U.S. and Canadian Pharmacists' Attitudes,
Knowledge, and Professional Practice Behaviors
Toward Dietary Supplements:
A Systematic Review

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:    Frankp@chiro.org

FROM:   BMC Complement Altern Med 2006 (Sep 19); 6 (1): 31 ~ FULL TEXT

OPEN ACCESS

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Della Kwan , Kristine Hirschkorn and Heather S Boon

Department of Pharmaceutical Sciences,
Leslie Dan Faculty of Pharmacy,
University of Toronto,
144 College Street,
Toronto, Ontario, M5S 3M2, Canada.

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Background   Although dietary supplements (DS) are widely sold in pharmacies, the legal, ethical, and practice responsibilities of pharmacists with respect to these products have not been well defined. This systematic review of pharmacists' attitudes, knowledge, and professional practice behaviours toward DS is intended to inform pharmacy regulators' and educators' decision making around this topic.

Methods   Eligible studies were identified through a systematic database search for all available years through to March 2006. Articles were analyzed for this review if they included survey data on U.S. or Canadian pharmacists' attitudes, knowledge, or professional practice behaviors toward DS published in 1990 or later.

Results   Due to the heterogeneity of the data, it was not possible to draw a conclusion with respect to pharmacists' general attitudes toward DS. Approximately equal numbers of pharmacists report positive as well as negative attitudes about the safety and efficacy of DS. There is strong agreement among pharmacists for the need to have additional training on DS, increased regulation of DS, and quality information on DS. In addition, survey data indicate that pharmacists do not perceive their knowledge of DS to be adequate and that pharmacists do not routinely document, monitor, or inquire about patients' use of DS. Despite this, a large proportion of pharmacists reported receiving questions about DS from patients and other health care practitioners.

Conclusions   Further research is needed to explore the factors that influence pharmacists' beliefs and attitudes about DS, to accurately evaluate pharmacists' knowledge of DS, and to uncover the reasons why pharmacists do not routinely document, monitor, or inquire about patients use of DS.

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Discussion

Pharmacists’ Attitudes toward Dietary Supplements

Due to the heterogeneity of the data, it was not possible to draw a conclusion about pharmacists’ attitudes toward DS in general. However, it appears that U.S. and Canadian pharmacists were fairly evenly split (half positive and half negative) on their attitudes toward the safety and efficacy of DS. These mixed findings may be the result of pharmacists not possessing, or perceiving the availability of, sufficient or consistent information on DS. Without information, understanding of these products is limited, as is confidence about their safety and efficacy. These findings could also be a product of the inconsistent definitions and categorizations of DS utilized across surveys. Of note, the results from one U.S. study suggest that pharmacist opinions of efficacy may depend on the type of herbal product [24].

In contrast, across surveys it is evident that there was a perceived lack of government oversight/regulation for DS. This may be related to the perceived shortcomings of the current U.S. federal regulations on dietary supplements. DSHEA does not require FDA to review evidence of the efficacy or safety of dietary supplements, so manufacturers have no burden to prove that their products are effective or safe [10]. Moreover, DSHEA does not require prospective testing to ensure safety [10]. To remove a product from the market, FDA must prove that the product is unsafe [10]. Under DSHEA, some dietary supplements that were banned from the U.S. market because of concern about their safety have been allowed to return (e.g., sassafras tea, dehydroepiandrosterone) [10]. The Canadian surveys were conducted before the introduction of the Natural Health Products Regulations which likely explains why pharmacists felt there was a need for regulation. Under the new regulations, all NHPs will require a product license before they can be sold in Canada [3]. Approval for sale will be granted by Health Canada based on several tiers of evidence of safety and efficacy [3]. Whether these regulations will positively affect pharmacists’ attitudes toward these products remains to be seen. In addition, there appears to be a perceived lack of quality information on DS. This may reflect the general lack of scientific information available on these products and/or pharmacists’ lack of knowledge or access to that which does exist. Further research is needed to reveal the factors that influence pharmacists’ beliefs and attitudes about DS. It is also likely that their beliefs and attitudes will differ depending on the type of DS.


Pharmacists’ Knowledge of Dietary Supplements

Survey data indicate that pharmacists do not perceive their knowledge of DS to be adequate and that a majority of pharmacists would like to receive additional training on DS, especially in the areas of interactions, side effects/adverse events, patient counseling, therapeutic uses, and dosing [19]. Of note, one U.S. study found that pharmacists’ knowledge of herbal products varied widely from herbal to herbal [24]. These findings may be related to the substantial diversity in the extent of DS education at schools of pharmacy. In a survey to describe U.S. pharmacy school curriculum offerings in the areas of natural products and complementary/alternative medicine, it was found that most schools were not providing natural product content in a formalized manner [30]. In most cases, natural products were taught in an elective course [30]. Among the included studies, only one U.S. study evaluated pharmacists’ actual knowledge of herbal medications [18]. However, that study had several methodological limitations including the use of a nonvalidated instrument [18].

It is clear that further research is needed to accurately evaluate pharmacists’ knowledge of DS in order to determine whether future continuing education programs and courses should be targeted at the introductory or intermediate level. Moreover, such research would enable the identification of topic areas that pharmacists require the most training in.


Pharmacists’ Professional Practice Behaviors with respect to Dietary Supplements

Based on survey findings, it appears that U.S. and Canadian pharmacists do not routinely document, monitor, or inquire about patients’ use of DS. The pharmacists who were more likely to ask patients about or record alternative medication use were the ones who worked in inpatient settings or reported receiving additional training in alternative medications or CAM [17, 20, 25]. None of the surveys asked pharmacists to provide explanations for their behavior. One reason might be the lack of professional practice standards which require pharmacists to routinely document, monitor, or inquire about patients’ use of DS. Another reason could be related to the lack of time during consultations to document. In any case, further research is needed to uncover the reasons behind the reported behaviors in these survey findings. This information will be crucial to pharmacy regulators in U.S. and Canada who are interested in developing professional practice standards for pharmacists in the area of DS.

In addition, many pharmacists reported recommending DS to patients [23, 25, 28] and receiving questions about DS from patients and other healthcare practitioners [7, 19, 20, 28]. Pharmacists appear to be becoming an increasingly important source of information on such products, which appears to be at odds with their assessment of their knowledge of these products.

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