I read with interest Anthony Cox’s piece on evidence-based medicine (EBM) in over-the-counter (OTC) products (The Pharmaceutical Journal 2014;293:176). As a community pharmacist with a strong support for EBM, I enjoyed the enthusiasm and desire to strive for this approach with OTC products. However, I found his piece offensive to community pharmacists implying what drives us is the ringing of the cash register with a fundamental disregard of evidence for the products we sell. If we were, as the author suggests, to “sideline” (does he mean keep a product but only sell it if the patient really wants it?) or “not stock” OTC treatments which have anything less than “clear evidence of effectiveness”, we would not have much left on our shelves. This is probably the ideal situation for the author but it is not the ideal situation for patients.
To quote from the same paper referenced in Cox’s piece (Medical Writing 2013;22:275–278), patients appear more likely to rely on personal experience or anecdotal evidence than robust clinical trial evidence when choosing an OTC product, and on the whole seem ambivalent about the need for evidence of effectiveness. This, coupled with advertising and that “the customer is always right”, means that patients may be unresponsive to messages about lack of evidence from the pharmacist.
If a patient asks me “does this product work?”, I will happily go into as much detail as I can about its evidence base, or lack thereof, thus giving the patient a full and informed choice. However, if a patient simply presents, for example, a cough medicine at the till to purchase, I will not stop to offload that item’s evidence base because it could be detrimental to that patient’s experience with that product (a potentially beneficial placebo effect destroyed) and it is also intrusive. Health beliefs count for a great deal and some patients understandably want to know more than others.
Fundamentally, I agree with Cox, but this is the real world and it is not as easy as clearing our shelves of low-evidence stock. Community pharmacies are businesses.