A consistent pattern of responses emerged despite the geographical differences of the participants. Consumers and pharmacists agreed that there is a need for pharmacists to take on a consultative responsibility for NHPs, which takes into account the characteristics of the 'new consumer'. In particular, both agreed that this responsibility is especially important in terms of pharmacists' traditional responsibilities for ensuring patient safety from adverse events and drug interactions associated with NHPs. Not all consumers are information strong though, as we found some evidence for the continued existence of passive patients who rely on their pharmacists for information about NHPs.
Consumers and NHPs
Consumers in this study generally did not rely on pharmacists for information about NHPs. Many consumers displayed characteristics of the 'new consumer'. They perceived themselves as being capable of making their own decisions regarding the use of NHPs and utilized a wide range of information resources (that may or may not include pharmacists) to make those decisions.
The majority of consumers in our study believed that they were well informed prior to coming to the pharmacy. Many found information from the Internet, friends or family, newspapers, magazines, books, health food stores, or other healthcare professionals (e.g., physicians, naturopaths):
Well, I'll do research, I'll have a look on the Internet, and then I'll ask people questions. I'll go into their shops, and I'll ask customer service or whoever is working in that area about questions.... Then I'll think about is it going to be good for me, looking at my whole, like what's happening with my own symptoms or whatever, and then I'll choose whether to try it, or whether to not try it. – Toronto consumer
Some consumers said they never even thought of asking the pharmacist about NHPs:
It never really would have occurred to me to have asked a pharmacist about anything that was natural. I would have gone to [health food store name]... for that type of information. Most of the stuff I would want to know would probably be more from a nutritional, preventative point of view and that I would think of more of a dietitian or something as a logical source to go for that type of thing as opposed to a pharmacist. – Vancouver consumer
Pharmacists made the observation that consumers today are information strong and critical of professional advice:
Well they come with pre-conceived ideas of what is or is not good and... I find myself in the position where I am either explaining why not or trying to understand the basis of the claims that these people are saying these particular products had made about them; I mean it's just very difficult. – Halifax pharmacist
Consumers also emphasized their skepticism about relying on expert advice:
We need to be open minded. You have to take some active control yourself, and these are people that you are consulting, not Gods that know everything. – Edmonton consumer
The Pharmacist as an NHP "consultant"
Despite the fact that most consumers do not rely on pharmacists for NHP-related advice, the majority of both consumers and pharmacists agreed that pharmacists need to be knowledgeable about NHPs. Our participants suggested that pharmacists could adopt a consultative role to help consumers identify and assess the range of information available, but not necessarily make the final decision for them regarding use.
There was high agreement among consumers that pharmacists need to be knowledgeable about NHPs because usage of NHPs is common among the general public:
Pharmacists should know that alternative medicines are part of our life, they are reality, and when they sell or fill a prescription, they should be aware that people are likely doing other things as well, and they need to know about it. They need to have a basic understanding about what alternative medicines are. – Edmonton consumer
More importantly, both consumers and pharmacists agreed that if NHPs are sold in the pharmacy, pharmacists should be responsible for, and knowledgeable about, them.
I would think that pharmacists should be responsible for the products that their store is selling and not just being one where you need a prescription; they should also be responsible for the vitamins and they should be responsible for the non-prescription drugs... the range of their responsibility is not just the things that are on prescription... – Halifax consumer
In my practice, I don't carry things that I don't know about.
- Edmonton pharmacist
Several consumers argued that pharmacists who are not knowledgeable about NHPs are not fulfilling their professional responsibilities:
When I talk to pharmacists who don't know about herbal remedies, I kind of think that they must not take their job very seriously...how can you help people if you don't know? – Vancouver consumer
Our participants suggested that pharmacists could adopt a consultative role to help consumers integrate all types of information when making decisions about the use of NHPs. As one pharmacist described the role:
I see that one of the roles we have as pharmacists that is very important is to help people to tie in all of their sources of information into something meaningful and useful for themselves. So, we really do need to have some kind of a general education regarding all the different modalities that are available to people so that we can help them make sense of all of the information they are being bombarded with for their own safety, but also for assisting and directing them to alternative choices that might be appropriate for them to use and to still keep it in a safe place and refer them on. – Edmonton pharmacist
Consumers expected pharmacists to assist them in the appropriate use of NHPs as they do for over-the-counter medications. They would like pharmacists to provide helpful information, but not necessary make the final decision about use:
I do expect them to give me suggestions. I will read the label but it doesn't always tell me what it's supposed to do for me. So if I expect that for the over the counter stuff, if the herbal things come in, I do expect that they should be able to tell me about the herbal things. If they are going to sell it and I am going to ingest it, I want to know. – Halifax consumer
Consumers perceived this to be especially important since NHPs can be pharmacologically active and the dosing instructions and safety information for NHPs are often confusing or missing from labels of products.
...particularly those that are [over] the counter I would think like knowing the most up-to-date literature and why a person would take vitamin C supplement and how much and what are the effects of taking too much...I don't think that information is readily available at the stores...so that may be a good role for pharmacist – to answer some of those questions – Halifax consumer
In addition, consumers would like pharmacists to help them identify trustworthy information sources.
Basically he is going to the same source as I could go to, but I would feel a little more comfortable that the pharmacist might be able to differentiate the fake web site from the real web site. – Edmonton consumer
Pharmacists also described themselves in a consultative role:
I think we have a responsibility to look up the information for them because we are supposed to be the accessible information provider. We know where to look for it and give them unbiased information. I think we are pretty good at that. – Vancouver pharmacist
The idea is to try to give them a bit of education. If they want to take something certainly they don't have to come to a pharmacy.... So I try to say look this is what we know, and I don't want to make the decision for them because it's not my decision to make. – Vancouver pharmacist
Overall, the majority of consumers and pharmacists agreed that pharmacists should be knowledgeable about NHPs and could adopt a consultative or advisory role to help consumers identify and assess the range of information available about a particular NHP.
Ensuring patient safety
Although pharmacists recognized the need to respect consumers' expertise and knowledge regarding NHPs, they also placed a great emphasis on their responsibility as pharmacists to ensure patient safety. When asked about their first priority with respect to patient care, the majority of pharmacists clearly identified patient safety, especially with respect to potential drug-herb interactions. This was also identified as a topic that generated many patient questions:
My first priority is making sure that whatever they are using is not interacting or we are watching for side effects, it is not going to affect their sugars; it is not going to cause any type of unfortunate effect... my first priority as a pharmacist is their safety. – Edmonton pharmacist
Consumers also agreed that pharmacists are in the best position to manage potential drug-NHPs interactions and to ensure the safe use of NHPs because they have expertise in conventional medications:
I know the pharmacy here, the pharmacists they have sitting rooms, a little room, and if they give you a prescription that you haven't had before they bring you in and sit you down and discuss it with you, and he's got, you know, records of what I take. If I want to try something new now because I am taking all these other medications, I check with him and he's got it all on the computer and he checks it all out and makes sure that I'm not on anything that is going to make my head burn off or something. – Edmonton consumer
He [the pharmacist] knows what I am taking, and because he has that knowledge, I'll ask, I would like to take this, what do you think? Is it going to react with something I am already taking, or you know is it worth it, or do you know of any studies? Because sometimes they will know studies of some new herbal stuff that is being really pushed on the market, and he can tell me it's not worth it. – Edmonton consumer
Pharmacists were comfortable with letting the consumer make the final decisions only if they were assured that the product would not cause harm:
So I guess it depends on what they are using it for and whether they have any medical conditions and whether they are on any medications; if they were otherwise healthy and want to try it I would say it's up to you. If they have some major medical conditions and I am not certain if it will cause any adverse reactions then I would probably recommend that they don't try it. – Toronto pharmacist
There is always that proviso if you are interested, it is certainly at this point for you, it does not look like it is going to conflict with anything else, if you want to try it, and assess it.... You know I don't know of anything that is going to hurt, so you know let's see how it goes. – Edmonton pharmacist
When dispensing prescriptions, some pharmacists are proactive and ask for information about NHP use. This allows the pharmacist to check for possible interactions so that they can intervene to protect the consumer. Pharmacists are very unlikely to actively recommend an NHP if a consumer does not first express interest in taking it:
I ask the patient what kind of herbal product they are on and then I would check the drug interaction, whether they agree with the prescription medication. This I would do, but as far as recommendation, I wait for the customer to ask me, rather then recommend an herb to them. – Vancouver pharmacist
However, the amount of input a pharmacist can have is ultimately determined by the patient because NHPs are available for self-selection. Thus, consumers may purchase these products without seeking the advice of a pharmacist. More importantly, NHPs are available for sale in a range of retail locations (i.e. health food stores, grocery stores). Consequently, checking for potential drug-NHP interactions is difficult or all but precluded, if the consumer does not approach the pharmacist.
The problem generally though is people shop at different places. So you know I buy this in here and this in there and I am not telling people when I am buying it; unless somebody points it out to me, I don't know that there is an interaction. – Toronto consumer
I think people just grab them and go. – Edmonton pharmacist
Overall, pharmacists tended to place a great emphasis on ensuring patient safety in terms of their responsibility. In contrast, most consumers emphasized the importance of making their own decisions, while acknowledging that pharmacists could play an important role in helping them to make choices that would not result in harm.
Consumers as patients
Although many of our participants fit the descriptions of the "new consumer" in the literature, some clearly wanted more of a partnership model of relationship with their pharmacists. What appears to differentiate these consumers is their view of a longer-term relationship between 'patients' and pharmacists:
[Jay] said the relationship between the pharmacist and the "client" and [Jen] has said the relationship between the pharmacist and "customer"; and to me, I don't want to be a "client". I mean, I know that I am, but I don't want my pharmacist to see me as a "client" or a "customer". I want them to see me more like a "patient" as opposed to a revenue source. – Toronto consumer
I do use the internet as well and I have some natural kind of books at home... but I do go to my pharmacist quite a bit...I have been going to the same pharmacist for the last five years since I live near her... so I kind of have a good relationship with her and I trust her and she knows that I have some allergies and things like that so I do talk to her about alternatives sometimes... – Vancouver consumer
Pharmacists made similar observations:
I also think it depends on the relationship each pharmacist has with their patient [s]. You know you were talking about how people are just going to go out and take whatever they want anyway. You know I don't find my patients are as much like that. If they trust you and you have a continuity of care relationship, they are more likely to ask you first. A lot of my patients won't take anything, even if they get a prescription from their doctor, they are like, and "Do you think this is okay? You know I don't trust them as much as I trust you". So, it really depends on the kind of practice you have. – Edmonton pharmacist
In the context of NHPs, the relationship between a consumer and the pharmacist matters. The degree of involvement a pharmacist has in the NHP decision-making process is ultimately controlled by the consumer. But since NHPs are sold in pharmacies, both consumers and pharmacists agreed that pharmacists have a responsibility to provide basic advice about NHPs, especially regarding their safety.