Article

Australian Hospital Pharmacists' Attitudes, Perceptions, Knowledge and Practices of CAMs

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Abstract

Background Although evidence suggests that some complementary and alternative medicines (CAMs) are beneficial they can also cause adverse effects. Hospital pharmacists are responsible for ensuring patient safety and wellbeing yet little is known about their perceptions, knowledge and practices of CAMs.AimTo explore hospital pharmacists' attitudes, perceptions, knowledge and practices of CAMs.Method An anonymous, self-administered questionnaire was distributed to pharmacists at four hospitals in Melbourne.Results107 completed surveys were received (76% response). 87% of pharmacists thought CAMs were unsafe and required monitoring yet 45% did not routinely ask patients about CAM use. 74% thought they had insufficient knowledge to identify when CAMs could affect patient safety and 88% thought CAMs needed more hospital-based research. Pharmacists were cautious about CAMs and concerned about safety, efficacy, cost and regulatory issues. 62% had received training about CAMs, and 83% were interested in further training. A mean score of 39.9% (SD 19.9) was obtained in the knowledge section. Several complementary therapies were considered useful, notably acupuncture.Conclusion Hospital pharmacists are responsible for the safe and appropriate use of medicines however this does not routinely extend to the use of CAMs. Despite receiving some education about CAMs, a lack of confidence and knowledge was identified. Clear guidelines and education is needed to improve communication about CAMs and optimise patient care. Hospital pharmacists have concerns about CAMs and would support further hospital-based research.

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... The aims of the empirical studies were focused on assessing pharmacist, consumer and pharmacy student perceptions regarding a pharmacist's responsibilities when selling complementary medicines. The studies explored consumers' and pharmacy students' perceptions regarding the responsibilities of pharmacists when selling complementary medicines and pharmacists' attitudes, [10,[23][24][25][26] knowledge, [24,27,28] practices [29][30][31][32] regarding their responsibility when selling complementary medicines, and any perceived barriers to providing information [33] regarding complementary medicines in pharmacy. The normative study aimed to explore ethical perspectives of selling complementary medicine in pharmacy. ...
... [24] Despite this, studies that surveyed pharmacists about what they actually do found that pharmacists rarely initiate communication with consumers about complementary medicines. [23,28,35] A number of studies sought to identify the barriers that pharmacists believe impede their ability to fulfil their responsibilities in relation to complementary medicines. [19,[36][37][38][39] Pharmacists consistently described a lack of confidence in their knowledge and skills in relation to complementary medicines and a lack of comfort in answering specific questions about complementary medicines from consumers. ...
... For example, pharmacists' perceive they are responsible for the provision of information, [10,34,[48][49][50] but they do not routinely initiate conversation with consumers about complementary medicines. [23,28,35] Although pharmacists identify a concern regarding the lack of scientific evidence for complementary medicines, this does not appear to affect them selling these products. A secret-shopper investigation by a consumer advocacy group found that nearly one-third of Australian pharmacies recommended a complementary medicine for stress, most of which lacked scientific evidence for effectiveness. ...
Article
Objective: The widespread sale of complementary medicines in community pharmacy raises important questions regarding the responsibilities of pharmacists when selling complementary medicines. This study reviews the academic literature that explores a pharmacist's responsibilities when selling complementary medicines. Methods: International Pharmaceutical Abstracts, Embase, PubMed, Cinahl, PsycINFO and Philosopher's index databases were searched for articles written in English and published between 1995 and 2017. Empirical studies discussing pharmacists' practices or perceptions, consumers' expectations and normative studies discussing ethical perspectives or proposing ethical frameworks related to pharmacists' responsibilities in selling complementary medicines were included in the review. Key findings: Fifty-eight studies met the inclusion criteria. The majority of the studies discussing the responsibilities of pharmacists selling complementary medicines had an empirical focus. Pharmacists and consumers identified counselling and ensuring safe use of complementary medicines as the primary responsibilities of pharmacists. No formal ethical framework is explicitly employed to describe the responsibilities of pharmacists selling complementary medicines. To the degree any ethical framework is employed, a number of papers implicitly rely on principlism. The studies discussing the ethical perspectives of selling complementary medicines mainly describe the ethical conflict between a pharmacist's business and health professional role. No attempt is made to provide guidance on appropriate ways to resolve the conflict. Conclusion: There is a lack of explicit normative advice in the existing literature regarding the responsibilities of pharmacists selling complementary medicines. This review identifies the need to develop a detailed practice-specific ethical framework to guide pharmacists regarding their responsibilities when selling complementary medicines.
... 3 A study at a major Sydney hospital reported that at the time of admission, 12% of patients were using one to fourteen CM (mean 2.6). 4 Increasing research and data on issues pertaining to CM have shown that some of these substances can have negative effects on patients, such as drug interactions and adverse reactions. 5 In a Melbourne-based study, Braun and Cohen demonstrated that many hospital pharmacists desired further training to assist them in the safe use of CM. 6 There is a need for hospital pharmacists to expand their knowledge of CM and to be able to seek information on CM to ensure their safe use. ...
... Although other studies have investigated Australian pharmacists experiences with CM, this is the first national survey to investigate hospital pharmacists' attitude, knowledge and information use and needs on CM. 6,11,12 Attitude and Knowledge Significant deficits were revealed in tested knowledge among hospital pharmacists on three common CM. These findings match research from local and overseas surveys, which report many pharmacists lack confidence in discussing CM, have concerns with safety and have poor knowledge about CM. 6,18,19 Only 28% of respondents in this study considered themselves confident in discussing CM with patients. ...
... Although other studies have investigated Australian pharmacists experiences with CM, this is the first national survey to investigate hospital pharmacists' attitude, knowledge and information use and needs on CM. 6,11,12 Attitude and Knowledge Significant deficits were revealed in tested knowledge among hospital pharmacists on three common CM. These findings match research from local and overseas surveys, which report many pharmacists lack confidence in discussing CM, have concerns with safety and have poor knowledge about CM. 6,18,19 Only 28% of respondents in this study considered themselves confident in discussing CM with patients. The link between black cohosh and hepatotoxicity has been highlighted in numerous publications over the past decade. ...
Article
Background The use of complementary medicines (CM) is increasing in the community. Hospital pharmacists need to expand their knowledge of CM and have access to and become familiar with reliable information sources.AimTo ascertain hospital pharmacists' knowledge on adverse effects of CM; and to investigate their information seeking practices and preferred sources of reliable information on CM.Method Anonymous self-administered surveys were sent to a stratified random sample of pharmacists across Australia. The questionnaire was designed to address five areas on CM: experience and attitude, knowledge, information use, preference for information sources and demographics.Results388 eligible responses were received (23% response rate). 81 respondents were hospital pharmacists. Around half of the hospital pharmacists sought information on CM at least monthly. The most frequently sought information was drug interactions, contraindications and adverse effects. A variety of sources were used to find the information, with the most popular being the Internet and MIMS, however, the most useful were specific web sites and drug information phone services. Only 36% of hospital pharmacists knew that hepatotoxicity is a potential adverse effect of black cohosh and 38% knew that glucosamine can interact with warfarin.Conclusion Many Australian hospital pharmacists had a limited knowledge on the adverse effects of common CM. Although hospital pharmacists often seek information on CM, many were unable to or unaware of where to access reliable information.
... Although some pharmacist surveys have indicated that most pharmacists consider it important to have CM knowledge and to be able to provide information to patients (Chang et al., 2000;Koh, Teo, & Ng, 2003;Naidu et al., 2005), Canadian and US studies report that only about half of the practicing pharmacists have positive attitudes towards CMs (Kwan et al., 2006;Welna et al., 2003). Furthermore, the ability of many pharmacists to take on the professional responsibility towards CM counseling is limited as studies investigating the knowledge of practicing pharmacists revealed that they generally rate their CM knowledge as inadequate and are not confident in answering patient enquiries (Braun & Cohen, 2007;Chang et al., 2000;Koh et al., 2003;Naidu et al., 2005;Semple et al., 2006). ...
... surveys (Braun & Cohen, 2007;Naidu et al., 2005;Semple et al., 2006) and a report (Easton, 2007). ...
... These numbers were overall lower, but similar in trend to one Canadian study which found that 71% of hospital pharmacists asked patients about CM use vs. 29% of community pharmacists (Montbriand, 2000). Brown et al., (2005) also reported that CM use is not routinely documented by American community pharmacists, whereas it has been found that CM use was recorded in the patient history by Australian hospital pharmacists (Braun & Cohen, 2007). These results indicate the presence of some specific strategies for CM documentation in the Australian hospital setting, but that the overall effectiveness of these strategies is still too low. ...
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Article
The widespread use of complementary medicines (CMs) within the general community, the health benefits and risks, and the role of pharmacists as advocates of appropriate use of medicines make it imperative to identify how pharmacists' meet customers CM information needs and lead quality use of medicine practices in regards to CMs within the pharmacy setting. A self-administered questionnaire was completed by 736 Australian pharmacists as part of a larger study on the use of CM within pharmacy practice. Personal use of CMs was common (76%). Most pharmacists saw CM counselling as their professional obligation, however, mainly regarding safety aspects. Only 24% of pharmacists always asked customers presenting with prescription medicines about concomitant CM use. Only 34% of pharmacists personally recommended CMs and less than 20% notified the respective Australian agency about an adverse drug reaction. On average, pharmacists only achieved about 50% of the knowledge score in a CM knowledge test on clinically proven benefit of CMs and CM-drug interactions. Most pharmacists supported undergraduate (76%) and additional CM education for pharmacists (85%). Many differences between hospital and community pharmacists, pharmacists working in pharmacies with or without an employed naturopath and pharmacists with and without CM training were noted and discussed. Yes Yes
... While in the area of medical therapeutics training of pharmacy programs follow this ethical principle, it is unclear if training in CAM therapies meets this standard. Available evidence from different countries and settings suggests that pharmacists lacked adequate knowledge and desired more information on various CAM modalities (7,8,9,10,11,12). This is particularly true in the Czech Republic where a previous study study with a subanalysis conducted in pharmacy students reported high self use of CAM and likelihood of recommending CAM therapies in future practice, and desire for more evidence-based information during training to discriminate among the many therapies (13,14). ...
... Likelihood of recommendation was strongly associated with self-reported use which is consistent with a previous report by Howard (11). Czech pharmacist and PT respondents in our study were less skeptical about CAM perceived effectiveness and safety in comparison with pharmacists from other studies (9,10,12). ...
Article
Background: No data exists regarding the attitude of practicing Czech pharmacists toward CAM and their interaction with patients about CAM therapies. Objectives: Describe attitudes of Czech pharmacists and pharmacy technicians toward complementary and alternative medicine (CAM), their self-reported CAM use and client recommendation behaviors. Methods: Design: A cross-sectional study using a validated self-administered survey (CAM Health Belief Questionnaire (CHBQ) and other questions). Setting: Community and hospital pharmacies. Subjects: Convenience sample of pharmacists and pharmacy technicians. Outcome measures: CHBQ score, self-reported CAM use, recommendation to clients and perceived CAM efficacy and safety. Results: Response rate was 99% (203 of 205). 80% were pharmacists and 20% pharmacy technicians. CHBQ mean score was 50.3 (maximum score 70) affirming positive attitudes toward CAM. Herbs, vitamins, massage and homeopathy were the most common therapies reported as used by respondents. Self-reported use of therapies was correlated with self-reported recommendation to patients. Ninety five percent recommended CAM; over 90% perceived CAM as effective and safe. Self-reported use of evidence-based resources was minimal. Conclusions: Czech pharmacists and pharmacy technicians have positive attitudes about CAM. Pharmacist and pharmacy technicians' recommendation of CAM therapies to clients is based on a culture of belief and self-use rather than knowledge of current evidence. Strategies for improving recommendation practices will need to address self-use and the inclusion of CAM evidence-based medicine training.
... Community pharmacists are one of the main suppliers of CAMs in Australia responsible for around 40% of total sales [3,5]. Overall, pharmacists' attitudes to statements about CAMs indicate they are cautious and concerned about issues such as safety, efficacy and regulation of the medicines [9]. In addition, pharmacists believe there is a lack of quality information and limited access to evidence based information [10]. ...
... The findings of this study are similar to many other studies that have found that many pharmacists lack confidence in discussing CAMs and have concerns with safety related to poor knowledge910111215,17]. Almost all pharmacists in the current study agreed that they should regularly ask consumers if they are using CAMs. ...
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Article
Complementary and alternative medicines (CAMs) are being used increasingly across the world. In Australia, community pharmacists are a major supplier of these products but knowledge of the products and interactions with other medicines is poor. Information regarding the use of CAMs by metropolitan pharmacists has been documented by the National Prescribing Service (NPS) in Australia but the views of rural/regional community pharmacists have not been explored. The aim of this pilot study was to explore the knowledge, attitudes and information seeking of a cohort of rural community pharmacists towards CAMs and to compare the findings to the larger NPS study. A cross sectional self-administered postal questionnaire was mailed to all community pharmacists in one rural/regional area of Australia. Using a range of scales, data was collected regarding attitudes, knowledge, information seeking behaviour and demographics. Eighty eligible questionnaires were returned. Most pharmacists reported knowing that they should regularly ask consumers if they are using CAMs but many lacked the confidence to do so. Pharmacists surveyed for this study were more knowledgeable in regards to side effects and interactions of CAMs than those in the NPS survey. Over three quarters of pharmacists surveyed reported sourcing CAM information at least several times a month. The most frequently sought information was drug interactions, dose, contraindications and adverse effects. A variety of resources were used to source information, the most popular source was the internet but the most useful resource was CAM text books. Pharmacists have varied opinions on the use of CAMs and many lack awareness of or access to good quality CAMs information. Therefore, there is a need to provide pharmacists with opportunities for further education. The data is valuable in assisting interested stakeholders with the development of initiatives to address the gaps in attitudes, knowledge and to improve effectiveness of information seeking behaviour.
... The same study also revealed increasing physician age as negatively associated with the belief that complementary medicine is effective. In line with findings of studies of general healthcare professionals' knowledge of CAM (Braun & Cohen 2007, Brown et al. 2008 ), Tiran (2006) highlighted a lack of understanding among obstetricians and midwives about the pharmacological nature of alternative therapies and their possible risks to pregnant women. Her data also suggest that conventional providers focus on the merits of the therapies themselves and rarely give conscious thought to the credibility or ability of the individual alternative practitioners who provide these therapies to pregnant women. ...
... There are also worries about the 'indiscriminate enthusiasm' (Tiran 2008) of some care providers in adopting complementary therapies in the treatment of pregnancy complications. This is especially the case given that there is evidence that many maternity care providers have received no training in the use of CAM or have little understanding of the pharmacological nature of alternative therapies and their possible risks to pregnant women (Tiran 2006, Braun & Cohen 2007, Brown et al. 2008, Lake 2009). In recent years, there have been calls among care practitioners for education and training about all aspects of complementary therapies/modalities and for the introduction of relevant courses in nursing or midwifery education institutions (Dayhew et al. 2009 ). ...
Article
This paper presents an integrative literature review examining the attitudes and referral practices of midwives and other maternity care professionals with regard to complementary and alternative treatment and its use by pregnant women. Use of complementary and alternative medicine during pregnancy is a crucial healthcare issue. Recent discussion has identified the need to develop an integrated approach to maternity care. However, there is a lack of understanding of attitudes and behaviours of maternity care professionals towards these treatments. A database search was conducted in MEDLINE, CINAHL, Health Source, AMED and Maternity and Infant Care for the period 1999-2009. An integrative review method was employed. Studies were selected if they reported results from primary data collection on professional practice/referral or knowledge/attitude towards complementary and alternative medicine by obstetricians, midwives and allied maternity care providers. A total of 21 papers covering 19 studies were identified. Findings from these studies were extracted, grouped and examined according to three key themes: 'prevalence of practice, recommendation and referral', 'attitudes and views' and 'professionalism and professional identity'. There is a need for greater respect and cooperation between conventional and alternative practitioners as well as communication between all maternity care practitioners and their patients about the use of complementary and alternative medicine. There is a need for in-depth studies on the social dimension of practice as well as the inter- and intra-professional dynamics that shape providers' decision to use or refer to complementary and alternative medicine in maternity care.
... 4 A Canadian interview study by Westfall, 5 on use of herb considered CAM to be safer than conventional pharmaceuticals because CAM was ''milder'', 'more natural', ''simpler'', and ''more familiar''. Again, some studies have given the reasons of the use of CAM to include; Emphasis on prevention and wellness 6 , Emphasis on healing rather than cure, 7 Non-invasive approach, 8 Accessibility, 9,10 etc. ...
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Article
This study aim at identifying the perceived benefits, problems and risk associated with CAM use among pregnant women in the Niger Delta Region. The study engaged a crosssectional survey method and was conducted among 325 women in twelve communities. Data collected for the study were analysed using quantitative methods at the univariate, bivariate and multivariate level, and thematic content analysis for the qualitative data. Findings from the study showed that ‘cultural belief’ (3.80±1.10), ‘accessibility’ (3.50±0.90), ‘meeting primary health needs’ (3.69±1.09) ‘easy affordability’ (3.30±1.18), warding off evil spirit (3.08±1.132), greater choices, control and participation (3.04±0.669); and emphasis on prevention and wellness (3.10±0.93) were all identified as the reasons for the use of CAM. On the other hand; ‘lack of standardisation’ (3.21±0.957) ‘lack of research institutes on CAM’ (3.28±0.686), ‘safety and precautions about CAM use’ (3.16±0.823), ‘too many quacks CAM practitioners’ (3.70±0.946) were all perceived as the risk involved in the use of CAM. Thus it is was recommended that as long as pregnant women continue to patronise the use of CAM, it is expedient that some form of regulation and standardisation be instituted by the government through the ministry of health at various levels.
... Flaxseed oil contains mostly of omega-3 (ALA) and partly of omega-6 (LA) fatty acids (Braun & Cohen, 2007). Human consumption of omega-3 fatty acids is proven to decrease the incidence of cardiovascular disease, reduce inflammation and prevent certain chronic diseases such as diabetes, hypertension, cancer, auto-immune diseases and arthritis (Simopoulos, 1999, Kris-Etherton et al., 2003, Larsson et al., 2004. ...
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Conference Paper
Milk fat has been considered as a hypercholesterolemic agent because it contains cholesterol and a generous proportion of saturated long-chain fatty acids. A nutritionally balanced product has led to the development of a choice fat source which has a critical impact on the fatty acid profile. The fortification of food with essential polyunsaturated fatty acids (PUFA), such as omega-3, is an in- teresting and timely topic. The health benefits associated with PUFA ingestion are several. Flaxseed oil which is rich in nutraceuticals omega-3 fatty acid has been reported to be a beneficial substitute for milk fat in some dairy products. However, a complete pilot scale research is essential to evaluate the cheese sensory properties as well as the fatty acids stability of flaxseed oil upon long-term storage. Hence, this study aimed to determine the composition and acceptability of flaxseed oil formulated reduced fat cheese with optimum levels of milk fat substituted by flaxseed oil. The control made from whole milk and two types of white cheese-like products were made from skim milk and a mixture of skim milk with flaxseed oil. Samples were subjected to (moisture, T.S, fat, protein, lactose, salt, ash, acidity (%) and pH value ) and sensory evaluation in addition to microbiological content tests (total counts and coliform groups) at zero, 15, 30 and 45 days. Incorporation of flaxseed oil into cheese showed clear change in the chemical composition comparing with the control and cheese that made from skim milk except in fat content which was lower than in the control without no change in flavour and texture. However, it increased slightly the colour of cheese into yellowish and had no effect on total counts and coliform counts. Flaxseed oil incorporation also gave compatible overall acceptability as compared to the control, therefore, fortification of cheese with flaxseed oil seems ideal and consumers may enjoy the health benefits of omega-3 fatty acids with reduced-fat cheese.
... The demand for education and training in the area of CMs is a recurrent message throughout the key stakeholder interviews and is discussed in a number of other studies. [55,65,70,71,[73][74][75][76][77][78]. In Australia, the quest for CM education in pharmacy training started a number of years ago [40,63,79]. ...
Full-text available
Article
Background Although pharmacists are entrusted to play a role in ensuring the safe and appropriate use of all medicines, in general, the inclusion of complementary medicines (CMs) into their professional practice has not been observed. The purpose of this study was to explore the perceptions and opinions of pharmacists and 8 key stakeholder leaders regarding the barriers that hinder pharmacists from providing care related to the use of CMs by patients/consumers and to identify solutions that would support pharmacists’ in extending their role in this area. Methods Semi-structured key informant interviews were conducted with 2 practicing pharmacists, 1 pharmacy owner, 1 key representative of a pharmacist professional organization, 1 key representative of a consumer advocacy group, 1 key representative of a medical professional organization, 1 key representative from a complementary medicine practitioner professional organization, 1 leader within a pharmacy school, 2 senior staff from a regulatory authority, and 1 key representative of the complementary medicine industry in Australia. Results A total of 9 barriers were identified in this study. Barriers including a lack of CMs knowledge, doubts about the evidence-base, a lack of research skills and access to reliable and reputable information dominated the discussions. A total of 7 solutions were proposed. Of those, the integration of CMs curricula into under-graduate and professional pharmacy education, and defining a clearer role for pharmacists’ standard of practice were considered the most important. Apposing opinions about the role of naturopaths in pharmacies were identified.. Conclusion It is anticipated that pharmacists will be required to formalise a role in ensuring the safe and appropriate use of complementary medicines to fulfil their professional and ethical responsibilities. However, pharmacists in general are not ready to take up this extended role. Individual key stakeholder groups have considered the existing barriers and have proposed solutions that are isolated measures. To facilitate further developments related to CMs and the professional practice of pharmacy, collaborative efforts between key stakeholders are needed to strategically plan and execute an extended role in a unified manner.
... Flaxseed oil contains mostly of omega-3 (ALA) and partly of omega-6 (LA) fatty acids (Braun & Cohen, 2007). Human consumption of omega-3 fatty acids is proven to decrease the incidence of cardiovascular disease, reduce inflammation and prevent certain chronic diseases such as diabetes, hypertension, cancer, auto-immune diseases and arthritis (Simopoulos, 1999, Kris-Etherton et al., 2003, Larsson et al., 2004. ...
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Article
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... However, most of the surveyed pharmacists seem to be uncomfortable answering the knowledge-based questions as evidenced by the low reliability estimate. This finding is rather similar to several studies that reported lack of confidence in knowledge or perceive inadequacy of knowledge in the area of natural products among community pharmacists (Clauson et al., 2003), as well as in the areas of complementary and alternative medicine (Braun & Cohen, 2007) and dietary supplements (Kwan et al., 2006) among surveyed hospital pharmacists. Thus, our research team decided to remove the knowledge-based questions in the survey. ...
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Pharmaceutical chemistry is one of the core subjects in the curriculum of Bachelor of Pharmacy program, however, its relevance in the practice of pharmacy in Malaysia has not been reported. Thus, this study is aimed to develop an instrument to evaluate pharmacist's perception on the application of such knowledge in the community and hospital settings. This survey instrument consist of three sections: (1) demographic information, (2) knowledge of pharmacist in pharmaceutical chemistry, and (3) perception of pharmacist on pharmaceutical chemistry subjects in pharmacy practice that were measured using 5-point Likert scale. Minor amendments were made after the first piloting (group 1, n=10) and then re-tested on another group of pharmacists (group 2, n=10). Cranach's alpha reliability test value was 0.308 (group 1) for the items measuring the knowledge domain, and 0.766-0.914 (group 1), 0.745-0.889 (group 2) for the items measuring the perception domain. Thus, due to the low reliability value, knowledge domain was removed. The final version of the survey was used to assess pharmacist's perception on the application of pharmaceutical chemistry knowledge in pharmacy practice.
... This may be because they also wanted to offer a more comprehensive 'healthcare solution' , which no doubt takes some time to provide. Previous studies have identified a lack of knowledge or lack of evidence as the main barriers to recommending CM products [4,6,11,161718192027]. As many pharmacists by their own admission do not have adequate training in CM, it is unclear whether in some cases they have truly assessed the evidence for a CM before reaching the conclusion that there is a lack of it. ...
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Background Complementary medicines (CMs) are widely used by the Australian public, and pharmacies are major suppliers of these medicines. The integration of CMs into pharmacy practice is well documented, but the behaviours of pharmacists in recommending CMs to customers are less well studied. This study reports on factors that influence whether or not pharmacists in Australia recommend CMs to their customers. Methods Data were collected from semi-structured interviews with twelve practicing pharmacists based in Brisbane, Australia. The qualitative data were analysed by thematic analysis. Results The primary driver of the recommendation of CMs was a desire to provide a health benefit to the customer. Other important drivers were an awareness of evidence of efficacy, customer feedback and pharmacy protocols to recommend a CM alongside a particular pharmaceutical medication. The primary barrier to the recommendation of CMs was safety concerns around patients on multiple medications or with complex health issues. Also, a lack of knowledge of CMs, a perceived lack of evidence or a lack of time to counsel patients were identified as barriers. There was a desire to see a greater integration of CM into formal pharmacy education. Additionally, the provision of good quality educational materials was seen as important to allow pharmacists to assess levels of evidence for CMs and educate them on their safe and appropriate use. Conclusions Pharmacists who frequently recommend CMs identify many potential benefits for patients and see it as an important part of providing a ‘healthcare solution’. To encourage the informed use of CMs in pharmacy there is a need for the development of accessible, quality resources on CMs. In addition, incorporation of CM education into pharmacy curricula would better prepare graduate pharmacists for community practice. Ultimately, such moves would contribute to the safe and effective use of CMs to the benefit of consumers.
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Background and purpose: Pregnant and breastfeeding women commonly use complementary medicine products (CMPs), including dietary supplements and herbal medicines. This study investigated women's reasons for use. Materials and methods A national, cross-sectional, online survey conducted between July–September 2019 investigated reasons for CMP use during pregnancy and lactation. Australian women who were currently pregnant and/or breastfeeding participated. Data analysis included descriptive statistics, Chi-square and principal component analyses. Results Of the 810 women surveyed (n = 354 pregnant; n = 456 breastfeeding), most reported prior CMP use and felt that CMPs had been beneficial to maintaining and optimising their own and their children's health. However, when ill, they preferred medicines prescribed by doctors or pharmacists. Perceived benefits to their unborn or breastfeeding babies' health and their own health (both cohorts), the health of their pregnancy (pregnant participants), and benefits to the breastfeeding process and breastmilk supply (breastfeeding participants) were important reasons for women's CMP use. Conclusion Women's reasons for CMP use centred on perceived benefits to their own health and the health of their babies. Women's prior positive experiences with CMP use, combined with preferences for pharmaceutical use when ill, indicates their use of CMPs can be considered complementary, rather than alternative, to biomedical health care.
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Background: Traditional medicine (TM) and complementary medicine (CM) products have played an increasingly important role in the business of pharmacy for over two decades in a number of countries. With a focus on the quality use of all medicines including complementary medicines, there have been a number of initiatives to encourage the integration of TM/CM products into professional practice. Recent studies report that many of the barriers that prevent such integration remain. Objectives: To explore the pharmacists' perspective regarding how barriers to the integration of TM/CM products into the professional practice of pharmacy could be resolved. Methods: Purposive sampling and snowballing were used to recruit 11 registered pharmacists who had worked in community pharmacy for a minimum of 6 months to participate in one of 3 focus groups. Focus group questions informed by previous studies, explored participants' perspectives on the actions required to support professional services related to TM/CM products. Results: Pharmacists proposed that five key stakeholders (professional pharmacy organizations, universities, government, pharmacy owners, and pharmacists) enact 4 developments that require a collaborative effort ("education and training", "building the evidence base", "developing reliable and accessible information resources", and "workplace support for best practice"). Manufacturers of TM/CM products were not identified by pharmacists as collaborators in these developments. Conclusion: Collectively, the findings from this study support a strategic model to guide the integration of TM/CM products into the professional practice of pharmacy.
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Background Community pharmacists play a significant role in the provision of non-prescription medicines. There is evidence that women self-medicate and use non-prescription medicines whilst breastfeeding. Studies have demonstrated that breastfeeding women are likely to seek advice from pharmacists, presenting a unique opportunity for pharmacists to provide on-going support of these women especially in relation to the appropriate use of non-prescription medicines. Objectives This study aimed to explore community pharmacists' attitudes and perspectives towards the use of non-prescription medicines during breastfeeding. Methods This exploratory study was conducted through semi-structured interviews with 30 community pharmacists in Western Australia, between July and September 2013. Transcribed data were analysed using descriptive and qualitative approaches. NVivo® Version 10.0 was used to organise qualitative data and quotations to facilitate thematic analysis. Results Four major themes emerged. Despite the positive attitudes and favourable perceived knowledge level, participants often found themselves in a dilemma when required to make clinical recommendations especially in situations where there was a therapeutic need for treatment but clear guidelines or evidence to suggest safety of the medicines or treatment in lactation was absent. Despite the popularity of complementary medicines, participants felt more confident in providing advice in relation to conventional over complementary medicines. Whilst medication safety is within the field of expertise of pharmacists, the absence of information and safety data was seen as a major challenge and barrier to enable pharmacists to confidently provide evidence-based recommendations. Conclusions This study has enhanced our understanding of the attitudes and perspectives of community pharmacists towards the use of non-prescription, including complementary medicines, during breastfeeding. Future studies are warranted to confirm the safety of commonly used or requested medicines in breastfeeding. University training and continuing education for pharmacists should include the latest information available regarding the use of both conventional and complementary medicines throughout lactation.
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Background: Most sales of complementary medicines within pharmacies are conducted by pharmacy support staff. The absence of rigorous evidence for the effectiveness of many complementary medicines raises a number of ethical questions regarding the sale of complementary medicines in pharmacies. Aim: Explore (1) what consumers expect from pharmacists/pharmacies with regard to the sale of complementary medicines, and (2) how pharmacy support staff perceive their responsibilities when selling complementary medicines. Methods: One-on-one semi-structured interviews were conducted with a convenience sample of pharmacy support staff and consumers in pharmacies in Brisbane. Consumers were asked to describe their expectations when purchasing complementary medicines. Pharmacy support staff were asked to describe their responsibilities when selling complementary medicines. Interviews were conducted and analysed using the techniques developed within Grounded Theory. Key findings: Thirty-three consumers were recruited from three pharmacies. Consumers described complementary medicine use as a personal health choice. Consumer expectations on the pharmacist included: select the right product for the right person, expert product knowledge and maintaining a wide range of good quality stock. Twenty pharmacy support staff were recruited from four pharmacies. Pharmacy support staff employed processes to ensure consumers receive the right product for the right person. Pharmacy support staff expressed a commitment to aiding consumers, but few evaluated the reliability of effectiveness claims regarding complementary medicines. Conclusions: Pharmacists need to respect the personal health choices of consumers while also putting procedures in place to ensure safe and appropriate use of complementary medicines. This includes providing appropriate support to pharmacy support staff.
Article
Background: The global market for complementary and alternative medicine (CAM) is projected to reach US$5 trillion by 2050. With increased global efforts to integrate complementary and alternative therapies into modern medicine, there is a need for health professionals to be well-informed about several aspects of CAM. Traditionally, pharmacy curriculums do not include in-depth courses on CAM. Objectives: To evaluate the knowledge and perceptions of senior pharmacy students on CAM and to document their perception towards the current curriculum related to CAM. Method: A cross sectional survey using a 20-item questionnaire was conducted. One hundred and thirty two questionnaires were distributed among final year pharmacy students at the Universiti Sains Malaysia (USM), of whom 96 responded (response rate 72.7%). The data were analyzed using SPSS version 14.0 and Microsoft ® Excel. Descriptive statistics including frequencies and percentages were used for data analysis. Results: An overwhelming proportion of the students (about 90%) agreed that knowledge about CAM is important to them as future pharmacy practitioners and 84.4% believed that clinical care should integrate the best of conventional and CAM practices; 89.6% of the respondents agreed that health professionals should be able to advise their patients on commonly used CAM methods. However 36.5% did not believe they had received sufficient training to advise patients on their use of CAM. Evaluation of students' knowledge about CAM found that only 31.3% attained a a score of 80% or more, whereas 68.8% had scores below 80%. Conclusion: This study showed that senior pharmacy students at Universiti Sains Malaysia USM overall have an positive perception of CAM, but their levels of knowledge appear to reflect the inadequacy of training about CAM in the current pharmacy curriculum. The study therefore highlights the need for curriculum review and innovation in order to introduce comprehensive courses related to CAM at USM, and perhaps at other pharmacy schools.
Article
to examine the use of complementary and alternative medicine during pregnancy using data from a longitudinal cohort study. the research was conducted as part of the Australian Longitudinal Study on Women's Health which was designed to investigate multiple factors affecting the health and well-being of women over a 20-year period. the younger cohort of the Australian Longitudinal Study on Women's Health who had completed four surveys in 1996, 2000, 2003 and 2006. the data reveal an increase both in consumption of complementary and alternative medicine and in consultations with general practitioners/specialists during pregnancy. Women utilised complementary and alternative medicine as a supplement for conventional maternity care. given the potential risks of some complementary and alternative medicine for pregnant women and their unborn child, it is essential that maternity care providers are adequately informed about these treatments and that further research investigates the details of such concurrent use.
Article
Complementary and alternative medicine (CAM) is one of the fastest growing areas of health care. This has necessitated an increased awareness and understanding of CAM by conventional health professionals. A questionnaire seeking information about use of and attitudes toward CAM was mailed to 1,365 Australian podiatric physicians. Ninety-one percent of Australian podiatric physicians surveyed have used at least one CAM therapy in the past 12 months, and 93% have treated patients with CAM or have recommended its use to patients. Overall, the respondents rated their knowledge of various CAM therapies as "average," and responses on the CAM Health Belief Questionnaire indicated that respondents tended not to endorse CAM health beliefs, with statements about CAM therapies being seen as "a threat to public safety" and effects being "usually due to the placebo effect" producing the strongest responses. Complementary and alternative medicine therapies are already being used in podiatric medical practice, and there are significant opportunities for further research into CAM education and clinical research relevant to podiatric medicine.
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A prior national survey documented the high prevalence and costs of alternative medicine use in the United States in 1990. To document trends in alternative medicine use in the United States between 1990 and 1997. Nationally representative random household telephone surveys using comparable key questions were conducted in 1991 and 1997 measuring utilization in 1990 and 1997, respectively. A total of 1539 adults in 1991 and 2055 in 1997. Prevalence, estimated costs, and disclosure of alternative therapies to physicians. Use of at least 1 of 16 alternative therapies during the previous year increased from 33.8% in 1990 to 42.1% in 1997 (P < or = .001). The therapies increasing the most included herbal medicine, massage, megavitamins, self-help groups, folk remedies, energy healing, and homeopathy. The probability of users visiting an alternative medicine practitioner increased from 36.3% to 46.3% (P = .002). In both surveys alternative therapies were used most frequently for chronic conditions, including back problems, anxiety, depression, and headaches. There was no significant change in disclosure rates between the 2 survey years; 39.8% of alternative therapies were disclosed to physicians in 1990 vs 38.5% in 1997. The percentage of users paying entirely out-of-pocket for services provided by alternative medicine practitioners did not change significantly between 1990 (64.0%) and 1997 (58.3%) (P=.36). Extrapolations to the US population suggest a 47.3% increase in total visits to alternative medicine practitioners, from 427 million in 1990 to 629 million in 1997, thereby exceeding total visits to all US primary care physicians. An estimated 15 million adults in 1997 took prescription medications concurrently with herbal remedies and/or high-dose vitamins (18.4% of all prescription users). Estimated expenditures for alternative medicine professional services increased 45.2% between 1990 and 1997 and were conservatively estimated at $21.2 billion in 1997, with at least $12.2 billion paid out-of-pocket. This exceeds the 1997 out-of-pocket expenditures for all US hospitalizations. Total 1997 out-of-pocket expenditures relating to alternative therapies were conservatively estimated at $27.0 billion, which is comparable with the projected 1997 out-of-pocket expenditures for all US physician services. Alternative medicine use and expenditures increased substantially between 1990 and 1997, attributable primarily to an increase in the proportion of the population seeking alternative therapies, rather than increased visits per patient.
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Osteoarthritis (OA) is the most common form of arthritis, and it is often associated with significant disability and an impaired quality of life. To review all randomized controlled trials (RCTs) evaluating the effectiveness and toxicity of glucosamine in OA. We searched MEDLINE, PREMEDLINE, EMBASE, AMED, ACP Journal Club, DARE, CDSR, and the CCTR. We also wrote letters to content experts, and hand searched reference lists of identified RCTs and pertinent review articles. All searches were updated in January 2005. Relevant studies met the following criteria: 1) RCTs evaluating the effectiveness and safety of glucosamine in OA, 2) Both placebo controlled and comparative studies were eligible, 3) Both single blinded and double blinded studies were eligible. Data abstraction was performed independently by two investigators and the results were compared for degree of agreement. Gotzsche's method and a validated tool (Jadad 1996) were used to score the quality of the RCTs. Continuous outcome measures were pooled using standardized mean differences (SMD) as the measure of effect size. Dichotomous outcome measures were pooled using relative risk ratios (RR). Analysis restricted to eight studies with adequate allocation concealment failed to show benefit of glucosamine for pain and WOMAC function. Collectively, the 20 analyzed RCTs found glucosamine favoured placebo with a 28% (change from baseline) improvement in pain (SMD -0.61, 95% CI -0.95, -0.28) and a 21% (change from baseline) improvement in function using the Lequesne index (SMD -0.51 95% CI -0.96, -0.05). However, the results are not uniformly positive, and the reasons for this remain unexplained. WOMAC pain, function and stiffness outcomes did not reach statistical significance. In the 10 RCTs in which the Rotta preparation of glucosamine was compared to placebo, glucosamine was found to be superior for pain (SMD -1.31, 95% CI -1.99, -0.64) and function using the Lequesne index (SMD -0.51, 95% CI -0.96, -0.05). Pooled results for pain (SMD -0.15, 95% CI -0.35, 0.05) and function using the WOMAC index (SMD 0.03, 95% CI -0.18, 0.25) in those RCTs in which a non-Rotta preparation of glucosamine was compared to placebo did not reach statistical significance. In the four RCTs in which the Rotta preparation of glucosamine was compared to an NSAID, glucosamine was superior in two, and equivalent in two. Two RCTs using the Rotta preparation showed that glucosamine was able to slow radiological progression of OA of the knee over a three year period (SMD 0.24, 95% CI 0.04, 0.43). Glucosamine was as safe as placebo in terms of the number of subjects reporting adverse reactions (RR=0.97, 95% CI, 0.88, 1.08). This update includes 20 studies with 2570 patients. Pooled results from studies using a non-Rotta preparation or adequate allocation concealment failed to show benefit in pain and WOMAC function while those studies evaluating the Rotta preparation show that glucosamine was superior to placebo in the treatment of pain and functional impairment resulting from symptomatic OA. WOMAC outcomes of pain, stiffness and function did not show a superiority of glucosamine over placebo for both Rotta and non-Rotta preparations of glucosamine. Glucosamine was as safe as placebo.
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To survey the use, cost, beliefs and quality of life of users of complementary and alternative medicine (CAM). A representative population survey conducted in 2004 with longitudinal comparison to similar 1993 and 2000 surveys. 3015 South Australian respondents over the age of 15 years (71.7% participation). In 2004, CAMs were used by 52.2% of the population. Greatest use was in women aged 25-34 years, with higher income and education levels. CAM therapists had been visited by 26.5% of the population. In those with children, 29.9% administered CAMs to them and 17.5% of the children had visited CAM therapists. The total extrapolated cost in Australia of CAMs and CAM therapists in 2004 was AUD$1.8 billion, which was a decrease from AUD$2.3 billion in 2000. CAMs were used mostly to maintain general health. The users of CAM had lower quality-of-life scores than non-users. Among CAM users, 49.7% used conventional medicines on the same day and 57.2% did not report the use of CAMs to their doctor. About half of the respondents assumed that CAMs were independently tested by a government agency; of these, 74.8% believed they were tested for quality and safety, 21.8% for what they claimed, and 17.9% for efficacy. Australians continue to use high levels of CAMs and CAM therapists. The public is often unaware that CAMs are not tested by the Therapeutic Goods Administration for efficacy or safety.
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Australian general practitioners' (GPs) attitudes toward and use of a range of complementary therapies (CTs) were determined through a self-administered postal survey sent to a random sample of 2000 Australian GPs. The survey canvassed GPs' opinions as to the harmfulness and effectiveness of CTs; current levels of training and interest in further training; personal use of, and use in practice of, CTs; referrals to CT; practitioners; appropriateness for GPs to practice and for government regulation; perceived patient demand and the need for undergraduate education. The response rate was 33.2%. Based on GPs' responses, complementary therapies could be classified into: nonmedicinal and nonmanipulative therapies, such as acupuncture, massage, meditation, yoga, and hypnosis, that were seen to be highly effective and safe; medicinal and manipulative therapies, including chiropractic, Chinese herbal medicine, osteopathy, herbal medicine, vitamin and mineral therapy, naturopathy, and homeopathy, which more GPs considered potentially harmful than potentially effective; and esoteric therapies, such as spiritual healing, aromatherapy, and reflexology, which were seen to be relatively safe yet also relatively ineffective. The risks of CTs were seen to mainly arise from incorrect, inadequate, or delayed diagnoses and interactions between complementary medications and pharmaceuticals, rather than the specific risks of the therapies themselves. Nonmedicinal therapies along with chiropractic are widely accepted in Australia and can be considered mainstream. GPs are open to training in complementary therapies, and better communication between patients and GPs about use of CTs is required to minimize the risk of adverse events. There is also a need to prioritize and provide funding for further research into the potential adverse events from these therapies and other therapies currently lacking an evidence base.
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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. 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. 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. 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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Our objective was to review all published trials of coenzyme Q10 for hypertension, assess overall efficacy and consistency of therapeutic action and side effect incidence. Meta-analysis was performed in 12 clinical trials (362 patients) comprising three randomized controlled trials, one crossover study and eight open label studies. In the randomized controlled trials (n=120), systolic blood pressure in the treatment group was 167.7 (95% confidence interval, CI: 163.7-171.1) mm Hg before, and 151.1 (147.1-155.1) mm Hg after treatment, a decrease of 16.6 (12.6-20.6, P<0.001) mm Hg, with no significant change in the placebo group. Diastolic blood pressure in the treatment group was 103 (101-105) mm Hg before, and 94.8 (92.8-96.8) mm Hg after treatment, a decrease of 8.2 (6.2-10.2, P<0.001) mm Hg, with no significant change in the placebo group. In the crossover study (n=18), systolic blood pressure decreased by 11 mm Hg and diastolic blood pressure by 8 mm Hg (P<0.001) with no significant change with placebo. In the open label studies (n=214), mean systolic blood pressure was 162 (158.4-165.7) mm Hg before, and 148.6 (145-152.2) mm Hg after treatment, a decrease of 13.5 (9.8-17.1, P<0.001) mm Hg. Mean diastolic blood pressure was 97.1 (95.2-99.1) mm Hg before, and 86.8 (84.9-88.8) mm Hg after treatment, a decrease of 10.3 (8.4-12.3, P<0.001) mm Hg. We conclude that coenzyme Q10 has the potential in hypertensive patients to lower systolic blood pressure by up to 17 mm Hg and diastolic blood pressure by up to 10 mm Hg without significant side effects.
Article
Aim: To survey the use of complementary medicines (CMs) by patients admitted to St Vincent's Hospital Sydney and identify potential interactions between CMs and other prescribed or over-the-counter medications. Method: Patients seen by clinical pharmacists in St Vincent's Hospital Sydney over a 3-week period in May 2000 were surveyed during the routine medication history. Patients taking CMs had their medication history recorded on the data collection form. Potential for interactions between the CM and the prescribed or over-the-counter medications was assessed. Results: Five hundred and eleven patients had their medication history taken, 61 (12%) were taking 156 CMs at the time. Ninety-one (58%) agents had been taken by 39 (64%) patients for more than one year. Patients ranged in age from 25 to 100 years with a median of 57 years. There was an even sex distribution, 30 females and 31 males. A high proportion (74, 47%) of the CMs had been self-prescribed and 25 (41%) patients took 103 (66%) CMs without the knowledge of their general practitioner. Twenty-two (36%) patients continued taking a total of 47 (30%) CMs in hospital. Twenty-four (51%) of the continued CMs were not charted. Eleven (18%) patients were also taking 20 medicines that could potentially interact with the CMs they were taking. Six patients were taking more than one potentially interacting substance. Conclusion: Use of CMs by patients admitted to St Vincent's Hospital Sydney appears significant and warrants routine inclusion in the patient medication histories. Potential drug interactions were found to occur. Pharmacists need to be aware of potential interactions and have access to information about interactions between CMs and other medicines.
Article
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.
Article
A survey was sent to 1,000 pharmacists in metropolitan Detroit U.S.A. (19.7% responded) and 750 pharmacists in the U.K. (57.9% responded) to assess the frequency of recommendations for health food stores, minerals, multivitamins, natural vitamins, protein supplements, Stresstabs®, and weight-reduction products. Pharmacists were also asked about their five most common reasons for recommending vitamins and minerals from a list of 16 items, which included alcoholism, anaemia, arthritis, athletically active, children, colds, dieting, fatigue, feeling nervous, headaches, old age, pain, pregnancy, prophylaxis, skin problems, stress or other. About 40% of the U.S.A. community pharmacists recommended multivitamins more than five times a week compared to 28-6% of U.K. community pharmacists. Anaemia (48.6%), dieting (44.8%), alcoholism (42.3%), pregnancy (400%), and fatigue (36.8%) were the five most common reasons for pharmacists to recommend vitamins and minerals, this was consistent, for the most part, with the American Medical Association's Council on Scientific Affairs report, however, a large number of pharmacists placed the non-specific symptoms of fatigue and stress in the five most common reasons for which they recommend vitamins or minerals.
Article
Context.— Research both in the United States and abroad suggests that significant numbers of people are involved with various forms of alternative medicine. However, the reasons for such use are, at present, poorly understood.Objective.— To investigate possible predictors of alternative health care use.Methods.— Three primary hypotheses were tested. People seek out these alternatives because (1) they are dissatisfied in some way with conventional treatment; (2) they see alternative treatments as offering more personal autonomy and control over health care decisions; and (3) the alternatives are seen as more compatible with the patients' values, worldview, or beliefs regarding the nature and meaning of health and illness. Additional predictor variables explored included demographics and health status.Design.— A written survey examining use of alternative health care, health status, values, and attitudes toward conventional medicine. Multiple logistic regression analyses were used in an effort to identify predictors of alternative health care use.Setting and Participants.— A total of 1035 individuals randomly selected from a panel who had agreed to participate in mail surveys and who live throughout the United States.Main Outcome Measure.— Use of alternative medicine within the previous year.Results.— The response rate was 69%.The following variables emerged as predictors of alternative health care use: more education (odds ratio [OR], 1.2; 95% confidence interval [CI], 1.1-1.3); poorer health status (OR, 1.3; 95% CI, 1.1-1.5); a holistic orientation to health (OR, 1.4; 95% CI, 1.1-1.9); having had a transformational experience that changed the person's worldview (OR, 1.8; 95% CI, 1.3-2.5); any of the following health problems: anxiety (OR, 3.1; 95% CI, 1.6-6.0); back problems (OR, 2.3; 95% CI, 1.7-3.2); chronic pain (OR, 2.0; 95% CI, 1.1-3.5); urinary tract problems (OR, 2.2; 95% CI, 1.3-3.5); and classification in a cultural group identifiable by their commitment to environmentalism, commitment to feminism, and interest in spirituality and personal growth psychology (OR, 2.0; 95% CI, 1.4-2.7). Dissatisfaction with conventional medicine did not predict use of alternative medicine. Only 4.4% of those surveyed reported relying primarily on alternative therapies.Conclusion.— Along with being more educated and reporting poorer health status, the majority of alternative medicine users appear to be doing so not so much as a result of being dissatisfied with conventional medicine but largely because they find these health care alternatives to be more congruent with their own values, beliefs, and philosophical orientations toward health and life. IN 1993 Eisenberg and colleagues1 reported that 34% of adults in the United States used at least 1 unconventional form of health care (defined as those practices "neither taught widely in U.S. medical schools nor generally available in U.S. hospitals") during the previous year. The most frequently used alternatives to conventional medicine were relaxation techniques, chiropractic, and massage. Although educated, middle-class white persons between the ages of 25 and 49 years were the most likely ones to use alternative medicine, use was not confined to any particular segment of the population. These researchers estimated that Americans made 425 million visits to alternative health care providers in 1990, a figure that exceeded the number of visits to allopathic primary care physicians during the same period. Recent studies in the United States2 and abroad3- 4 support the prevalent use of alternative health care. For example, a 1994 survey of physicians from a wide array of medical specialties (in Washington State, New Mexico, and Israel) revealed that more than 60% recommended alternative therapies to their patients at least once in the preceding year, while 38% had done so in the previous month.2 Forty-seven percent of these physicians also reported using alternative therapies themselves, while 23% incorporated them into their practices. When faced with the apparent popularity of unconventional medical practices and the fact that people seem quite willing to pay out-of-pocket for these services,1 the question arises: What are the sociocultural and personal factors (health status, beliefs, attitudes, motivations) underlying a person's decision to use alternative therapies? At present, there is no clear or comprehensive theoretical model to account for the increasing use of alternative forms of health care. Accordingly, the goal of the present study was to develop some tentative explanatory models that might account for this phenomenon. Three theories that have been proposed to explain the use of alternative medicine were tested: Dissatisfaction: Patients are dissatisfied with conventional treatment because it has been ineffective,5- 6 has produced adverse effects,6- 7 or is seen as impersonal, too technologically oriented, and/or too costly.6- 15Need for personal control: Patients seek alternative therapies because they see them as less authoritarian16 and more empowering and as offering them more personal autonomy and control over their health care decisions.14,16- 19Philosophical congruence: Alternative therapies are attractive because they are seen as more compatible with patients' values, worldview, spiritual/religious philosophy, or beliefs regarding the nature and meaning of health and illness.19- 24 In addition to testing the validity of these 3 theoretical perspectives, this study also sought to determine on an exploratory basis how the decision to seek alternative therapies is affected by patients' health status and demographic factors.
Article
Context Widespread use of herbal medications among the presurgical population may have a negative impact on perioperative patient care.Objectives To review the literature on commonly used herbal medications in the context of the perioperative period and provide rational strategies for managing their preoperative use.Data Sources The MEDLINE and Cochrane Collaboration databases were searched for articles published between January 1966 and December 2000 using the search terms herbal medicine, phytotherapy, and alternative medicine and the names of the 16 most commonly used herbal medications. Additional data sources were obtained from manual searches of recent journal articles and textbooks.Study Selection We selected studies, case reports, and reviews addressing the safety and pharmacology of 8 commonly used herbal medications for which safety information pertinent to the perioperative period was available.Data Extraction We extracted safety, pharmacodynamic, and pharmacokinetic information from the selected literature and reached consensus about any discrepancies.Data Synthesis Echinacea, ephedra, garlic, ginkgo, ginseng, kava, St John's wort, and valerian are commonly used herbal medications that may pose a concern during the perioperative period. Complications can arise from these herbs' direct and pharmacodynamic or pharmacokinetic effects. Direct effects include bleeding from garlic, ginkgo, and ginseng; cardiovascular instability from ephedra; and hypoglycemia from ginseng. Pharmacodynamic herb-drug interactions include potentiation of the sedative effect of anesthetics by kava and valerian. Pharmacokinetic herb-drug interactions include increased metabolism of many drugs used in the perioperative period by St John's wort.Conclusions During the preoperative evaluation, physicians should explicitly elicit and document a history of herbal medication use. Physicians should be familiar with the potential perioperative effects of the commonly used herbal medications to prevent, recognize, and treat potentially serious problems associated with their use and discontinuation. There is enormous public enthusiasm for herbal medications. Two recent surveys have found widespread use among the presurgical population.1- 2 Morbidity and mortality associated with herbal medications may be more likely in the perioperative period because of the polypharmacy and physiological alterations that occur.3 Such complications include myocardial infarction, stroke, bleeding, inadequate oral anticoagulation, prolonged or inadequate anesthesia, organ transplant rejection, and interference with medications indispensable for patient care. Of the herbal medications that clinicians are likely to encounter, we have identified 8 of the herbs that potentially pose the greatest impact to the care of patients undergoing surgery. These herbs account for more than 50% of all single herb preparations among the 1500 to 1800 herbal medications sold in the United States.4- 5 Nonherbal dietary supplements, such as vitamins, minerals, amino acids, and hormones, are beyond the scope of this review. Some of these nonherbal dietary supplements that patients undergoing surgery are most likely to take, such as glucosamine and chondroitin for osteoarthritis,6- 7 appear to be safe. Limited information is available, however, on the use of these supplements in the presurgical population. In this article, we consider safety and US regulatory issues for herbal medications; review the literature on the identified 8 commonly used herbal medications as they affect perioperative care; and propose rational strategies for managing the preoperative use of these agents. The prevention, recognition, and treatment of complications begin with explicitly eliciting and documenting a history of herbal medicine use. Familiarity with the scientific literature on herbal medications is necessary because the current US regulatory mechanism for commercial herbal preparations sold in the United States does not necessarily protect the population against unpredictable or undesirable effects. Our goal is to provide a framework for physicians practicing in the contemporary environment where widespread herbal medicine use occurs. PREOPERATIVE USE OF HERBAL MEDICATIONS ABSTRACT | PREOPERATIVE USE OF HERBAL MEDICATIONS | REGULATION AND SAFETY OF HERBAL MEDICATIONS | METHODS | RESULTS | COMMENT | REFERENCES The most extensive surveys on the use of complementary and alternative medicine use in the United States revealed that approximately 12% of the population used herbal medications in 1997,8- 9 representing a 380% increase from 1990. Patients undergoing surgery appear to use herbal medications significantly more frequently than the general population. For instance, Tsen et al1 reported that 22% of patients who underwent evaluation in their preoperative clinic took herbal medications. Also, Kaye et al2 found that 32% of patients in an ambulatory surgery setting admitted to using herbal medications. More than 70% of the patients in the study by Kaye et al2 failed to disclose their herbal medicine use during routine preoperative assessment. Explanations for this lack of disclosure include patient-held beliefs that physicians are not knowledgable about herbal medications or are prejudiced against their use.10 Some patients may fear admitting to their physicians their use of unconventional therapies.11 Others may neglect to mention that they are taking herbal medications when they are using them for reasons perceived as unrelated to their medical care.12 Still other patients would not consider these substances to be medications, and they may neglect to report them during routine preoperative questioning. For these reasons, it is necessary for physicians to specifically seek out a history of herbal medicine use in presurgical patients. REGULATION AND SAFETY OF HERBAL MEDICATIONS ABSTRACT | PREOPERATIVE USE OF HERBAL MEDICATIONS | REGULATION AND SAFETY OF HERBAL MEDICATIONS | METHODS | RESULTS | COMMENT | REFERENCES Herbal medications were classified as dietary supplements in the Dietary Supplement Health and Education Act of 1994.13 This law exempts herbal medications from the safety and efficacy requirements and regulations that prescription and over-the-counter drugs must fulfill (ie, preclinical animal studies, premarketing controlled clinical trials, or postmarketing surveillance). The burden is shifted to the US Food and Drug Administration to show that a product is unsafe before it can be removed from the market.14 In addition, the inability to patent herbal medications discourages the manufacturers from performing the costly research required for conventional drugs.15 The current US regulatory mechanism provides little assurance that commercial herbal preparations have predictable pharmacological effects and that product labels provide accurate information. The potency of herbal medications can vary from manufacturer to manufacturer and from lot to lot within a manufacturer.16- 18 Plants may be misidentified or deliberately replaced with cheaper or more readily available alternatives.19- 22 Moreover, herbal medications, especially those of Eastern origin, can be adulterated with heavy metals, pesticides, and even conventional drugs.23- 25 Some herbal manufacturers have tried to standardize their herbal products to fixed concentrations of selected chemical constituents.26 The benefit of this effort is uncertain, however, because many products achieve their effects through the combined or synergistic actions of different compounds.27 Even when advertised and labeled as standardized, potency can still vary considerably.28 Because there is no mechanism for postmarketing surveillance, the incidence and exact nature of adverse events is unknown. Empirical evidence gained from a long history of herbal medication use supports the notion that most are safe.29 Nevertheless, some of these medications have been associated with serious harm.30- 31 More than 5000 suspected herb-related adverse reactions were reported to the World Health Organization before 1996.32 Between January 1993 and October 1998, 2621 adverse events, including 101 deaths, associated with dietary supplements were reported to the US Food and Drug Administration.33 However, adverse events are underreported because there is no central mechanism for mandatory reporting as there is for conventional medications. Other factors that contribute to underreporting are that physicians do not always recognize adverse events associated with herbal medication use34 and that patients are reluctant to report and seek treatment for the adverse reactions.35 This reluctance has been attributed to the belief that physicians cannot be consulted in the use of unconventional therapies and that patients are unwilling to admit the use of these remedies to physicians. The deficiencies in monitoring adverse events for herbal medicines mean that safety profiles are usually limited to animal studies, case reports, or predictions derived from known pharmacological results.
Chapter
Background Osteoarthritis (OA) is the most common form of arthritis, and it is often associated with significant disability and an impaired quality of life. Objectives To review all randomized controlled trials (RCTs) evaluating the effectiveness and toxicity of glucosamine in OA. Search strategy We searched MEDLINE, PREMEDLINE, EMBASE, AMED, ACP Journal Club, DARE, CDSR, and the CCTR. We also wrote letters to content experts, and hand searched reference lists of identified RCTs and pertinent review articles. All searches were updated in January 2005. Selection criteria Relevant studies met the following criteria: 1) RCTs evaluating the effectiveness and safety of glucosamine in OA, 2) Both placebo controlled and comparative studies were eligible, 3) Both single blinded and double blinded studies were eligible. Data collection and analysis Data abstraction was performed independently by two investigators and the results were compared for degree of agreement. Gotzsche's method and a validated tool (Jadad 1996) were used to score the quality of the RCTs. Continuous outcome measures were pooled using standardized mean differences (SMD) as the measure of effect size. Dichotomous outcome measures were pooled using relative risk ratios (RR). Main results Analysis restricted to eight studies with adequate allocation concealment failed to show benefit of glucosamine for pain and WOMAC function. Collectively, the 20 analyzed RCTs found glucosamine favoured placebo with a 28% (change from baseline) improvement in pain (SMD - 0.61, 95% CI - 0.95, - 0.28) and a 21% (change from baseline) improvement in function using the Lequesne index (SMD - 0.51 95% CI - 0.96, - 0.05). However, the results are not uniformly positive, and the reasons for this remain unexplained. WOMAC pain, function and stiffness outcomes did not reach statistical significance. In the 10 RCTs in which the Rotta preparation of glucosamine was compared to placebo, glucosamine was found to be superior for pain (SMD - 1.31, 95% CI - 1.99, - 0.64) and function using the Lequesne index (SMD - 0.51, 95% CI - 0.96, - 0.05). Pooled results for pain (SMD - 0.15, 95% CI - 0.35, 0.05) and function using the WOMAC index (SMD 0.03, 95% CI - 0.18, 0.25) in those RCTs in which a non-Rotta preparation of glucosamine was compared to placebo did not reach statistical significance. In the four RCTs in which the Rotta preparation of glucosamine was compared to an NSAID, glucosamine was superior in two, and equivalent in two. Two RCTs using the Rotta preparation showed that glucosamine was able to slow radiological progression of OA of the knee over a three year period (SMD 0.24, 95% CI 0.04, 0.43). Glucosamine was as safe as placebo in terms of the number of subjects reporting adverse reactions (RR= 0.97, 95% CI, 0.88, 1.08). Authors' conclusion This update includes 20 studies with 2570 patients. Pooled results from studies using a non-Rotta preparation or adequate allocation concealment failed to show benefit in pain and WOMAC function while those studies evaluating the Rotta preparation show that glucosamine was superior to placebo in the treatment of pain and functional impairment resulting from symptomatic OA. WOMAC outcomes of pain, stiffness and function did not show a superiority of glucosamine over placebo for both Rotta and non-Rotta preparations of glucosamine. Glucosamine was as safe as placebo.
Article
A survey was sent to 1,000 United States (U.S.) pharmacists (19.7% responded) and 750 British pharmacists (63.0% responded) to assess their perceived knowledge, perceived usefulness, referrals, and utilization of alternative health approaches (AHA). More than 50% of U.S. and British citizens had 'never heard of' or 'only heard of' about half of the 21 AHA assessed. Acupuncture was the AHA felt to be most useful by the majority of pharmacists, both in the U.S. (83.8%) and in Britain (91.0%). Osteopathy (38.6%) and chiropractic (33.5%) were most often referrals by U.S. pharmacists, whereas homeopathy (14.7%) and osteopathy (14.5%) were most often referrals by British pharmacists. The most utilized AHAs were osteopathy (21.8%) and chiropractic (19.3%) by U.S. pharmacists and homeopathy (10.1%) and herbal medicine (6.0%) by British pharmacists. Differences exist in the perceived knowledge, perception of usefulness, referrals, and utilization of AHAs between U.S. and British pharmacists. It is quite likely that the low-response rates, particularly among the U.S. pharmacists, may mask even greater ignorance about AHAs. It may also underestimate the proportion of pharmacists who are of the view that AHAs are useless and not worthy of answering questions about.
Article
A survey was sent to 1,000 pharmacists in metropolitan Detroit U.S.A. (19.7% responded) and 750 pharmacists in the U.K. (57.9% responded) to assess the frequency of recommendations for health food stores, minerals, multivitamins, natural vitamins, protein supplements, Stresstabs, and weight-reduction products. Pharmacists were also asked about their five most common reasons for recommending vitamins and minerals from a list of 16 items, which included alcoholism, anaemia, arthritis, athletically active, children, colds, dieting, fatigue, feeling nervous, headaches, old age, pain, pregnancy, prophylaxis, skin problems, stress or other. About 40% of the U.S.A. community pharmacists recommended multivitamins more than five times a week compared to 28.6% of U.K. community pharmacists. Anaemia (48.6%), dieting (44.8%), alcoholism (42.3%), pregnancy (40.0%), and fatigue (36.8%) were the five most common reasons for pharmacists to recommend vitamins and minerals, this was consistent, for the most part, with the American Medical Association's Council on Scientific Affairs report, however, a large number of pharmacists placed the non-specific symptoms of fatigue and stress in the five most common reasons for which they recommend vitamins or minerals.
Article
Research both in the United States and abroad suggests that significant numbers of people are involved with various forms of alternative medicine. However, the reasons for such use are, at present, poorly understood. To investigate possible predictors of alternative health care use. Three primary hypotheses were tested. People seek out these alternatives because (1) they are dissatisfied in some way with conventional treatment; (2) they see alternative treatments as offering more personal autonomy and control over health care decisions; and (3) the alternatives are seen as more compatible with the patients' values, worldview, or beliefs regarding the nature and meaning of health and illness. Additional predictor variables explored included demographics and health status. A written survey examining use of alternative health care, health status, values, and attitudes toward conventional medicine. Multiple logistic regression analyses were used in an effort to identify predictors of alternative health care use. A total of 1035 individuals randomly selected from a panel who had agreed to participate in mail surveys and who live throughout the United States. Use of alternative medicine within the previous year. The response rate was 69%. The following variables emerged as predictors of alternative health care use: more education (odds ratio [OR], 1.2; 95% confidence interval [CI], 1.1-1.3); poorer health status (OR, 1.3; 95% CI, 1.1-1.5); a holistic orientation to health (OR, 1.4; 95% CI, 1.1-1.9); having had a transformational experience that changed the person's worldview (OR, 1 .8; 95% CI, 1 .3-2.5); any of the following health problems: anxiety (OR, 3.1; 95% CI, 1.6-6.0); back problems (OR, 2.3; 95% CI, 1 .7-3.2); chronic pain (OR, 2.0; 95% CI, 1.1 -3.5); urinarytract problems (OR, 2.2; 95% CI, 1.3-3.5); and classification in a cultural group identifiable by their commitment to environmentalism, commitment to feminism, and interest in spirituality and personal growth psychology (OR, 2.0; 95% CI, 1.4-2.7). Dissatisfaction with conventional medicine did not predict use of alternative medicine. Only 4.4% of those surveyed reported relying primarily on alternative therapies. Along with being more educated and reporting poorer health status, the majority of alternative medicine users appear to be doing so not so much as a result of being dissatisfied with conventional medicine but largely because they find these health care alternatives to be more congruent with their own values, beliefs, and philosophical orientations toward health and life.
Article
Herbal medicine is increasing in popularity in the United States. The market continues to grow, with a presence being established for commercially-prepared herbal products in community pharmacies throughout the nation. This survey was conducted to describe that presence in pharmacies and to describe pharmacists' perceptions of this product class. A response rate of 26.3% (n = 512) was achieved for a five-page mail survey sent to a geographically stratified random sample of community pharmacies in the United States. Approximately 73% of pharmacists responding indicated that their pharmacy carried commercially-prepared herbal products. Attitudinal items were included to measure pharmacists' perceptions toward these products, as those perceptions have the potential to influence attitudes and subsequently behavior (such as clinical involvement with patients wishing to integrate herbal products into an existing regimen). Pharmacists, on average, did not believe that herbal products are well standardized, or that the products are well accepted by the Food and Drug Administration or the National Association of Boards of Pharmacy. Much potential exists for pharmacists to fill a role as information provider to patients who self-medicate with herbal medicines; must their perceptions of the product class be changed first?
Article
To describe Victorian general practitioners' attitudes towards and use of a range of complementary therapies. A self-administered postal survey sent to a random sample of 800 general practitioners (GPs) in Victoria in July 1997. 488 GPs (response rate, 64%). GPs' knowledge; opinions about harmfulness and effectiveness; appropriateness for GPs to practise; perceived patient demand; need for undergraduate education; referral rates to complementary practitioners; and training in and practice of each therapy. Acupuncture, hypnosis and meditation are well accepted by the surveyed GPs, as over 80% have referred patients patients to practitioners of these therapies and nearly half have considered using them. General practitioners have trained in various therapies--meditation (34%), acupuncture (23%), vitamin and mineral therapy (23%), hypnosis (20%), herbal medicine (12%), chiropractic (8%), naturopathy (6%), homoeopathy (5%), spiritual healing (5%), osteopathy (4%), aroma-therapy (4%), and reflexology (2%). A quarter to a third were interested in training in chiropractic, herbal medicine, naturopathy and vitamin and mineral therapy. General practitioners appear to underestimate their patients' use of complementary therapies. There is evidence in Australia of widespread acceptance of acupuncture, meditation, hypnosis and chiropractic by GPs and lesser acceptance of the other therapies. These findings generate an urgent need for evidence of these therapies' effectiveness.
Article
This systematic review aimed to assess the effects of Serenoa repens in the treatment of Benign Prostatic Hyperplasia (BPH). Trials were searched in computerized general and specialized databases (MEDLINE, EMBASE, Cochrane Library, Phytodok), by checking bibliographies, and by contacting manufacturers and researchers. Trials were eligible if they (1) randomized men with BPH to receive preparations of Serenoa repens (alone or in combination) in comparison with placebo or other BPH medications, and (2) included clinical outcomes such as urologic symptom scales, symptoms, or urodynamic measurements. Eligibility was assessed by at least two independent observers. Information on patients, interventions, and outcomes was extracted by at least two independent reviewers using a standard form. The main outcome measure for comparing the effectiveness of Serenoa repens with placebo or other BPH medications was the change in urologic symptom scale scores. Secondary outcomes included changes in nocturia and urodynamic measures. The main outcome measure for side effects was the number of men reporting side effects. 2939 men from18 randomized trials lasting 4 to 48 weeks were assessed. 16 trials were double-blinded and treatment allocation concealment was adequate in 9 studies. Compared with placebo, Serenoa repens improved urinary symptom scores, symptoms, and urinary flow measures. The weighted mean difference (WMD) for the urinary symptom score was -1.41 points (scale range 0-19), (95%CI = -2.52, -0.30, n = 1 study) and the risk ratio (RR) for self rated improvement was 1.75 (95%CI = 1.21, 2.54, n = 6 studies). The WMD for nocturia was -0.76 times per evening (95%CI = -1.22, -0.32; n = 10 studies). The WMD for peak urine flow was 1.93 ml/sec (95%CI = 0.72, 3.14, n = 8 studies). Compared with finasteride, Serenoa repens produced similar improvements in urinary symptom scores (WMD = 0.37 IPSS points (scale range 0-35), 95%CI = -0.45, 1.19, n = 2 studies) and peak urine flow (WMD = -0.74 ml/sec, 95%CI = -1.66, 0.18, n = 2 studies). Adverse effects due to Serenoa repens were mild and infrequent. Withdrawal rates in men assigned to placebo, Serenoa repens or finasteride were 7%, 9%, and 11%, respectively. The evidence suggests that Serenoa repens improves urologic symptoms and flow measures compared with placebo. Serenoa repens produced similar improvement in urinary symptoms and flow compared to finasteride and is associated with fewer adverse treatment events. The long term effectiveness, safety and ability to prevent BPH complications are not known.
Article
The use and sales of herbal medications have increased dramatically over the past several years. Pharmacists are in an ideal position to educate patients about herbal medicines. This study was intended to determine the knowledge and attitudes of pharmacists regarding herbal medications. A survey was distributed to pharmacists at several state and regional meetings in Virginia and North Carolina between August and October 1998. The survey evaluated demographic data, attitudinal scales, and a 15-item herbal medicine knowledge test. Pharmacists immediately returned the surveys to the distributor on completion. Of the 217 surveys distributed, 164 met the inclusion criteria for further evaluation. Of the pharmacists surveyed, 68.0% practiced in a community pharmacy, 45.1% had previous continuing education on herbal medications, and 73.6% sold herbal medications in their practice settings. The average score on the herbal knowledge test was 6.3 (maximum score of 15). Pharmacists with previous continuing education scored significantly higher than those without prior continuing education (p < 0.001). Of the 15 questions, the five that pharmacists were most likely to answer correctly assessed the uses of herbal medications. Additionally, pharmacists with prior continuing education or with access to herbal medication information at their practice site were more likely to agree that providing information about herbal medication is a pharmacist's professional responsibility (p = 0.02 and p = 0.01, respectively). The findings from this study demonstrate that pharmacists were more likely to answer correctly about the uses of herbal medications than about drug interactions, adverse drug effects, and precautions of herbal medications. Additionally, pharmacists with previous continuing education on herbal medications were more knowledgeable about these products. With the increasing use of herbal medications, there is a greater need for pharmacy training programs in this area.
Article
A dramatic increase in the use of complementary and alternative medicines has been observed. The use of such remedies in the presurgical population has implications for the anesthesiologist because of the potential for drug interactions, side effects, and medical liability. This study was undertaken to quantify the use of herbal remedies and vitamins in the presurgical population of a large tertiary care center. A one-page questionnaire was distributed to all patients presenting for evaluation in the preoperative clinic over an 11-week period. Patients answered questions regarding use of prescription and nonprescription medications, herbal remedies, and vitamins. Twenty-two percent of presurgical patients reported the use of herbal remedies, and 51% used vitamins. Women and patients aged 40-60 yr were more likely to use herbal medicines. Over-the-counter medication use was strongly associated with herbal preparation use. The most commonly used compounds, from highest to lowest, included echinacea, gingko biloba, St. John's wort, garlic, and ginseng. Alternative medicine use is common in the preoperative period.
Article
Herbal dietary supplements represent a potential and possibly an overlooked cause for drug interactions in transplant recipients. Two patients are reported which suggest that St. John's Wort (SJW) may induce cytochrome P-450 3A4 activity and/or P-glycoprotein expression. Both of these mechanisms are significantly involved in the metabolism and absorption of cyclosporine (CSA) and other immunosuppressants. After two renal transplant recipients started self-medicating with SJW, their CSA concentrations were consistently documented to be subtherapeutic. While on SJW, one patient developed acute graft rejection due to low CSA concentrations. In both patients, termination of SJW returned their CSA concentrations to therapeutic values. Patients taking SJW concomitantly with CSA or other medications whose absorption and metabolism are mediated by cytochrome P-450 and/or P-glycoprotein should require close monitoring. Potential herb-prescription drug interactions are not just limited to SJW. Inquiries regarding the usage of herbal supplements should be an integral component of a transplant recipient's medication history.
Article
Widespread use of herbal medications among the presurgical population may have a negative impact on perioperative patient care. To review the literature on commonly used herbal medications in the context of the perioperative period and provide rational strategies for managing their preoperative use. The MEDLINE and Cochrane Collaboration databases were searched for articles published between January 1966 and December 2000 using the search terms herbal medicine, phytotherapy, and alternative medicine and the names of the 16 most commonly used herbal medications. Additional data sources were obtained from manual searches of recent journal articles and textbooks. We selected studies, case reports, and reviews addressing the safety and pharmacology of 8 commonly used herbal medications for which safety information pertinent to the perioperative period was available. We extracted safety, pharmacodynamic, and pharmacokinetic information from the selected literature and reached consensus about any discrepancies. Echinacea, ephedra, garlic, ginkgo, ginseng, kava, St John's wort, and valerian are commonly used herbal medications that may pose a concern during the perioperative period. Complications can arise from these herbs' direct and pharmacodynamic or pharmacokinetic effects. Direct effects include bleeding from garlic, ginkgo, and ginseng; cardiovascular instability from ephedra; and hypoglycemia from ginseng. Pharmacodynamic herb-drug interactions include potentiation of the sedative effect of anesthetics by kava and valerian. Pharmacokinetic herb-drug interactions include increased metabolism of many drugs used in the perioperative period by St John's wort. During the preoperative evaluation, physicians should explicitly elicit and document a history of herbal medication use. Physicians should be familiar with the potential perioperative effects of the commonly used herbal medications to prevent, recognize, and treat potentially serious problems associated with their use and discontinuation.
Article
Evidence supports the fact that alternative medical therapies play an increasingly prominent role in healthcare. Relevantly, this study posed three questions: (1) Do physicians ask their patients about their use of herbs/dietary supplements? (2) Do physicians use the available resources to evaluate the possible drug interactions and/or side effects of the dietary supplements? and (3) Are physicians aware of the side effects, drug interactions and contraindications of ten commonly used herbs? A questionnaire was randomly distributed to medical students and faculty of the State University of New York, Health Science Center at Brooklyn. One hundred sixty five surveys were returned out of 193 handed out (85%). Analysis revealed that although many physicians asked their patients about their use of alternative remedies, most do not check the remedies in a reference text. Age and training were negatively correlated in a statistically significant manner with (1) the likelihood of a physician prescribing alternative medicines; (2) checking the side effects and drug interactions of over the counter and prescription medications in a reference text; (3) asking patients specifically about alternative medicines; and (4) checking the side effects and drug interactions of alternative remedies in a reference text. In a question matching ten herbs and side-effects, the highest score was six out of ten correct and the average number correct was 1.32 with a standard deviation of 1.39. Clearly, physicians may be aware of different forms of alternative medicines. However, physicians are still not treating herbs in the same manner as other types of medications. There is no doubt that patient care would be greatly enhanced if physicians educated themselves and stayed in touch with their patients' beliefs and health care behavior.
Article
To survey pharmacists about personal/professional practices regarding dietary supplements, specifically personal use and recommendation patterns, reference usage, and desired computerized decision-support features. Anonymous, self-administered survey. National pharmacy association meeting. Practicing pharmacists who answered questions about dietary supplements. Acceptability of specific references, desired features in computerized decision support, frequency of personal use, and recommendations to patients, family, or friends. 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. 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.
Article
Benign prostatic hyperplasia (BPH), nonmalignant enlargement of the prostate, can lead to obstructive and irritative lower urinary tract symptoms (LUTS). The pharmacologic use of plants and herbs (phytotherapy) for the treatment of LUTS associated with BPH has been growing steadily. The extract of the African prune tree, Pygeum africanum, is one of the several phytotherapeutic agents available for the treatment of BPH. To investigate the evidence whether extracts of Pygeum africanum (1) are more effective than placebo in the treatment of Benign Prostatic Hyperplasia (BPH), (2) are as effective as standard pharmacologic BPH treatments, and (3) have less side effects compared to standard BPH drugs. Trials were searched in computerized general and specialized databases (MEDLINE (1966-2000), EMBASE, Cochrane Library, Phytodok), by checking bibliographies, and by contacting relevant manufacturers and researchers. Trials were eligible if they (1) were randomized (2) included men with BPH (3) compared preparations of Pygeum africanum (alone or in combination) with placebo or other BPH medications (4) included clinical outcomes such as urologic symptom scales, symptoms, or urodynamic measurements. Eligibility was assessed by at least two independent observers. Information on patients, interventions, and outcomes were extracted by at least two independent reviewers using a standard form. The main outcome measure for comparing the effectiveness of Pygeum africanum with placebo and standard BPH medications was the change in urologic symptoms scale scores. Secondary outcomes included change in urologic symptoms including nocturia and urodynamic measures (peak and mean urine flow, prostate size). The main outcome measure for adverse effects was the number of men reporting adverse effects. A total of 18 randomized controlled trials involving 1562 men met inclusion criteria and were analyzed. Only one of the studies reported a method of treatment allocation concealment, though 17 were double-blinded. There were no studies comparing Pygeum africanum to standard pharmacologic interventions such as alpha-adrenergic blockers or 5-alpha reductase inhibitors. The mean study duration was 64 days (range, 30-122 days). Many studies did not report results in a method that permitted meta-analysis. Compared to men receiving placebo, Pygeum africanum provided a moderately large improvement in the combined outcome of urologic symptoms and flow measures as assessed by an effect size defined by the difference of the mean change for each outcome divided by the pooled standard deviation for each outcome (-0.8 SD [95% confidence interval (CI), -1.4, -0.3 (n=6 studies)]). Men using Pygeum africanum were more than twice as likely to report an improvement in overall symptoms (RR=2.1, 95% CI = 1.4, 3.1). Nocturia was reduced by 19%, residual urine volume by 24% and peak urine flow was increased by 23%. Adverse effects due to Pygeum Africanum were mild and comparable to placebo. The overall dropout rate was 12% and was similar between Pygeum Africanum (13%), placebo (11%) and other controls (8%). A standardized preparation of Pygeum africanum may be a useful treatment option for men with lower urinary symptoms consistent with benign prostatic hyperplasia. However, the reviewed studies were small in size, were of short duration, used varied doses and preparations and rarely reported outcomes using standardized validated measures of efficacy. Additional placebo-controlled trials are needed as well as studies that compare Pygeum africanum to active controls that have been convincingly demonstrated to have beneficial effects on lower urinary tract symptoms related to BPH. These trials should be of sufficient size and duration to detect important differences in clinically relevant endpoints and use standardized urologic symptom scale scores.
Article
The purpose of this study was to measure trends in the prevalence and cost of alternative medicines and alternative practitioner use in an Australian population and to obtain a profile of users and their beliefs. In 2000, we repeated a 1993 representative population survey of persons ages 15 years or older living in South Australia, which provided 3,027 personal interviews. We assessed the rates of use, types of alternative medicine and therapists, costs, and beliefs of users and nonusers. Comparisons in usage patterns with the 1993 survey were also made. In 2000, the overall use of at least one nonmedically prescribed alternative medicine (excluding calcium, iron, and prescribed vitamins) was 52.1% (CI +/- 1.8). Users were more likely to be female, be better educated, have a higher income, and be employed. Since 1993, females were using significantly more herbal medicines, ginseng, Chinese medicines, and aromatherapy oils. Many were self-prescribed. Among users, 57.2% (CI +/- 1.2) did not tell their doctor. In 2000, 23.3% of respondents had visited at least one alternative practitioner with increasing use of acupuncturists, reflexologists, aromatherapists, and herbal therapists. Most thought alternative medicines were safe but thought they were, or should be, subject to the same standards as prescribed medicines. Among respondents, 92.9% wished product information to be of standard and content similar to those supplied with pharmaceuticals. Extrapolation of the costs to the Australian population gives an expenditure on alternative therapies in 2000 of $AUD2.3 billion and for the U.S. population an annual expenditure of $US34 billion. In Australia this represents a 120 and 62% increase in the cost of alternative medicines and therapists, respectively, since 1993. In 2000 expenditure on alternative therapies was nearly four times the public contribution to all pharmaceuticals. The public appears to have ambivalent standards for alternative therapies but wishes to be empowered with accurate information to facilitate self-prescription. The public health ramifications of an expanding alternative medicine industry are great.
Article
This national multisite study examined complementary and alternative medicine (CAM) use by surgical patients during the two weeks preceding their surgery. A simple descriptive design consisting of anonymous self-report questionnaires was used to measure CAM use and determine participant demographics. A purposive sample of adult, English-speaking, elective outpatients from 16 hospitals representing seven US regions was used. Data were collected randomly at each site. Sixty-seven percent of participants disclosed use of all types of CAM; 27% consumed herbs, 39% used dietary supplements, 54% took vitamins, and 1% reported use of homeopathics. Thirty-four percent of participants reported using CAMs that potentially can interact with anesthetics and inhibit coagulation. The results of this study suggest that perioperative nurses should encourage patients to disclose CAM use and should educate patients about anesthetic interactions that may contribute to bleeding.
Article
To determine the patterns of use, knowledge, and attitudes toward complementary and alternative medicine (CAM) among pharmacists. Anonymous self-administered survey. 61st International Congress of International Pharmaceutical Federation (FIP), Singapore Traditional Chinese Medicine (TCM) Research Symposium, and retail and hospital pharmacies in Singapore. Pharmacists attending the FIP Congress, TCM Symposium, and pharmacists working in retail and hospital pharmacies. Frequency of use of different types of CAM by demographic attributes, knowledge scores, and attitudinal scores. Of the 430 surveys received, 420 fit the criteria for inclusion. Of the pharmacists, 84.3% reported use of some form of CAM in their lifetime. CAM was used for chronic and acute conditions. There was no difference in use of CAM based on gender and income. The mean score on the knowledge test was 7.23 of 10. Of the pharmacists, 72.6% were moderately satisfied with CAM and 79.4% indicated they would recommend CAM to family and friends. They received information on CAM from books/magazines (64%), friends/family (35.7%), and the Internet (31.4%). Eighty-one percent (81%) of pharmacists felt they had inadequate skills and knowledge to counsel patients on herbal medicine and 90.5% felt the professional curricula should have more components on CAM. The use of CAM among pharmacists is widespread and prevalent. The increased use of CAM necessitates the need for more education. Pharmacists acknowledge that CAM may have a place in health care and accept their role as information providers. There is also a need for reliable sources of information on CAM.
Article
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. Descriptive study. Minnesota. Cross-sectional questionnaire mailed in June 2000. A random sample of 1,017 pharmacists with active Minnesota licenses. 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. 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.
Article
Despite substantial growth in the use of complementary medicine, no comprehensive national study has been undertaken of the naturopathic and Western herbal medicine component of the healthcare workforce in Australia. This study aimed to examine the nature of these practices and this currently unregulated workforce in Australia. A comprehensive survey questionnaire was developed in consultation with the profession and distributed nationally to all members of the naturopathic and Western herbal medicine workforce. The practices of herbal medicine and naturopathy make up a sizeable component of the Australian healthcare sector, with approximately 1.9 million consultations annually and an estimated turnover of $AUD 85 million in consultations (excluding the cost of medicines). A large proportion of patients are referred to practitioners by word of mouth. Up to one third of practitioners work in multidisciplinary clinics with other registered sectors of the healthcare community. The number of adverse events associated with herbal medicines, nutritional substances and homoeopathic medicines recorded in Australia is substantial and the types of events reported are not trivial. Data suggest that practitioners will experience one adverse event every 11 months of full-time practice, with 2.3 adverse events for every 1000 consultations (excluding mild gastrointestinal effects). These data confirm the considerable degree of utilisation of naturopathic and Western herbal medicine practitioners by the Australian public. However, there is a need to examine whether statutory regulation of practitioners of naturopathy and Western herbal medicine is required to better protect the public.
Article
Many people use complementary or alternative medicine (CAM). It is estimated that over 50% of patients that require health care use CAM either in conjunction with, or separate from, conventional health care. Despite the popular use of CAM, patients do not always inform their conventional medicine health carers of their CAM use. The medical practitioner is in most cases the first health care professional a person contacts concerning a health care matter, and needs to have a full history of a health problem to understand and provide optimum care. This literature review aims to provide an understanding of the degree to which patients disclose their use of CAM to their medical practitioners, and their reasons for not doing so. A comprehensive literature search identified 12 studies published between 1993 and 2002 that examined what percentage of consumers did not disclose to their medical practitioners their use of CAM, and their reasons for not doing so. The rate of non-disclosure of those using CAM is as high as 77% in some studies. The main reasons patients provided for not disclosing their use of CAM to their medical practitioners were concerns about a negative response by the practitioners, the belief that the practitioner did not need to know about their CAM use, and the fact that the practitioner did not ask. The pre-conceptions patients have that influence their non-disclosure may be based on three issues. First, beliefs and concerns that influence their decision-making, second personal experiences in their consultations with medical practitioners, and third, the desire for more control over their health care. Medical practitioners need to acknowledge the concerns and beliefs of patients in making their health care decisions, and work with patients so that the use of CAM is acknowledged and the patients' needs, beliefs and concerns respected.
Article
To assess actions of community pharmacists in response to their patients' concurrent use of prescription medications and complementary and alternative medicine (CAM). Nonexperimental, cross-sectional mail survey. Texas. 107 community pharmacists. Not applicable. Pharmacists' self-reported rate of patient inquiry about CAM use and actions taken in response to CAM use. 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. 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.
Article
There has been a definite increase in the popularity and use of complementary and alternative medicines, including herbal medicines, in the last ten years. The aim of this study was to determine the prevalence and patterns of use of herbal medicines and vitamin supplements by patients in the preoperative period. A questionnaire was offered to all patients attending the pre-admission clinics at St. Vincent's Hospital and Box Hill Hospital, Melbourne, over an eight-month period in 2002. In all, 1102 questionnaires were completed (91.8% response rate). The prevalence of herbal medicine use was 14.3%, with an average user age of 54.0 years and 61.4% female predominance. The five most popular herbs were Garlic, Evening Primrose, Gingko, St. John's Wort and Echinacea. The commonest reasons for herbal medicine use were acute and chronic medical conditions. 63.2% of patients had self-prescribed. 27.8% of herbal remedy users had informed the hospital doctors and 41.8% had notified their general practitioner. The prevalence of vitamin supplement use was 20.4%, with an average user age of 54.8 years and 66.2% female predominance. The five most popular vitamins were multivitamins, followed by vitamin B, C, E and D. The commonest reasons for vitamin use were maintenance of general well-being and health. The use of herbal medicines and vitamin supplements preoperatively by patients is common. Clinicians should endeavour to familiarize themselves with the more popular and significant herbal medications and, as part of the routine preoperative assessment, ask all their patients about their consumption of herbal remedies.
Article
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. To determine the knowledge and attitudes of pharmacists toward CAM. An anonymous, self-administered questionnaire was designed and mailed to 1500 randomly selected pharmacists in New South Wales, Australia. 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. 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.
Article
Due to the growing use of herbals and other dietary supplements healthcare providers and consumers need to know whether problems might arise from using these preparations in combination with conventional drugs. However, the evidence of interactions between natural products and drugs is based on known or suspected pharmacologic activity, data derived from in vitro or animal studies, or isolated case reports that frequently lack pertinent information. The usefulness of such information is questionable. More recently an increasing number of documented case reports, in vivo studies, and clinical trials have evaluated herbal-drug interactions. Results have sometimes been contradictory and more research is needed. Since there is a lack of rigorous studies that can establish the clinical significance of herb-drug interactions, an evidence-based evaluation of the current literature concerning commonly used herbal-drug interactions, as well as other dietary supplements, was conducted.
Article
To study the perceptions and attitudes of primary care physicians concerning their patients' use of complementary medicine. A questionnaire was distributed to all 165 primary care physicians attending a routine continuing-medicine education program. Items included physicians' estimated rates of patient utilization of complementary medicine or herbal remedies and of patient reportage of such use; physicians' knowledge about side effects and interactions of herbal remedies; and frequency with which physicians questioned their patients on the use of complementary medicine and herbal remedies. The compliance rate was 90.0% (n=150). Sixty-eight percent of physicians estimated that up to 15% of their patients use complementary medicine; 58% always or often asked their patients about it; 50% estimated that 10% of patients report use of complementary medicine, and 60% estimated the same rate for herbal remedies; 51% believed that herbal remedies have no or only mild side effects; more than 70% claimed that they had little or no knowledge about what herbal remedies are; 24% never referred patients for complementary medicine, and 69% did so occasionally. Twenty-five percent had some training in complementary medicine, and 31% practiced some kind of complementary medicine. Most of the physicians believed that people turn to alternative methods when they are dissatisfied with conventional medicine. Physicians underestimate the rate of complementary medicine use by patients, suggesting that many patients do not report such use to their physician. Since alternative treatments are potentially harmful and may interact with conventional medications, physicians should be encouraged to communicate with patients about complementary medicine in general and herbal remedies in particular, and they should regularly include questions about their use when taking histories. They should also inform themselves about risks of alternative treatments particularly with herbal remedies, and have access to appropriate information systems.
The integration of complementary therapies in Australian general practice: results of a national survey Received: 16 August 2006 Revisions requested after external review: 16 November 2006 Revised version received
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Cohen MM, Penman S, Pirotta M, Da Costa C. The integration of complementary therapies in Australian general practice: results of a national survey. J Altern Complement Med 2005; 11: 995-1004. Received: 16 August 2006 Revisions requested after external review: 16 November 2006 Revised version received: 24 July 2007 Accepted: 19 August 2007
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Pharmacy labour force to Canberra: Australia Institute of Health and Welfare
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Pharmacists' knowledge and attitudes toward herbal medicine
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Pharmacists' patterns of use, knowledge, and attitudes toward complementary and alternative medicine
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A Mac Donald R Serenoa repens for benign prostatic hyperplasia Cochrane Database Syst Rev
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