**Disclaimer:  I usually write fact-based posts but this is an opinion-piece.  I’d like to consider my opinion well-informed and evidence-informed, but still my opinion regardless.

It’s so disappointing when someone in healthcare goes down [the selling supplement] route, really makes you feel like you don’t know who to trust anymore. [Healthcare professional] in particular always seemed so sincere and truthful on Instagram. That’s a few Irish pharmacists/ doctors now that have stated selling supplements…

It was a comment earlier this week to me in the Inbox.  And in short, I agree.  But this week, this issue just kept popping up so let’s unpack it a little more….

I found it a little ironic that the papers erupted this week with the news that healthcare professionals had been paid €€€ by a pharmaceutical company.  It’s important to note that this was all publicly declared and nothing hidden.  And this was about marketing.

To put it in context:  Pharmaceutical companies make money.  A lot of it. In fairness, many do reinvest this in not-for-profit patient supports or ongoing research and development.  But they are a for-profit business.  If they want me – or another colleague – to share our expertise or experience with them, and they will in turn take what they gleaned from our time and work to make money, yes, it’s not entirely unreasonable for them to reimburse healthcare professionals for, essentially, work

Urban Mythbusting

It’s a tired conspiracy theory/urban myth but just in case:  Doctors do not have quotas or do not get reimbursement from pharmaceuticals for prescribing certain drugs/antibiotics or any incentive at all, frankly, for administering vaccines. Work done for pharmaceutical companies is contributing unique expertise, feedback from our real-life clinical experience, or carefully approved and tightly regulated independent research in the interest of patient care.  It must be transparent, declared, and is often part of large grants that support university or medical schools. There is careful external and independent review of research. In Ireland, we have the distinct privilege as doctors and patients to have the freedom of shared decision-making without many external influences except bed/test availabililty. That includes no direct-to-patient ads from pharmaceuticals “Ask your doctor if [X] is right for you” like they do in the US. We also do not have insurance companies who decide which pharmaceutical drugs will or wont’ be reimbursed on a prescription (“prior authorizations”) Drugs costs are also controlled here. What does it look like if you don’t have these things? Well, in short USA where patients can’t even afford their insulin.  

.

Just declare it. Sin é.  That is what medical ethics require.  And we are increasingly strict on letting pharmaceuticals sponsor doctor’s professional development so that they don’t influence either our prescribing or decision making for patients.

Okay, that sounds good.

But then what about Big Vitamin or Big Supplement?  I wrote earlier this week about how this industry is far less regulated and far more lucrative than pharma.

How so?  Supplements differ from medications in that 1) they do not have to go through the rigorous HRPA 2) they don’t need to prove they work.

What does it mean for you as a patient?

It makes it possible that your healthcare professional has attended biased continuing professional development -OR – have a financial interest in what they prescribe for you.

Let’s break down using 2 examples from my real-life experiences this week:

The Sponsored Talk:

Earlier this week, I received an invitation to speak to group of allied health care professionals.  My name had been put forward to them by another colleague.  I was surprised that my colleague had turned it down, but then again, she is very busy.  I agreed.  Then I got an odd email back from the group representative and said that had gotten sponsorship from a food company.  The food company needed to know my views on their health claims.  My response was, essentially, that I happy to talk at a sponsored event but not happy to either promote a product or alter my talk to support marketed health claims.  I was unsurprised when I received a response:

“Thank you very much. I spoke to [sponsor] today and unfortunately … they can’t have a speaker that doesn’t support their research, etc. They will find a speaker.”

Let’s be very clear:  sponsorship is, unfortunately, necessary to fund continuing professional development.  To speak to that group, it was going to be a on private supported platform that would register attendance for education certificates and apply for CPD recognition.  All of this involves a cost. To keep the education itself at no cost to the healthcare professional, many companies sponsor the platform costs.

That, in itself is not a problem.  It IS a problem when they use that money to essentially buy advertising to a targeted market.

What that means for you as a patient is this difference:

You attend your nurse specialist for your chronic disease and s/he suggests making sure you are getting enough Vitamin D, either with a vitamin or in getting outdoors and fortified foods.

Versus

You attend your nurse specialist for your chronic disease and s/he suggests adding in GreenCow* fortified milks because s/he consciously? Unconsciously? remembers from a recent (sponsored!) talk that they had unique fortification formula that was shown (In their own paid-for research) to be better than other options.

Not a problem?  It’s just a glass of milk?  Now replace that situation with

“take something over the counter, like paracetamol or ibuprofen, for any mild pain you might have when you get home”

versus

“try taking Paramaxabrufalief DuoXtra* when you get home if you have any pain”

and now you see the problem. This recommendation is commercially biased (even if not completely consciously) and coming from a place of authority and trust.

The Supplement Seller:

Earlier this week, I talked at length about supplements after watching a recent parade of healthcare professionals market supplements, vitamins, and their soon-to-be opened IV drip bars.  At some point, one could shrug and say:  Caveat Emptor (buyer beware). In that setting, these were supplements being marketed in a aesthetics industry to a target audience who are, on the whole, relatively healthy and able to afford luxury items.

Regardless, I feel somehow that the packaging of supplements as “natural” makes us give them a free pass that we would, understandably, never extend to pharmaceuticals.

Where it felt different was later in the week:  a new patient with chronic disease was referred to me.  As routine, I asked all patients about their prescribed medications. Now, many patients are on both prescribed medications and also take the odd one or two supplements. I usually list them separately. In this case, this patient had only an impressive list of supplements. The patient lamented the lot was costing them over €300/mo. – including the shipping from an obscure pharmacy from the other side of the country from them, which apparently was the only pharmacy that carried the “right” supplements. What was different is that this patient wasn’t influenced by Instagram but had these recommended by an IMC-registered doctor in a position of authority, expertise, and trust.  Nor was it “feel good” or beauty reasons but with the (implied?) understanding these would actually help their chronic disease.

And this is where the supplement industry has the potential to be worse than the pharmaceutical industry:  

• Pharmaceuticals do have to go through rigorous approval and licensing and regulation(HPRA). They must demonstrate efficacy (how they actually work and how well) and continual independent oversight (which led to the newspaper article at the beginning of this piece)  However, supplements simply don’t have to do that.   Is the patient fully aware of the lack of evidence for the recommended supplement?

• Supplements are not included on the medical card or DPS reimbursement so patients are simply out of pocket for the costs.  Is the patient fully informed and involved in evaluating the cost-benefits in the decision?

• In situations where the person recommending the supplement may be perceived as an authority or expert, patients may not ask question regarding evidence, cost, or conflict of interest.

• Is the patient always completely clear that this supplement is a complementary or alternative therapy — and whether or not their healthcare professional may directly or indirectly profit or have any financial interest in recommending or prescribing this product?**

Bottom-line:  Whether it’s pharmaceuticals or supplements, patients deserve transparency, trust, and evidence-based care.  The supplement industry shouldn’t get held to different standards in regards to ethics or oversight just because of the “natural” marketing.

*Fictional products used for illustrative purposes for obvious legal reasons.

**IMC guidelines and accepted medical ethics are very clear on doctors responsibility on declaring conflicts of interest, and how it should not influence patient-care or decision-making. Sometimes it’s obvious:  if you attend a private medispa and they have racks of supplements for sale, a reasonable patient should assume that they are making something of a profit from selling this product.  It is also a for-profit aesthetics business, not acute healthcare.  No further declaration is necessary.   Sometimes it’s less obvious:  it is possible that you would be unaware that your pharmacist or doctor has a financial interest in the recommended supplement until it was clearly stated.  That said, as we discussed in HBOT, there are no strong anti-kickback laws in Ireland, so doctors are free to recommend treatments or supplements from which they profit as long as potential conflict of interest is clear to the patient.

Conflict of interest declaration:  I have none, but since writing on it this week, I have several ideas for some. Starting with developing something worthy of the name Paramaxabrufalief DuoXtra