An appeal for scientific criticism in pharmacy practice

A much revered wise-saying in Akan goes like this; “Dua kontonkyitonkyi na ɛma yɛhunu dwumfoɔ”. An English rendition of which will be, “a crooked piece of wood reveals the skillful carver”. This adage gives us a test for artful craftsmanship, pointing to the fact that it takes so much learned or innate skill to make meaning out of a seemingly useless situation. In the context of professional practices it illumines us to understand that skill is what sets apart the professional from a lay person.

In our modern world, many thanks to information communication technology(IT), both pharmacists and the lay public now have an almost free access to a large breadth of information on drugs, specifically, and healthcare in general. But much as breadth in perspective is seen effortlessly, so much skill and labour are required to discover depth. The capacity to process and make meaning of the same information presented to both the pharmacist and the lay person is what sets the one apart from the other. And this skill is most relevant in situations when there are obvious contradictions or unfilled gaps with the pieces of information presented. It is requisite for a pharmacist, a sine qua non, in order for him or her to excel in the chosen profession, to possess the skill to expertly sift the available pieces of information on drugs and take an informed position. There will be no difference if a pharmacist also absorbs any information presented hook, line and sinker just as the lay person. In the events when there are unfilled gaps with the available information, a recourse to an educated guess will be necessary. A pharmacist who proceeds along this line of thought is guided by the merits of scientific criticism in his or her practice.

A recent report tells of a pharmacist who declined to dispense diazepam to a client, having been requested of the latter for that drug by name to relieve an episode of insomnia, and recommended the intake of chamomile tea instead. Was scientific criticism involved in the decision-making process here? That depends on what this pharmacist would give for a reason. It is a scientific argument if the pharmacist’s reason is that diazepam is a controlled substance, a prescription-only drug (POM), and therefore the client required a valid prescription to access it (The Legal Argument). It is a scientific argument if the pharmacist is just being mindful that the habit of taking a drug to induce sleep could lead that client to a state of drug dependency or addiction (The Addiction Argument). It is again a scientific argument if the pharmacist’s recommendation was a matter of preference for natural therapies and a personal disposition to promote any therapy of natural origin above synthetic drugs (The Orientation Argument).

In this case, however, an argument made within pharmacology (The Pharmacology Argument) will not stand the test of scientific criticism. Why, because whereas a large body of knowledge has been documented in literature in favour of diazepam, currently there is an information gap as far as the herb chamomile is concerned. The pharmacist most likely knows, or at least can easily access, so much information on the pharmacology of diazepam, including its chemical identity, mechanism of action, duration of activity, known and predictable drug interactions, risk of tolerance and its addiction potential, safe dosing regimens, and much more. This wealth of information on diazepam has, rather unexpectedly, bred a common phobia against it within the healthcare community. On the other hand, the literature is currently not as much rich with these pieces of information towards chamomile. It is fine if this dearth of information on the pharmacology and toxicology of chamomile is appreciated and not misinterpreted to mean a better safety profile of this herb compared to diazepam. To wit, our pharmacist will not be right in this instance if his or her recommendation to that client was on the basis of an idea that chamomile tea is a safer option.

To elaborate on the pharmacology argument, how else could chamomile effect sedative properties if it does not contain active principles (secondary metabolites) which also interfere with the activities of one or more neurotransmitters in the CNS? Assuming even that the active principle(s) in chamomile does not exert action on the GABA-ergic neuronal pathways diazepam is known to be involved with, it is very reasonable to say that that active compound and diazepam are both molecular entities and for that matter the classical laws of drug-receptor interaction hold all the same. The only difference here being that whereas the active principle(s) in chamomile is naturally derived, and perhaps not yet isolated, diazepam is a purely synthetic drug. It is only when we were to have a detailed pharmacological profile of chamomile can we scientifically compare this natural therapy with diazepam along the lines of pharmacology.

It makes so much difference how we defend our positions and choices in the practice of pharmacy. If doing a scientific criticism means taking a position opposed to the orthodox viewpoint on the matter do it for being the noblest course of action. This holds true so long as some pieces of evidence, either documented or experiential, can be adduced in defence of the position espoused.

A coalition of pharmacists against professional drug peddling?

In the community where my retail pharmacy is located a colleague pharmacist is sponsoring the OTCMS shops around to fiercely compete with me. What is his modus operandi? He moves about with his van from his own business territory, and entering my territory hops from one OTCMS shop to another, to supply them with not only Class C medicines but also the Class A and B groups according to the requirements of those shops.

 

He calls this activity a smart business move enabling him to extend the boundaries of his business territory, I call it professional drug peddling and everything but ingenious. For the benefit of this discussion let's explain "professional drug peddling" as the practice of a licensed wholesale or retail pharmacy carrying bulk  stocks of medicines from the registered premises on an itinerant journey and selling these stocks in portions to other pharmaceutical facilities en route, usually covering long distances and many days in trekking.

Direct end-to-end delivery of stocks from a wholesale premises to a retail or dispensing facility is excluded from the scope of this definition.

 

Our usage of the qualification of "professional" is not intended to imply quality of performance but, rather, the fact that such activities are done by the direct instructions or under the supervision of pharmacists.

 

Professional drug peddling, which is both an illegality in Ghana and an affront to sound ethical principles of pharmacy practice, is gradually establishing itself as a normal practice in this country and I am not the only victim of its consequences. A full analysis of the ripple effects of professional drug peddling in this country will require a broad-based enquiry beyond the strengths of this rather short discussion, but we do not have to develop an academic thesis for anyone to comprehend that professional drug peddling is the direct cause how OTCMS shops can access Class A and B medicines. When a wholesale pharmacy sends out a trekking mission to the field with a part of its stocks, it must of necessity make sales on the field and not waste fuel. Faced with a dilemma between survival and ethics, the choice naturally would go in the way of the former option. Ethics will always be slaughtered on the alters of survival instincts.

 

By law a pharmacy is a fixed premises, never a movable structure. The laws in Ghana give practical significance to this assertion by providing for the registration of pharmacies or other premises for the dispensing of medicines separately from the licensure of the practitioners who work in these premises. Itinerant vans of licensed wholesale pharmacies in effect move the premises of those wholesale/retail pharmacies in part from the recognized location to other territories. This practice contravenes existing regulations of pharmaceutical practice, perhaps only giving an exception for direct end-to-end delivery of stocks from a wholesale premises to a retail/dispensing facility in response to a concluded transaction for being of a different business model. So to reiterate, professional drug peddling is unlawful in Ghana, at least as of the present time, and hence any pharmacy or a pharmacist who perpetrates it commits an illegality.

 

From the point of view of ethics pardon me to ask if we as pharmacists are ever mindful of the effects our deeds and misdeeds, actions and inactions, have on our profession and colleague pharmacists at large. In the present scenario, professional drug peddling adversely affects the standards of pharmacy practice and nurtures an unfavourable environment which makes it extremely difficult for other pharmacies to thrive, with pharmacies in the small districts and rural areas hit the hardest.

 

When once in a discussion with a senior officer of the Pharmacy Council around this subject matter I asked why the regulator has not been successful in curtailing this phenomenon, his answer pierced me to the core. He in turn asked me of what cadre of professionals the supervising practitioners of wholesale pharmacies are which do send out vans on trekking. At the end of the discussion I couldn't help but agree with him that our predicament is one of in-fighting. Just a handful, in relative terms, of pharmacists are by this means fighting against the larger body of pharmacists and also making the work of the regulator more difficult. He was quite point-blank, that many of the challenges Pharmacy Council is grappling with were caused by one pharmacist or the other, only for the bigger fold to turn back with criticisms that the Council is not doing much for our profession.

 

So, how about resorting to the approach of self-regulation in an attempt to exterminate the fledgling phenomenon of professional drug peddling in this country?  A prompt action is necessary before this phenomenon gets fixed in the minds of current and future generations of Ghanaian pharmacists as both acceptable and lawful.

In the considered opinion of this writer, no other instrumentality could be superior to self-discipline at controlling misdemeanour.

 

In our context "self" refers to the PSGH and the entire body of pharmacists. This is a call to reactivate the erstwhile committee of the PSGH charged with self-regulation of members of the professional body, as well as the pharmaceutical environment, to deliver on its mandate.

 

As a second step the writer recommends the formation of a coalition of pharmacists to volunteer information and field evidence to support the work of the aforesaid committee. These volunteers scattered across the length and breadth of this country, keeping watchful eyes for professional drug peddlers from their community pharmacies as sentry posts, could report with the timely information and evidence to facilitate the work of that committee and the Pharmacy Council.

 

Possibly, such an advocacy group of pharmacists will be a game-changer for pharmacy practice in our dear country.

Pharmacoprudence

If you are looking for a single word to describe the varied job functions of the clinical pharmacist, that word is "pharmacoprudence".

 We, members of the Apothecary fraternity, have inherited a very fortunate heritage; a word to describe any field of particular study or endeavour, old or new, of a natural origin or acquired, may be formed by simply prefixing the root morpheme " pharmaco-" (obtained from the Greek pharmakon, for drug) to a tail word with a suggestive character. Hence we have in our lexicon words such as pharmacology, pharmacognosy, pharmacokinetics, pharmacodynamics, pharmacopoeia, pharmacopaedia, pharmacotherapy, pharmacogenomics, pharmacoepidemiology, pharmacovigilance, et cetera; words which are each pregnant with ideas which otherwise could only have been expressed sufficiently through elaborate usage of common vocabulary.

 The word "pharmacoprudence" first appeared in the year 2012 in an article published as an Idea Paper in the online journal INNOVATIONS in Pharmacy. In that seminal paper the word "pharmacoprudence" was originally suggested as the terminological equivalent of the word "jurisprudence" and was conceived to carry parallel connotations.

 Jurisprudence, as used in common notion, means the study of the nature and administration of law. On the same level pharmacoprudence may be explained simply as the study of the components and administration of healthcare. In that seminal paper the term "pharmacoprudence" was defined as 'the science and practice of the rational, efficient, efficacious and economical utilization of therapeutic agents'. It embodies such interrelated concepts, specialized learning and activities as clinical pharmacology, pharmacotherapeutics, pharmacoeconomics, pharmaceutical compounding, complementary and alternative therapy, rational drug utilization, medical records management, medication use reviews, pharmacovigilance, pharmacoepidemiology, pharmaco-medical information systems management, medical sociology, et cetera.

 In parallel with the lawyer who is the advocate of a client in the administration of law, the clinical pharmacist is the advocate of the patient in particular, and the whole healthcare system in general, to safeguard against abuse and misuse in the process of delivery of healthcare services. Like the former the services of the latter should have to be solicited for by a client, when pharmacoprudence is practised in a private office, but where the clinical pharmacist is an employee of a healthcare institution the performance of the role of pharmacoprudence becomes a professional obligation. Again, like the lawyer, the clinical pharmacist should have to specialize and confine his/her practice to a few, selected medical and/or pharmaceutical specialties to ensure concentrated learning and activity.

 Indeed so much similarities may be found upon detailed analysis of the job functions of both the lawyer and the clinical pharmacist that the juxtaposition of the terms jurisprudence and pharmacoprudence is more than apt. Furthermore, the term "pharmacoprudence" is more excellent in beauty in comparison with the phrase "clinical pharmacy", in the sense that the former circumvents a very serious ambiguity that inheres in the usage of the latter; the fact that the phrase "clinical pharmacy" naturally restricts this field of practice to only practitioners within conventional healthcare institutions, to the exclusion of community pharmacists and pharmacists who may perform same job functions in private business offices. In contrast, the term pharmacoprudence captures all these practice settings.

 Therefore I commend the term "pharmacoprudence" to you as preferred to the traditional phrase "clinical pharmacy", for your usage both in your lay and technical discussions, so that you avoid unnecessary ambiguity and carry your communications forcefully.


 References:
Adjei M. Clinical Pharmacy: A Theoretical Framework for Practice. Innov Pharm. 2012; 3(3): Article 83. http://pubs.lib.umn.edu/innovations/vol3/iss3/2.