Pharmacy and herbal medicine in the US

Herbal supplements in Jordan: a cross-sectional survey of pharmacists' perspectives and knowledge

OBJECTIVES

Pharmacists are ideal partners for engaging with the needs and expectations of patients. They can play a vital role by providing information and supplying herbal medicines. In some community settings, pharmacists are also the main first point of care. This study explored Jordanian community pharmacists' perspectives and knowledge of herbal medicines available in pharmacies.

DESIGN

A cross-sectional study using an online survey was developed, and it was distributed via social media platforms. The one-way analysis of variance (ANOVA) test was used to compare the mean knowledge scores between different demographic groups. Multiple linear regression analysis was used to identify predictors of herbal medicines knowledge.

SETTING

Jordanian community pharmacies.

PARTICIPANTS

401 Jordanian community pharmacists.

RESULTS

Herbal supplements are sold in practically all pharmacies (98.5%). Slimming aids (14.7%), followed by sexual and sports enhancements (14%) and maintaining general health (12.1%) were most requested by Jordanian customers. While supplements for maintaining general health (12%), followed by slimming aids (11.4%) and skin conditions (9.3%) were most recommended by Jordanian pharmacists. 63.1% were not aware of potential herb-drug interactions, 95.6% did not receive complaints from customers about herbal medicines and 41.2% would not report adverse reactions to the national pharmacovigilance services. The mean knowledge score for knowledge of use, regulation, adverse reactions, and drug interactions was 3.7 (SD: 0.7), 3.5 (SD: 0.8), 3.6 (SD: 0.8), and 3.6 (SD: 0.8) (out of 5), respectively. ANOVA test showed that total pharmacists' knowledge scores significantly differed based on the length of time practising pharmacy (p<0.05).

CONCLUSION

This study highlights some key concerns relating to recommendations, awareness and reporting of herbal medicines among Jordanian community pharmacists. Pharmacists need enhanced education to provide objective and evidence-based information on the benefits-risks of herbal medicines. Future studies need to be carried out to confirm whether our findings are transferable to other Middle Eastern countries.

Community Pharmacists' Views and Experiences with ADR Reporting for Complementary Medicines: A Qualitative Study in New Zealand

INTRODUCTION

Detecting signals of safety concerns associated with complementary medicines (CMs) relies on spontaneous reports submitted by health professionals and patients/consumers. Community pharmacists are well placed to identify and report suspected adverse drug reactions (ADRs) associated with CMs, but pharmacists submit few CMs ADR reports.

OBJECTIVES

The aim of this study was to explore New Zealand community pharmacists' views and experiences with ADR reporting for CMs.

METHODS

Qualitative, in-depth, semi-structured interviews were undertaken with 27 practising community pharmacists identified through purposive and convenience sampling. Data were analysed using a general inductive approach.

RESULTS

Participants were familiar with systems for reporting ADRs, believed ADR reporting for CMs important, and that pharmacists should contribute. However, few submitted reports of CMs ADRs and none encouraged patients/consumers to do so. Participants explained this was because they had never been informed by patients about ADRs associated with CMs. Participants said they would report serious ADRs; time pressures, lack of certainty around causality, lack of awareness of mechanisms for reporting CMs ADRs, and lack of remuneration were deterrents to reporting. Participants were aware of intensive-monitoring studies for prescription medicines, understood the rationale for considering this approach for CMs and recognised there would be potential practical difficulties.

CONCLUSIONS

Participants used their knowledge of CMs safety concerns to minimise risk of harms to consumers from CMs use, but most had a passive approach to identifying and reporting ADRs for CMs. There is substantial potential for pharmacists to adopt proactive strategies in pharmacovigilance for CMs, particularly in recognising and reporting ADRs, and empowering CMs users to do the same.

Community pharmacists' professional practices for complementary medicines: a qualitative study in New Zealand

Background Complementary medicines are a popular healthcare choice among patients/consumers, and most pharmacies sell these products. Pharmacists are well-placed to advise on complementary medicines, but their training and practices for these products are not optimal. Pharmacists' professional practices for complementary medicines ought to be influenced by professional codes of ethics and standards. Objective To examine community pharmacists' perspectives on complementary medicines in New Zealand, including motivations and justifications for selling these products, and professional and ethical issues complementary medicines raise for pharmacists. Setting Community pharmacists in New Zealand. Method Qualitative, semi-structured interviews with 27 New Zealand practising community pharmacists identified through purposive and convenience sampling. Main outcome measure Participants' views, experiences, and professional practices for complementary medicines. Results Participants struggled to clearly describe products they considered complementary medicines. Perspectives towards these products ranged from strongly supportive to somewhat sceptical; none was strongly opposed. Participants had several motivations for selling complementary medicines, particularly consumer demand and profits. Participants acknowledged ethical issues concerning complementary medicines, including lack of evidence of efficacy and pharmacists' limited training/knowledge. Few referred explicitly to complementary-medicines-related statements in the Pharmacy Council of New Zealand's Code of Ethics, or indicated these guided their practice. Conclusion Participants sold complementary medicines despite having limited knowledge on these products and concerns about efficacy; participants justified this as they believe they are providing an holistic option for patients, and/or ensuring complementary medicines do no harm. Participants were mindful of ethical/professional issues regarding complementary medicines, but were not necessarily aware of, or guided by, explicit statements in the Pharmacy Council of New Zealand's Code of Ethics.

Use of National Consumer Survey Data to Explore Perceptions of Complementary and Alternative Medicine

Background:

Although Complementary and Alternative Medicine (CAM) has been the standard of therapy in Asia for centuries, it started receiving more attention in the U.S. in the last three decades.

Objectives:

The primary study objective was to explore individuals' perspectives of CAM. A secondary objective was to describe individuals' perceptions of pharmacists’ roles in facilitating their use of these services and products.

Methods:

Data were obtained from the 2015 and 2016 National Consumer Surveys on the Medication Experience and Pharmacist Roles. Data were collected from adults residing in the United States via on-line, self-administered surveys coordinated by Qualtrics Panels between April 28 and June 22, 2015 (n = 26,173) and between March 14 and 30, 2016 (n = 10,500). This study focused on written comments made in the surveys with Content Conventional Analysis applied to the text. Four researchers were trained to conduct coding to assess inter-judge reliability. The four judges had a high level of agreement which was greater than 0.95 for category type.

Results:

Out of a total of 36,673 respondents, 80% (29,426) submitted written comments at the end of the survey. Of these, 2,178 comments were about medications or health and 170 (8%) comments specifically about CAM, of which 136 (6%) were usable for analysis. Conventional Content Analysis revealed five themes:1)The role of pharmaceutical and insurance companies in CAM; 2) Overuse of medications; 3)Physicians can play a role in creating a balance between prescription use and CAM; 4) Individuals believe that CAM is more effective than Western medicines and prefer it; 5) Individuals want pharmacists to have a better understanding of CAM. Theresults of this study reveal individuals’ opinions regarding how they want CAM to be considered in their interactions with their healthcare team.

Conclusion:

Emergent themes suggest that individuals are interested in receiving more professionals’ healthcare to become more knowledgeable about CAM.

Looking Back at US Pharmacy’s Past to Help Discern Its Future

Objective: To review specific literature that aimed to predict the future of US pharmacy, beginning in the late 1980s. Data Sources: Articles were identified from searching MEDLINE, CINAHL, Google Scholar, and references of relevant articles. The following combinations of search terms were used: future, pharmacy, prediction, and forecast. Study Selection and Data Extraction: The following inclusion criteria were applied: (1) full-text commentary, review, or original research and (2) focused predominantly on the pharmacy in the United States. Data on predictions for the future of pharmacy were extracted. Data Synthesis: We selected 3 articles published between 1988 and 2006, with each aiming to project the future for the following decade. We examined each prediction in light of the current knowledge. Relevance to Patient Care and Clinical Practice: Educators, practitioners, and other stakeholders should consider reflecting on the changes in pharmacy for the past 3 decades and applying both historical and emerging trends to improve patient care and sustain practice in the third decade of the 21st century and beyond. Conclusion: Most of the predictions for the future of pharmacy from the past 3 decades materialized, with some still in progress (reimbursement for pharmacy services), whereas others manifested in unexpected ways (transition from shortage to excess of pharmacists). Current forces shaping pharmacy include, but are not limited to, growing spending and use of specialty drugs, automation of pharmacy operations, growth of pharmacy in the digital health enterprise, and growing consumer interest in the use of analytical pharmacy that tests drugs before dispensing.

Community pharmacists' views on the regulation of complementary medicines and complementary-medicines practitioners: a qualitative study in New Zealand

OBJECTIVES

To examine community pharmacists' perspectives on CMs regulation in New Zealand, where proposals for CMs regulations had recently been suspended and where, currently, CMs are only weakly regulated.

METHODS

Qualitative, in-depth, semi-structured interviews with New Zealand practising community pharmacists are identified through purposive and convenience sampling. Data were analysed using a general inductive approach.

KEY FINDINGS

Participants held mixed views regarding harmonisation of CMs regulations across Australia and NZ; some supported an NZ national regulatory framework for CMs, based on the Australian system. Participants recognised the current CMs regulatory framework in NZ as inadequate, that regulation was required to some extent, and that mandatory regulation was not necessarily required. A key reason given in support of CMs regulations was the need for greater assurances around quality of CMs. Participants also supported a regulatory framework that incorporated assessment of the safety of CMs, but were less convinced of the need for, or feasibility of, requiring evidence of efficacy from clinical trials. Participants believed that regulation of CMs practitioners, such as herbalists, and CMs retailers was important, although there were mixed views as to whether regulation should be statutory or whether self-regulation would be adequate.

CONCLUSIONS

On the basis of these findings, pharmacists would be expected to welcome proposals for national regulations for CMs in NZ: such regulations should address concerns regarding product quality, inappropriate health claims and supporting evidence, and therefore should support pharmacists in meeting their obligations under the NZ Pharmacy Council's Code of Ethics.

Preparation of Arjunāriṣṭa Using Microbes Isolated from Woodfordia fruticosa Flowers (Dhayati)

Objective:

To verify the utility of isolated fermentative microbes from Woodfordia fruticosa flowers for preparation of Arjunāriṣṭa formulation and its comparative evaluation with the same formulation prepared by traditional method.

Methodology:

In the present technique, isolated colonies of microorganisms from Woodfordia fruticosa (Dhātakī) flowers on Saubroad dextrose media were separated and suspended in sterile water. This suspension was aseptically added in previously sterilized mixtures containing all intended ingredients for Arjunāriṣṭa which was thereafter incubated for 20 days at 37°C to achieve optimal fermentation. The formulation thus obtained was further subjected to various evaluation tests.

Result:

Arjunāriṣṭa was prepared using a new approach, and in that, isolated microorganisms from the flowers of Woodfordia fruticosa (Dhātakī) were used. It was found that the new approach was successful in generating approximately same quantities of alcohol content in comparison with traditional methods which have shown varying concentration of alcoholic content. Moreover, the new process prevents the growth of unwanted microbes thus, optimizing standards for purity and safety of the formulation.

Conclusion:

The formulation prepared by a new procedure showed marked uniformity for different parameters such as alcohol production, total phenol content, total solid content as compared to that prepared by the traditional method. Similarly, the results of thin layer chromatography, high performance thin layer chromatography showed marked uniformity related to quality, safety, efficacy, and reproducibility of the new method as compared to the traditional one. Thus, the modern technique was found to show reproducibility and facilitate easier quality assessment.

Human serum albumin-specific recognition of the natural herbal extract of Stryphnodendron polyphyllum through STD NMR, hyphenations and docking simulation studies

Over the last two decades, new and more advanced strategies that help in the rapid screening and identification of new ligands for a specific macromolecule have become an important domain.

Medications, youth therapeutic cultures and performance consumptions: A sociological approach

This article analyses performance consumptions among young people. The theme is explored along two main axes. The first concerns the social heterogeneity in this field, considered on two levels: the different purposes for those investments - cognitive/mental and physical performance; and the different social contexts - university and work - where performance practices and dispositions may be fostered. The second axis explores the roles of pharmacological and natural consumptions, and their interrelationship, in the dissemination of these practices. The empirical data for this analysis were drawn from an ongoing research project on performance consumptions among young people (aged 18-29 years) in Portugal, including both university students and young workers without university education. The results correspond to the stage of extensive research, for which a questionnaire was organised at a national level, using non-proportional quota sampling. On the one hand, they show that (a) there is a hierarchy of acceptance of consumptions according to their purposes, with cognitive/mental performance showing higher acceptance and (b) both pharmaceuticals and natural products are consumed for every type of performance investment. On the other, the comparison between students and workers introduces a certain heterogeneity in this general backdrop, both in terms of the purposes for their consumptions and their opting for natural or pharmacological resources. These threads of heterogeneity will prompt a discussion of the dynamics of pharmaceuticalisation within the field of performance, in particular how therapeutic cultures may be changing in terms of the way individuals relate to medications, expanding their uses in social life.

Availability and needs of herbal medicinal information resources at community pharmacy, Riyadh region, Saudi Arabia

A cross-sectional survey of community pharmacists in Riyadh region, Saudi Arabia was conducted over a period of 6 months from July through December 2011. Data collection was carried out using a structured self-administered questionnaire. The survey questionnaire consisted of a brief introduction to the study and eleven questions. The questions consisted of close ended, multiple-choice, and fill-in short answers. A stratified random sample of one thousand and seven hundred registered pharmacy practitioners all over Saudi Arabia were randomly chosen to respond to the survey. The data from each of the returned questionnaire were coded and entered into Statistical Package for the Social Sciences (SPSS) version 19 software (SPSS Inc., Chicago, IL, USA) which was used for statistical analysis. Only one thousand four hundred one pharmacists responded to the survey (response rate is 82.4%) with a completely answered questionnaire. The study results show that 59.7% of the participants sometimes discuss herbal medicine use with their patients, while only 4.25% never discuss it. The study shows 48.5% of participated pharmacists record herbal medicine use sometimes where only 9.4% of them never did so. However, with regard to initiation of the discussion, the study shows that 44.3% of the respondents reported that patients initiate herbal issue discussion while 20.8% reported that pharmacists initiate the discussion. This discussion was reported to be a one time discussion or an ongoing discussion by 14.3% or 9.9% of the respondents respectively. According to the study results, respondents reported that the most common barriers that limit discussing herbal medicines' use with their patients were lack of time due to other obligations assigned to the community pharmacist (46%), lack of reliable resources (30.3%), lack of scientific evidence that support herbal medicine use (15.2%), or lack of knowledge of herbal medicines (13.4%). Yet, a small number of respondents was concerned about interest in herbal medicines (9.1%) and other reasons (2.4%). So it is urgent to ensure that pharmacists are appropriately educated and trained. Extra efforts are needed to increase the awareness of pharmacists to adverse drug reactions reporting system at Saudi Food and Drug Authority. Finally, more consideration to herbal issues should be addressed in both pharmacy colleges' curricula and continuous education program..

A qualitative study of herbal medicine use in the Ukraine: implications for US pharmacy practice

INTRODUCTION

Half of nearly all new immigrants in the United States come from only 10 countries, including the Ukraine. Immigrants bring facets of their culture to their new country; therefore, it is important for health care providers to have an appreciation and understanding of cultural differences in regard to the use of herbal medicine.

OBJECTIVES

To determine health care provider and patient preferences for herbal versus synthetic medications, health care provider didactic training in pharmacognosy and trends in herbal medication use in the Ukraine.

METHODS

Ten health care providers, pharmacists and physicians, were interviewed to determine their views on herbal medicine use in Ukraine using semistructured in-depth face-to-face interviews.

RESULTS

Ukrainian practitioners and patients viewed herbal medicines as safer than synthetic drugs, appropriate and preferable for use in chronic and preventative programs. Synthetic drugs were viewed as more desirable for use in the acute setting. Preference for synthetic versus herbal medication was not price driven.

CONCLUSIONS

The inclusion of pharmacognosy training in the US pharmacy curricula is recommended to facilitate US health care professional's ability to provide pharmaceutical care both to new US immigrants and to the increasing number of US citizens utilizing herbal medications.

An instrument to evaluate pharmacists' patient counseling on herbal and dietary supplements

OBJECTIVE

To develop a measure of pharmacists' patient counseling on herbal and dietary supplements.

METHODS

A systematic process was used for item generation, testing, and validation of a measure of pharmacists counseling on herbal and dietary supplements. Because a pharmacist-patient encounter may or may not identify an indication for taking an herb or dietary supplement, the instrument was bifurcated into 2 distinct components: (1) patient counseling in general; and (2) patient counseling related to herbal and dietary supplements.

RESULTS

The instrument demonstrated high reliability and desirable construct validity. After adjusting for item difficulty, we found that pharmacists tended to provide more general patient counseling than counseling related to herbal and dietary supplements.

CONCLUSION

This instrument can be applied to assess the quality of counseling provided by pharmacists and pharmacy students, and the outcomes of pharmacist and pharmacy student education on herbal and dietary supplements.

Ethnomedical uses of Zingiberaceous plants of Northeast India

AIM OF THE STUDY

Family Zingiberaceae consists of large number of medicinal plants and is well known for its use in ethnomedicine. The objective of this study is to systematically analyse and document the traditional knowledge regarding the use of Zingiberaceous plants for the treatment of various human ailments from NE India, adding information to the valuation of biodiversity and, to forward suggestions for its sustainable use, conservation and for future pharmacological studies.

MATERIALS AND METHODS

A survey on the utilization of medicinal plants belonging to Zingibereceae of North-eastern states was carried out by interviewing herbalists followed by collecting plant specimens and identifying the specimen. Ethnobotanical information on traditional plants was catalogued through structured questionnaires in consultations with traditional healers.

RESULTS

A total of 34 species were documented belonging to 9 genera of Zingiberaceae for about 25 types of ailments, 67.6% of which were used in curing multiple disorders. Arunachal Pradesh hosts maximum number of Zingiberaceous plant (88%). Rhizomes were found to be the primary plant material as a source for medication and poultices as the predominant mode of preparation. Gastrointestinal conditions (58%) and chest and lungs (41%) related ailments were the main categories for which these plants are used.

CONCLUSIONS

The study establishes Zingiberaceae as a medicinal family since 41% of all the available Zingiberaceous plant species in NE were found to possess medicinal value. Some new use of herbs also appeared in this study for the first time.

Self-reported competence of Estonian community pharmacists in relation to herbal products: findings from a health-system in transition

Recent health-system reforms in Estonia have resulted in an increased emphasis on primary health care and evidence-based medicine. Community pharmacies are the primary source of herbal products, and pharmacists have an important role in ensuring the safe and effective use of herbal products. The objective of this study was to explore the self-reported competence of pharmacists and the self-reported provision of community pharmacy services in relation to herbal products. A survey instrument was mailed to a random sample of 154 (50%) community pharmacies in Estonia in February 2005. Responses were received from 114 pharmacists and six assistant pharmacists (response rate 77.9%). Among the respondents, 64.1% self-evaluated their knowledge of herbal products as good or excellent. However, only 35.0% reported they experienced no problems in counselling about herbal products, while only 35.8% recognized the importance of continuing education. Pharmacists attached a high level of importance to providing information about herbal products' mode of action, administration, potential side-effects and interactions. There was an apparent mismatch between pharmacists' self-reported competence and their self-reported provision of advice about herbal products. Health system reforms in Estonia may need to be accompanied by enhanced training for pharmacists to provide advice about the safe and appropriate use of herbal products.

The ethics of dietary supplements and natural health products in pharmacy practice: a systematic documentary analysis

OBJECTIVES

Many natural health products and dietary supplements are purchased in pharmacies and it has been argued that pharmacists are in the best position to provide patients with evidence-based information about them. This study was designed to identify how the pharmacist's role with respect to natural health products and dietary supplements is portrayed in the literature.

METHOD

A systematic search was conducted in a variety of health databases to identify all literature that pertained to both pharmacy and natural health products and dietary supplements. Of the 786 articles identified, 665 were broad-coded and 259 were subjected to in-depth qualitative content analysis for emergent themes.

KEY FINDINGS

Overwhelmingly, support for the sale of natural health products and dietary supplements in pharmacies is strong. Additionally, a role for pharmacist counselling is underscored. But another recurrent theme is that pharmacists are ill-equipped to counsel patients about these products that are available on their shelves. This situation has led some to question the ethics of pharmacists selling natural health products and dietary supplements and to highlight the existence of an ethical conflict stemming from the profit-motive associated with sales of natural health products and dietary supplements.

CONCLUSIONS

This analysis raises concerns about the ethics of natural health products and dietary supplements being sold in pharmacies, and about pharmacists being expected to provide counselling about products of which they have little knowledge.

Professional practices and experiences with complementary medicines: a cross-sectional study involving community pharmacists in England

Objective

As retailers of complementary medicines (CMs), pharmacists are well placed to advise consumers on the safe and effective use of these products; where CMs are available in pharmacies, pharmacists should be well informed about such products. This study explored the extent to which CMs are available in community pharmacies in England, and examined pharmacists' experiences, professional practices and training with regard to these products.

Method

A cross-sectional study was conducted, involving a structured questionnaire posted to community pharmacists. Coded follow-up mailings were sent to non-responders after 2 and 4 months, and a reminder telephone call made after 3 months.

Setting

All community pharmacists in six areas (Devon, Cornwall, Bradford, Leeds, Manchester, Stockport) of England (total n = 1337).

Key findings

The response rate was 66.5%. Overall, 92% of respondents reported that CMs (excluding vitamins/minerals) are sold in the pharmacy in which they practise, 81% had received requests from patients/consumers for specific CMs in the previous year, and 58% had recommended CMs. Around 70% of respondents rarely/never asks about CMs use when counter-prescribing conventional medicines or when receiving reports of suspected adverse drug reactions (ADRs) associated with conventional medicines.

In total, 40% of respondents had undertaken training in complementary/alternative medicine (CAM). Pharmacists who had undertaken training were more likely to ask patients/consumers specifically about use of CMs when counter-prescribing conventional over-the-counter (OTC) medicines (37.0% versus 23.4%, respectively; χ2 = 17.4; P = 0.0003) and when receiving reports from patients/customers of suspected ADRs associated with conventional (prescribed or OTC) medicines (35.6% versus 23.8%, respectively; χ2 = 13.0; P = 0.0003).

Conclusion

CMs are widely available in pharmacies in England, and pharmacists interact with users of these products. An opportunity exists for pharmacists to embrace a professional role as expert advisors on CMs. However, pharmacists' training, professional practices and competence with respect to CMs first need to improve.

Canadian pharmacy students' knowledge of herbal medicine

OBJECTIVE

To determine fourth-year Canadian pharmacy students' knowledge of herbal medicine and whether that knowledge is associated with mandatory instruction in herbal medicine.

METHODS

Standardized multiple-choice tests assessing students' herbal knowledge were distributed to all fourth-year BSc pharmacy students at 5 pharmacy schools in Canada.

RESULTS

The Quebec response rate was too low to include in the analysis. Herbal knowledge test scores were positively associated with having previously taken an herbal medicine class and completion of a pharmacy practicum. However, postsecondary education, age, and gender were not associated with herbal knowledge test scores. Students at the University of British Columbia had the highest score, followed by Alberta, Nova Scotia, and Ontario.

CONCLUSION

Pharmacy students' knowledge of herbal medicine varies depending on the school attended and higher herbal knowledge test scores appear to be most closely related to mandatory herbal instruction.

Pharmacists and Natural Health Products: A systematic analysis of professional responsibilities in Canada

PURPOSE: Natural health products (natural health products) such as herbs, vitamins and homeopathic medicines are widely available in Canadian pharmacies. The purpose of this paper was to conduct a systematic analysis of Canadian pharmacy policies and guidelines to explore pharmacists' professional responsibilities with respect to natural health products. METHODS: Legislation, codes of ethics, standards of practice and guidance documents that apply to the practice of pharmacy in each Canadian jurisdiction were systematically collected and examined to identify if, and how, these instruments establish professional duties in regard to natural health products. RESULTS: The majority of Canadian jurisdictions now include some explicit reference to natural health products in standards of practice policy or guideline documents. Often natural health products are simply assumed to be included in the over-the-counter (OTC) product category and thus professional responsibilities for OTCs are relevant for natural health products. A minority of provinces have specific policies on natural health products, herbals or homeopathy. In addition, the National Association of Pharmacy Regulatory Authorities' Model Standards of Practice specifically refers to natural health products. Most policy documents indicate that pharmacists should inquire about natural health product use when counselling patients and, when asked, should provide accurate information regarding the efficacy, toxicity, side effects or interactions of natural health products. Public messaging also indicates that pharmacists are knowledgeable professionals who can provide evidence-based information about natural health products. CONCLUSIONS: Explicit policies or guidelines regarding pharmacists' professional responsibilities with respect to natural health products currently exist in the majority of Canadian jurisdictions.

U.S. and Canadian pharmacists' attitudes, knowledge, and professional practice behaviors toward dietary supplements: a systematic review

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.

Conclusion

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.

Ethnobotany of medicinal plants used by Assamese people for various skin ailments and cosmetics

The present paper deals with the medicinal plants used by the people of Assam for curing different skin ailments and for cosmetics. A total of 85 plants belonging to 49 families have been documented for their therapeutic use against skin diseases and as herbal care. The herbal medicines were prepared from various plant parts of single plant, or multiple plants. The majority of the preparation was made using water as the medium. The mode of application was topical, but in many cases it was also administered orally. In several cases the pure herbal preparations was administered along with milk, ghee, honey, coconut oil, curd, etc. Remedies for 18 skin ailments were documented through this study. About 14 plants are known for their use to cure multiple skin diseases. Among these Curcuma longa and Melia azaderach constitute the major plants. The herbal cosmetic products used by the people of Assam ranges from the enhancement of skin colour, hair care, removal of ugly spots, colouring of nails, palms, and teeth. However, many of the plant preparations used for enhancing beauty were also applied for therapeutic use. Herbal remedies were also available for skin burns, prickly heat and pimples. Information on nine plants used for managing dry skin also emerged from this study.

Rapid and reliable determination of illegal adulterant in herbal medicines and dietary supplements by LC/MS/MS

In recent years, dietary supplements and herbal medicines are increasing in popularity all over the world. However, it is problematic that some manufacturers illegally included synthetic drugs in their products. Due to the extremely complex matrices of those products, most existing methods for screening illegal adulterations are time-consuming and liable to false positive. In this paper, a robust LC/MS/MS method for the high-throughput, sensitive and reliable determination of illegal adulterations from herbal medicines and dietary supplements was established. Minimal LC separation was employed and MRM was used to simultaneously monitor the three transitions under their respective optimal collision energy for each compound. Positive results were determined only if well-defined peaks appeared at all of the three transitions and the ratios among the peak areas were within given threshold. In this study, the method had been applied for the screening of nine most commonly adulterated therapeutic substances, such as sildenafil (Viagra) and famotidine, and the lower limits of detection of these compounds ranged from 0.05 to 1.5 ng/ml. Little sample preparation was needed for this method and the analysis time was less than 5 min/sample. The reliability has been demonstrated by the test with blank matrix. Over 200 products that were under suspicion by SDA of China had been assayed and till now no false negative or positive result was found. This method is rapid, simple, reliable and capable of screening multiple adulterants in one run.

Community pharmacists' actions when patients use complementary and alternative therapies with medications

OBJECTIVE

To assess actions of community pharmacists in response to their patients' concurrent use of prescription medications and complementary and alternative medicine (CAM).

DESIGN

Nonexperimental, cross-sectional mail survey.

SETTING

Texas.

PARTICIPANTS

107 community pharmacists.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Pharmacists' self-reported rate of patient inquiry about CAM use and actions taken in response to CAM use.

RESULTS

A majority (71.0%) of pharmacists had encountered patients who were using CAM, which was defined broadly in the survey to include herbal products, vitamins and minerals, homeopathic products, massage, meditation, and other types of CAM. Pharmacists documented CAM use by patients in 11.0% of cases and reported monitoring for drug-related problems in 38.4% of users. Among CAM users, pharmacists most often encouraged CAM use if medically appropriate. Pharmacists were not comfortable with responding to CAM inquiries but believed they needed adequate knowledge about CAM. In general, pharmacists rarely asked patients about their CAM use. Pharmacists' rate of inquiry about CAM use increased significantly when this information could be documented in patient profiles and when pharmacists had additional training in CAM. Also, in pharmacies that stocked herbal or homeopathic products, pharmacists were significantly more likely to encourage the use of CAM when medically appropriate and to recommend other CAM therapies appropriate for patients' conditions. When no references were available to research CAM, pharmacists tended to neither encourage nor discourage CAM use based on lack of scientific evidence of their effectiveness.

CONCLUSION

Most community pharmacists had patients who used CAM, but they were not proactive in inquiring about or documenting this use. They most often encouraged CAM use if deemed medically appropriate. Pharmacists' actions differed on the basis of professional and practice setting characteristics. To ensure optimal drug therapy outcomes, pharmacists should be more proactive in identifying and documenting CAM use by patients.

Naturopaths practice behaviour: provision and access to information on complementary and alternative medicines

Background

The increasing use of complementary and alternative medicines in Australia has generated concern regarding the information on these products available to both healthcare providers and the public. The aim of this study was to examine the practice behaviours of naturopaths in relation to both the provision of and access to information on complementary and alternative medicines (CAM).

Methods

A representative sample of 300 practicing naturopaths located nationally were sent a comprehensive survey which gathered data on self reported practice behaviour in relation to the provision of information on oral CAM to clients and the information needs of the practitioners themselves

Results

A response rate of 35% was achieved. Most practitioners (98%) have a dispensary within their clinic and the majority of practitioners perform the dispensing themselves. Practitioners reported they provided information to clients, usually in the form of verbal information (96%), handwritten notes (83%) and printed information (75%). The majority of practitioners (over 75%) reported always giving information on the full name of the product, reason for prescribing, expected response, possible interactions and contraindications and actions of the product. Information resources most often used by practitioners included professional newsletters, seminars run by manufacturers, patient feedback and personal observation of patients. Most practitioners were positive about the information they could access but felt that more information was required in areas such as adverse reactions and safe use of CAM in children, pregnancy and breastfeeding. Most naturopaths (over 96%) were informed about adverse events through manufacturer or distributor newsletters. The barriers in the provision of information to clients were misleading or incorrect information in the media, time constraints, information overload and complex language used in printed information. The main barrier to the practitioner in information access was seen as the perceived division between orthodox and complementary medicine practitioners.

Conclusion

Our data suggest most naturopaths were concerned about possible interaction between pharmaceuticals and CAM, and explore this area with their patients. There is scope to improve practitioners' access to information of adverse events including an increased awareness of sources of information such as the Australian Therapeutic Goods Administration (TGA) website.

Attitudes of Australian pharmacists toward complementary and alternative medicines

BACKGROUND

The increase in the use of complementary and alternative medicine (CAM) by the general public has led to increasing interest in how health professionals view these therapies.

OBJECTIVE

To determine the knowledge and attitudes of pharmacists toward CAM.

METHODS

An anonymous, self-administered questionnaire was designed and mailed to 1500 randomly selected pharmacists in New South Wales, Australia.

RESULTS

Four hundred eighty-four responses were received, with 77% of respondents indicating that they had personally used CAM and 60% correctly identifying that CAM was comprised of more than just botanicals and nutritional agents. The most commonly used CAMs were herbal and vitamin supplements (74%), which was significantly above use of the next most frequent CAM, massage therapy (6%). Most pharmacists (71%) reported offering CAM products for sale; however, 27% of these practices did not have access to CAM information for pharmacy staff or patients. Pharmacists generally viewed CAM positively and believed that they enhanced the customers' image of pharmacy (57%), increased customer numbers (87%), and could increase annual sales (72%). Ninety-one percent of respondents believed that it is necessary for pharmacists to have knowledge of both CAM and conventional medicine to be able to inform patients about their treatment options. Books and journal articles were their primary information sources, with the main reasons for recommending CAM evidence of efficacy and to maintain general health.

CONCLUSIONS

CAM use is prevalent among Australian pharmacists. While pharmacists are aware of their role as educators about both CAM and conventional medicines, there is a need for greater access to CAM resources and education on these therapies.

Knowledge, attitudes, and behaviors of healthcare providers for botanical and dietary supplement use for postmenopausal health

OBJECTIVE

To identify the knowledge, attitudes, and behaviors of health care providers (physicians and nurses) regarding the use of botanical dietary supplements (BDS) for peri- and postmenopausal women.

DESIGN

Health care providers (physicians and nurse practitioners/nurse midwives) completed a questionnaire to assess knowledge, attitudes, and behaviors regarding botanical dietary supplement use for peri- and postmenopausal women. A total of 62 providers were included in the final analysis.

RESULTS

Two thirds of providers reported that they had limited or no knowledge about botanical dietary supplements. By far, the majority of providers had no formal training nor had they studied these supplements on their own. Although knowledge was limited, a majority of providers wanted additional training predominantly because of growing patient awareness and use and were open to using these therapies for their patients either in combination with conventional Western medicine or as the only support for relief of peri- and postmenopausal symptoms. However, only 25% of providers regularly asked their peri- and postmenopausal patients about use of botanical dietary supplements. Providers who had practiced longer (> or =11 y) were more likely to be knowledgeable about dietary supplements and to have studied on their own (P < 0.01), to believe that botanicals are part of evidence-based medicine (P < 0.05), and to have talked to their patients (P < 0.05) about use of these therapies. Increased knowledge also appeared to predict a more positive attitude on the part of providers toward their patients who use BDS (P < 0.001) as well as more proactive behavior related to referring and recommending these therapies as treatment (P < 0.01).

CONCLUSIONS

Our findings suggest that knowledge about botanical therapies among health care providers caring for peri- and postmenopausal women is quite low, but they are open to learning more about these modalities and using them for treatment, if appropriate. Our results suggest that increased years in practice is related to increased knowledge, more positive attitudes, and more proactive behaviors related to botanical dietary supplements.

Pharmacists' personal use, professional practice behaviors, and perceptions regarding herbal and other natural products

OBJECTIVES

To characterize pharmacists' personal and family use of, professional practice behaviors regarding, and perceptions of herbal and other natural products (H/NPs), and to ascertain whether these characteristics differ by pharmacists' education, practice setting, and other demographic characteristics.

DESIGN

Descriptive study.

SETTING

Minnesota.

INTERVENTION

Cross-sectional questionnaire mailed in June 2000.

PARTICIPANTS

A random sample of 1,017 pharmacists with active Minnesota licenses.

RESULTS

Of the 533 respondents, 282 (53%) reported personal use of H/NPs, and 240 (45%) reported having recommended H/NPs to a family member. Pharmacists working in community/outpatient settings and pharmacists living in nonurban areas were more likely to report H/NP use. Patients' requests, consumer demand, manufacturer's reputation, and manufacturer's ability to provide product quality data were key factors influencing respondents' decisions to purchase and stock H/NPs in the pharmacy. Trade journals/professional newsletters, continuing education coursework, reference texts, and reports of randomized clinical trials were considered very important sources of information about H/NPs. However, almost all respondents (95%) felt available information on H/NPs was "not adequate" or only "somewhat adequate." Half the pharmacists (51%) believed that H/NPs were safe, but only 19% believed they were effective. Slightly more than half of the respondents (56%) reported suggesting to a patient that he or she try an H/NP. The amount of government oversight of H/NPs was considered "not adequate" by 78% of pharmacists. On average, pharmacists reported that patients ask them questions regarding H/NPs 7 times per 40-hour workweek; other health care practitioners ask an average of 1.3 times per week.

CONCLUSION

Pharmacists' personal use of H/NPs is as high or higher than that of other groups of Americans, and they use similar products. Decisions to stock H/NPs in a pharmacy are influenced by consumer demand and concern for product quality. Pharmacists desire more information on H/NPs and more government oversight of these products, and pharmacists are increasingly being sought out as sources of information regarding H/NPs.

Plants and the central nervous system

This review article draws the attention to the many species of plants possessing activity on the central nervous system (CNS). In fact, they cover the whole spectrum of central activity such as psychoanaleptic, psycholeptic and psychodysleptic effects, and several of these plants are currently used in therapeutics to treat human ailments. Among the psychoanaleptic (stimulant) plants, those utilized by human beings to reduce body weight [Ephedra spp. (Ma Huang), Paullinia spp. (guaraná), Catha edulis Forssk. (khat)] and plants used to improve general health conditions (plant adaptogens) were scrutinized. Many species of hallucinogenic (psychodysleptic) plants are used by humans throughout the world to achieve states of mind distortions; among those, a few have been used for therapeutic purposes, such as Cannabis sativa L., Tabernanthe iboga Baill. and the mixture of Psychotria viridis Ruiz and Pav. and Banisteriopsis caapi (Spruce ex Griseb.) C.V. Morton. Plants showing central psycholeptic activities, such as analgesic or anxiolytic actions (Passiflora incarnata L., Valeriana spp. and Piper methysticum G. Forst.), were also analysed.Finally, the use of crude or semipurified extracts of such plants instead of the active substances seemingly responsible for their therapeutic effect is discussed.

Assessment of the Quality of Reference Books on Botanical Dietary Supplements

OBJECTIVE

To review books on botanical dietary supplements (BDS) targeted to pharmacists and physicians to assess their overall quality as primary and secondary reference books.

DESIGN

We purchased 52 books for initial review based primarily on their titles. After eliminating books not written for health care professionals and books that contained very limited information on BDS, we selected 22 texts to review in depth.

PARTICIPANTS

The review team consisted of four pharmacists--two with PhDs in pharmacognosy, one with a PhD in pharmaceutics, and one with a PharmD who is a senior medical student.

RESULTS

The authors, reviewers, and editors of some books were highly qualified; others lacked the qualifications to summarize scientific information in a balanced, unbiased manner. Many books contain unsubstantiated statements. The books judged to be of the highest quality provide primary references to support all statements and advise the reader that insufficient information is available to assess potential drug interactions and safety during pregnancy and lactation.

CONCLUSION

The quality of the information presented in the reviewed books varies dramatically. The most critical information gaps include the potential for drug interactions and the safe use of specific botanicals during pregnancy and lactation.

Dietary supplement survey of pharmacists: personal and professional practices

OBJECTIVE

To survey pharmacists about personal/professional practices regarding dietary supplements, specifically personal use and recommendation patterns, reference usage, and desired computerized decision-support features.

DESIGN

Anonymous, self-administered survey.

SETTING/LOCATION

National pharmacy association meeting.

SUBJECTS

Practicing pharmacists who answered questions about dietary supplements.

OUTCOME MEASURES

Acceptability of specific references, desired features in computerized decision support, frequency of personal use, and recommendations to patients, family, or friends.

RESULTS

Seventy (70) pharmacists completed the survey. A majority (52.9%) reported taking dietary supplements including echinacea, zinc, and chromium picolinate. Fewer than half of pharmacists stated they have recommended a dietary supplement to a patient. Pharmacists stated that the top information sources were: published clinical trials, allopathic health care providers, alternative medicine practitioners, and word of mouth. The Internet was an important source for recommendations although not for personal use. The most highly accepted (>70%) print references included The Review of Natural Products and the World Health Organization Monographs on Selected Herbal Products. More than 90% rates the ability to view reference citations and computerized alerts on drug-dietary supplement interactions "very important" or "important". Interest was high in accessing computerized monographs.

CONCLUSIONS

Pharmacists are self-educating about dietary supplements. Among pharmacists surveyed, there was some consensus as to which references were acceptable. There is a demand for dietary supplements information to be included in pharmacy computer systems, specifically to check for interactions against the patient's.drug profile. Although practitioners in Western and alternative medicine, as well as journal articles, are preferred information sources, the Internet and word of mouth are also important sources. Personal use of dietary supplements correlated with a twofold increase in the likelihood that a pharmacist would recommend a dietary supplement to a patient.

Complementary therapy use by nursing, pharmacy and biomedical science students

Attitudes towards the use of complementary therapies by students of undergraduate Bachelor of Nursing, Pharmacy and Biomedical Sciences were determined using a self-administered questionnaire. Overall, 78% of students had used a complementary therapy in the past year and 56% had visited a complementary therapy practitioner. The therapies most used were those involving vitamins, mineral and other supplements. Practitioners specializing in this area were the most visited, followed by chiropractors. Commonly used products included vitamin C, multivitamins, B group vitamins, garlic, iron and echinacea. Most students thought complementary therapies improved quality of life, with friends and family providing the main sources of information. There were few differences attributable to course or gender. The results suggest that these students have favorable attitudes towards complementary therapies and that many choose to use them as part of normal health care.