Top Counseling Points on Natural Therapies

A common theme we see in the community pharmacy is patients wanting to treat their symptoms or their condition using natural therapies. In fact, the natural and alternative medicine market has grown quite large, with sales exceeding $7 billion in 2016.¹ With that being said, here are my top tips on discussing natural and alternative therapies with your patients:

• Clarify the patient’s interpretation of ‘natural’ or ‘alternative.’ Is penicillin a natural and alternative therapy? How about lithium carbonate? After all, both are found in nature and lithium is just a naturally occurring element; in fact, natural food stores also sell lithium in a different salt form. Also, if those are natural, what about medications that are minimally modified, like ampicillin or simvastatin? What about arteminisin, the antimalarial that was first discovered in an ancient Chinese medication reference? Or Prialt (ziconatide), which was developed from the venom of the cone snail?^2,3 The point is, where the line is drawn on "natural" versus "synthetic" is going to depend on the person, and so when someone is looking for a natural therapy it is an important distinction to clarify with them. This might also be a good time to discuss their prescription medications with them. Maybe they don’t know that it is in fact a natural product or at least derived from a natural product; if they knew, those patients might feel more comfortable taking it.
• Although many natural therapies are effective, being natural is unrelated to efficacy. Many natural therapies are effective when used in the right patient; many are prescription and some are over the counter. For example, in another Pharmacy Times article³, black elderberry was discussed as a potential treatment for influenza. There is actually some evidence that it is effective, and because it is not harmful, it seems reasonable for patients with influenza to take the supplement. While I would never recommend they take it in place of Tamiflu, they certainly could take it in addition to their Tamiflu regimen. There of course isn’t any evidence that it is effective as an adjunctive therapy to Tamiflu, but the only risk is the patient wasting the $15 the supplement costs. As with any other treatment, our job is to help the patient learn the potential benefits and potential risks and allow them to make their own decision about their treatment.
• Natural does not mean safe. Just because something is being advertised as "natural," "holistic," or "alternative" does not mean it is safe for them or even safe at all. Even something as innocuous sounding as calcium supplementation is now being called into question due to lack of evidence that it prevents fractures in post-menopausal women and some concerns over whether it could contribute to heart disease. Although most recent evidence suggests it might not, the lack of benefit with calcium and any potential for risk means that we should think twice before recommending it and certainly include their physician in that discussion.^5,6,7
• When they find a supplement that is right for them, be sure it is USP verified. Unfortunately, a lot of the bottles on the shelf have substances in them that are not on the label and/or do not contain the substance in the stated amount. In New York, for example, the Board of Pharmacy ordered multiple retailers to remove supplements from their shelf after hiring an independent lab for verification and discovering that the majority of them did not match the label and could contain dangerous fillers and ingredients that were not listed.⁸ USP verification matters and should be recommended whenever possible.
• Many nonpharmacologic therapies are safe, effective, and free of side effects. Many patients seem to go to therapies they view as natural because they are scared of taking medications or feel that because they ‘need medicine’ that they are becoming older, sicker, etc. In addition to encouraging them to take the medication (ex. “they are both pills you’ll have to take—why don’t you take the one your doctor prescribed?”), this is a good time to remind them of things they can do that are not ‘pills they have to take.’ Swimming, biking, and other exercises can help with pain control, diabetes, high blood pressure, and depression; eating a healthy diet can help with many of those conditions; and there is some evidence that acupuncture can help with chronic pain.⁹ This is a good time to bring these things up with the patient.
• If there is a supplement that is effective and a good choice for them—recommend it! It doesn’t make sense to be ‘for’ or ‘against’ natural therapies—it’s not a religion to believe in, but rather additional treatment options that need to be scrutinized and matched to the appropriate patients, just like every other therapy on the market. When it seems like a good choice for the patient, don’t hesitate to recommend it based on whether or not it is natural.

References:

• US sales of herbal supplements increase by 7.7% in 2016 [news release]. American Botanical Council website. Sep. 7, 2017. Accessed online March 2, 2018 at: http://cms.herbalgram.org/press/2017/USSalesofHerbalSupplementsIncreaseby77percentin2016.html.
• Tu Y. The discovery of arteminisin (qinghaosu) and gifts from Chinese medicine. Nat Med. 2011; 17(10):1217-1220.
• Ziconotide: a review of its pharmacology and use in the treatment of pain. Neuropsychiatr Dis Treat 2007;3(1): 69—85.
• Sibley C. Elderberries: a potent cold and flu remedy? Pharmacy Times 2017; Accessed online March 2, 2018 at http://www.pharmacytimes.com/contributor/cate-sibley-pharmd/2017/10/elderberries-a-potent-cold-and-flu-remedy.
• Calcium supplements may damage the heart. Johns Hopkins Medicine 2016; Accessed online March 2, 2018 at https://www.hopkinsmedicine.org/news/media/releases/calcium_supplements_may_damage_the_heart.
• Calcium and heart disease: what is the connection? Harvard Heart Letter 2017; Accessed online March 2, 2018 at https://www.health.harvard.edu/heart-health/calcium-and-heart-disease-what-is-the-connection
• Bolland M, Leung W, Tai V, et al. Calcium intake and risk of fracture: a systematic review. BMJ. 2015. 351: h4580.
• O’Connor A. New York attorney general targets supplements at major retailers. The New York Times. 2015; Accessed online March 2, 2018 at https://well.blogs.nytimes.com/2015/02/03/new-york-attorney-general-targets-supplements-at-major-retailers.
• Pendick D. Acupuncture is worth a try for chronic pain. Harvard Health Blog. 2013; Accessed online March 2, 2018 at https://www.health.harvard.edu/blog/acupuncture-is-worth-a-try-for-chronic-pain-201304016042.