A 43-year-old patient with well-controlled blood pressure replaced her prescriptions with a cheaper herbal treatment, a liquid containing an extract from a small fruit-bearing tree known as zapote blanco. Four months later, she ended up in an El Paso emergency room with stage IV hypertension.
This is just one of the cases that University of Texas at Austin College of Pharmacy experts follow as the economy sours and more and more people turn to over-the-counter (OTC) drugs and alternative medicines such as herbals to treat their illnesses--sometimes putting their health at risk.
It's all out there. Chinese herbal medicine in cancer care, glucosamine and chondroitin for arthritis, fish oil and St. John's wort for depression, Ginkgo biloba for memory enhancement and ginseng for stress and fatigue. And, of course, a staggering number of OTC drugs to help everything from headaches to insomnia to insect bites.
"Sufferers of various ailments are reaching for these products because of the painful economic downturn, an increased availability of non-prescription drugs as well as a growing self-care revolution in the country," said Renee Acosta, clinical assistant professor of pharmacy who teaches a course on OTC drugs.
"But the trends could have profound implications including abuse and worsening conditions that could escalate into major medical problems," she said. "Those embracing self care may not have enough information to determine if their medical condition is right for self treatment."
If you have a favorite remedy that has passed down for generations or have been scaling down on medications as you juggle the cost of groceries and housing, you are not alone. According to a recent analysis from IMS Health, a research firm that tracks prescriptions, the number of all prescriptions dispensed in the United States is lower than last year. Statistics also show physician office visits are declining.
Over-the-counter drugs, medicines that are available to the public without a prescription, account for the majority of all medications used in the United States. Eighty percent of Americans reported using an OTC medication in the past year to treat at least one ailment. This is almost twice the number of people who consulted a physician or took a prescription product.
An increasing number of powerful drugs are scheduled to lose patent protection and may become available over the counter, Acosta said. Safety issues on the "switched medications" and other OTC products include inaccurate dosing, overdose, misuse, addiction and prolonged or inappropriate use.
"The OTC market is vast and growing all the time," she said, adding that there are more than 100,000 products on the market. "For many people, the market offers an opportunity to make their own health care decisions while for others, it provides an alternative to seeking medical attention.
"Patients are faced with hundreds of OTC products and the anticipated increase in the number of prescription medications that will be reclassified as nonprescription will make the choices even harder. When you have a prescription you are under the care of a doctor and a pharmacist, but once it becomes over the counter, there is little control.
"Many people assume that because they are non-prescription drugs that they are safe," she said. "But consumers need to remember to treat these products with respect."
The College of Pharmacy has taught OTC drug courses for years and this fall hired a faculty member to teach complementary and alternative medicine (CAM). The college also has a faculty member who specializes in herbal use among Mexican Americans and another who studies CAM patterns in African Americans.
"Botanicals and nutritional supplements can be extremely helpful to patients when used under the care of a qualified practitioner, or with proper knowledge," said Rosa Schnyer, a doctor of acupuncture and Chinese botanical medicine who joined the faculty this semester.
"It is important for pharmacists to know which non-prescription botanical and nutritional pharmaceuticals are safe for patients to use over the counter, and which may interact negatively with their medications," she said, adding that 62 percent of adults in the U.S. use some form of CAM to either augment or replace conventional medical care.
Schnyer's course gives students an evidence-based overview of the most commonly used practices, including OTC botanical and nutritional supplements, homeopathy and traditional Chinese medicine while providing an introduction to the philosophical, historical and cultural fundamentals of CAM. Students also learn about the benefits of meditation, prayer and creative arts therapies such as art, music and dance as well as mind-body medicine--techniques designed to enhance the mind's capacity to affect bodily function.
Dr. José O. Rivera, assistant dean in the College of Pharmacy and director of the UT El Paso-UT Austin Cooperative Pharmacy Program in collaboration with Dr. Armando González-Stuart, has been studying herbal use and potential problems for the past eight years.
His research has shown that more and more people, particularly along the U.S.-Mexican border, are using herbal products instead of conventional medicines to treat health problems but are failing to inform a physician about the use.
Mexican Americans, Rivera said, have a higher use rate of CAM compared with the national trend. The custom of using herbs is part of the Hispanic culture and even more common among poor Hispanics who may lack health insurance.
His research has shown that only 31 percent of patients using home remedies ever report their use to a conventional health care provider. Many participants in the study also said their physicians never asked whether they used complementary and alternative medicines.
"Although medicinal plants are commonly assumed to be a safe, inexpensive and natural alternative to conventional medications, some herbal products could potentially pose a health risk to consumers," Rivera said. "Some are dangerous and exotic. It's a vicious cycle because some people don't tell their doctors because they are scared of what doctors will say. This omission makes them at risk for potentially dangerous drug interactions.
"In turn, doctors--some of whom think this is voodoo medicine--need to be educated as to the value of some alternative medicines."
Commonly used herbal products are chamomile, aloe vera, peppermint, lime, garlic and oregano, eucalyptus, cinnamon, cactus, wormwood, mullein plant, orange tree flower, linden tree flower, Ginkgo biloba and ginseng, among many others.
Herbals are used for a diverse array of aliments, including gastrointestinal ailments, skin infections, urinary infections, minor skin abrasions and infections, fatigue, sterility, anxiety, insomnia, kidney and bladder stones, hemorrhoid treatment, rheumatism, asthma, diabetes, high blood pressure and even cancer.
Rivera's most recent publication is based on a bi-national study in Ciudad Juárez, Mexico, and El Paso, Texas, that evaluated the use of herbal products in this border population.
In all his studies, Rivera has found a high percentage of participants learn about herbal use from family members. He also found that more females used herbals than males. And most believe herbal products are effective and not harmful in any way.
However, toxicity has been documented with the use of several herbals and home remedies, including lead-based salts (azarcon, greta and albayalde) used to treat "empacho," a condition best described as blocked intestines. Some plants and fungi (mushrooms) that may have medicinal or nutritional value can easily be confused with poisonous species by an inexperienced person.
The herbal products gordolobo and creosote bush have been associated with liver damage. Of major concern to many researchers is the use of urine therapy to treat diabetes. Some Mexican Americans have misconceptions about insulin, including thinking that it causes blindness or addiction, Rivera said.
In addition, there are worries about the plant, Salvia divinorum, which causes hallucinations and is becoming increasingly popular among adolescents. It has been put on the Drug Enforcement Agency list as a public health risk.
Find a list of herbal products, their use and possible side effects online.
"Aside from the toxic effects and potential for abuse, other herbal remedies may be potentially dangerous due simply to ineffectiveness," he said.
Such was the case of the woman, who decided to switch to herbals for high blood pressure, and ended up in the hospital.
"Americans spend billions of dollars on many natural products--most of the time without scientific evidence of efficacy and safety," Rivera said. He recommends more clinical trials to evaluate herbal products.
A recent study published in the Journal of the American Medical Association found the herbal extract Ginkgo biloba doesn't prevent or delay the progression of dementia of Alzheimer's disease, a big disappointment to the millions of Americans who take it. It is estimated that sales of the supplement reached $107 million in 2007, according to the Nutrition Business Journal.
"This is not a surprising finding as Alzheimer's is a poorly understood disease that even the best pharmaceutical products only offer very minimal improvements," said Rivera. "But it is just one study, although a very large study."
The educational portion of his research is to boost awareness among border-area health care providers so they can advise patients of the dangers of using some herbal remedies and explain the right way to use them.
He began a Web site that contains photographs and information about commonly used herbs, less-known regional herbs and information on studies related to herbal products.
African Americans also are substantial users of CAM therapies yet little is known about their patterns of CAM use. Dr. Carolyn Brown, professor of pharmacy, has been trying to find out. Her study, funded by the National Institutes of Health, looks at patterns of CAM use by African Americans. She is exploring patients' treatment decisions, particularly as they relate to use of prescribed medications and complementary and alternative treatment practices.
"The way people view health and the actions they take to treat their conditions are heavily influenced by their cultural and ethnic background," she said.
Her research focuses on understanding cultural and social elements that may affect both quality of care and therapeutic outcomes of patients with chronic illnesses, particularly ethnic minority patients who experience a disproportionate burden of poor health.
"As the country becomes more diverse, chronic diseases such as hypertension and diabetes will continue to increase," Brown said. "As a result, more people will be using treatments like home remedies, herbal medicines and spiritual healers.
"The uses of these alternative medicines--particularly those that are inexpensive as in home remedies--have been on the increase even before the financial downturn. But now even more so."
Brown has found that many patients use alternative medicines simultaneously with prescribed therapies.
"Of course," she said, "this could be potentially dangerous especially if these other therapies worsen the medical conditions or interact with their medication therapy."
Brown works to make current and future pharmacists more aware of and sensitive to the ethnic and cultural differences in patients.
"If you use some other treatment like vinegar or herbs along with your prescribed medication for high blood pressure," she said, "please let your doctors or pharmacists know so that they can help you receive the best care possible."
All of the efforts--the OTC drug courses, the research and the herbal Web site--are important to help pharmacy students, other health care providers and the public increase their knowledge of these products, Acosta said.
"As trends change to self care, so does the traditional role of a pharmacist," she said.
Acosta trains students how to choose the proper OTC product and be able to assess the patient's condition, including risk factors and most common adverse effects and warnings. Her class examines what product would be best for a cough, cold, allergy, insomnia, drowsiness, fatigue, headache, fever, contact-lens related disorders, insect bites and stings, fungal skin infections, diarrhea, nausea, vomiting, poisoning, heartburn, oral pain, tobacco use and dependence, among many others. Students also learn about home testing and monitoring devices.
"Pharmacists are the most accessible health professional," said Acosta. "Even if people decide to treat themselves, it is still important to seek their advice."
According to a 2006 survey by the American Pharmacist Association, pharmacists make an average of 32 recommendations a week on OTC drugs.
Students also learn how to watch for high-risk populations such as those on multiple medications, pregnant patients, nursing mothers and the very old and the very young who are more vulnerable to harm from drugs, including OTC drugs. Non-prescription use in the older age population has increased significantly, Acosta said, and there are increased risks for drug interactions.
As more prescription drugs become available over the counter, it becomes even more important to read labels and learn about possible side effects and interactions.
"We want our students to learn about their consulting role when they become pharmacists," said Acosta. "They will need to seek out the opportunity to help people with OTC products--walk them over to the shelves and talk to the patient."