A study done in the United Kingdom showed that consumers welcome the opportunity to self-select medicines in that country's pharmacy class. Three out of four of the British consumers in the study felt that re-configured pharmacies with easier access to non-prescription medicines was a good idea, half because it would save their own time or that of their doctor, and the remainder because it offered greater choice."

But this doesn't appear to be referenced, so I can't find the study to see how reliable it is.

Have I missed anything? If you're aware of any evidence for the efficacy of self-selection of P-meds, please do let me know by dropping me an e-mail at healthydoseofskepticism@gmail.com. I would be particularly interested in any evidence that could be provided by the GPhC, and might drop them a line to see what they have to say on the matter. 

In contrast, I stumbled across a study from New Zealand, which concludes that, when purchasing a pharmacy medicine for the first time, in 62.2% of cases the sale was influence by pharmacy staff. This study has its limitations of course, but if true (and from my personal experience of many years of community pharmacy work it would appear about right), it would seem a shame to eliminate this from the medicines buying experience. 

There is also some evidence that patients who approach the pharmacy counter with a specific product in mind are given poorer advice than those who ask for a recommendation based on their symptoms- again something I have experienced both as a pharmacist and a customer. 

Of course patients can still ask for the expertise of pharmacy staff, but how many of them will know to ask, and how many will simply pick the nearest thing and hope for the best?

I'm going to hopefully write another post about my concerns about how the patient experience will be affected. If you have any thoughts on this, again do get in touch. If you're a customer in a pharmacy, I would love to know whether you think self-selection of Over-The-Counter medicines would be good for you. 

A call to arms: Why pharmacists should call for Open Data

Pharmacists of the world, unite and take over.

Pharmacy has been hit hard over the past few weeks. We've had MPs accusing us of being smartie counters, and a badly written BBC News expose implying that we are all merrily dealing benzo's to make a quick buck. (I may attempt another blog post on this at some point)

I believe that historically, pharmacy has drawn the short straw. In my opinion. our professional body, the Royal Pharmaceutical Society, seems to lag behind other bodies when it comes to media savviness, and it often feels like we have very little impact or voice when it comes to the healthcare profession as a whole. Even now, its still a rare occastion that a pharmacy-related story will actually have a pharmacist commenting on it in the news- GPs, doctors and nurses are simply much more vocal and recognisable to an audience. 

But here is an opportunity, and it has been handed to us on a silver platter by Ben Goldacre and the BMJ. I'm sure you may have heard by now, but there is a pretty large campaign on the go to allow for more transparent reporting of clinical trial data. This has been prompted by the case of Roche's Tamiflu, but its wider implications on patient safety and care are huge.

All the information you need about the BMJ's Open Data campaign can be found here.  

Today I tweeted Ben Goldacre to ask what involvement there has been from the pharmacy bodies. The answer? A big fat zero. There has been no involvement at all, from any of them.

So here is my call to arms. If you are a pharmacist, or if you are affiliated with the pharmacy profession, lets contact the RPS, the GPhC, NPA, PSNC, and anyone else who will listen. Lets tell them how important this is to us and how we want them to represent us and get our voice heard.

After all, to be experts in medicine, we need to have access to information about medicine. And that information has to be accurate, reliable, accessible, and unbiased. Without open data, we simply cannot do our jobs properly or with the degree of safety that we would like to. It may seem like a trial not being published is far removed from handing over a prescription to a patient over the counter, but the fact of the matter is that patients are dying due to the lack of transparency. How can we counsel a patient on side effects, for example, when patient level data from trials has been withheld? How can a patient be prescribed the best medicine for their condition when most of the trials involving the drug haven't been published? 

Moreover, what a great way to represent ourselves as a profession who, more than anything, care about the health- and safety- of our patients, and who are willing to speak up when it counts. What a fantastic opportunity for our professional bodies to prove what they can do. 

H xxx

The Importance of Being Human

The more I talk to homeopaths and other alternative medicine practitioners, the more I realise that the distinction between in vitro and in vivo testing is unclear to many.

It may be due to ignorance, or it may be in a desperate bid to pad out the lack of real-life clinical evidence, or to stun us all into silence with impressive looking sciencey stuff, but it seems that alternative medicine supporters are desperate to throw in vitro studies my way as "evidence" that their treatments work. But here's the thing: it's not evdience that it works at all. In fact, for the purposes of informing treatment decisions, any in vitro data might as well be discarded before you even bother reading it. 

Why do i say this? Well, the easiest way to explain this is in picture form (drawings are courtesy of Haymond) :

A petri dish filled with gel, with some cells in it (an in vitro experiment)

A petri dish filled with gel, with some cells in it (an in vitro experiment)

A human being  (well, okay, I know some people might think scientists aren't quite human beings but, y'know, we thought we'd still use one as an example). (in vivo)

A human being  (well, okay, I know some people might think scientists aren't quite human beings but, y'know, we thought we'd still use one as an example). (in vivo)

As you can see from these pictures, a few cells in a petri dish actually look (and act) rather differently to a functioning, whole human body. So positive (or negative) results in an in vitro study actually bear very little resemblance to real life clinical situations. What  in vitro testing is great for is as preliminary evidence- to make new discoveries and to guide further research, and to find out the all-important details of how something may work. But we can't use some cells in a petri dish to say "Yes, this will definitely work for this or that illness". The only sort of evidence that we can use to decide if a drug is effective in any particular illness is a robustly designed clinical trial, and even then we can't use that as a cast iron guarantee. 

I'm hoping that you will forgive me for this horrendous oversimplification, but it is hopefully a useful point to make. So, the next time you come across some in vitro studies being used as "evidence" that homeopathy works, you know that they're actually scraping the barrel, particularly gievn the fact that homeopathis is supposed to have been around for 2000 years. I'd expect after that amount of time that they'd have more than cell culture studies to their name.