Complimentary and Alternative Medicines plus Tobacco Cessation

On Thursday, AphA-ASP sponsored an "OTC Herbal Medicines" Talk. This doctor who was trained in western medicine went to do a post-doc in china and then later taught Chinese medicine at UC Berkeley. She apparently received government funding to treat outbreaks of measles in the Chinese children and was active in promoting MMR vaccinations as well. She reviewed various herbs and medicines that could relieve common ills such as the cold, mild rashes, or pain. She stated that all of these remedies are available in Chinatowns throughout San Francisco and the Bay Area. Someone even asked how lay people can select effective Chinese medicines for their illnesses since these herbs are not FDA approved ( officially evaluated for their effectiveness, safety, or harmful interactions with pharmacologic agents). Her response was that people should consult knowledgeable Chinese herbalists who can give recommendations based on clinical trials that support the effectiveness and safety of the herbs.

But gathering from her talk, most of her recommendations come from her patients’ clinical outcomes, and not standardized clinical trials. But what was interesting was hearing the theories about imbalance of elements within a person that causes a disease to manifest. For example, too much heat or cold in the body could create an imbalance. Too much wind in a woman results in menstral cramps. It sounds like Feng Shui meets biology. The theories are too abstract for someone like me who has an empirical understanding rooted in the western medicine that is taught here at UCSF.

Even in our Clinical Pharmacy class, the herbal supplements section is mostly taught in a self-study format. We will only be covering 10 herbs this quarter, like Gingko Biloba and St. John’s Wort. And we do not even learn how to counsel someone how to use them, only know when to recommend to a patient to change dosages or not to use the herb concurrently with a drug due to an adverse drug reaction. St. John’s is well documented for inducing Cytochrome P450, which is an enzyme in the small intestines and the liver, that can decrease bioavailability of P450 substrates. It is daunting but interesting at the same time to realize the wealth of active ingredients that can be sequestered from natural sources. Optimistically, further research into uncovering new herbs can compliment or replace current accepted methods of treatment. It seems evident from her talk that we as future health professionals have a long way to go in terms of bridging these two systems of health care to call truly call it integrated medicine.

The pharmacies that are on the frontier of this movement is Pharmaca, a chain pharmacy that is growing at an exponential rate across the bay area which specializes in integrated medicine. I talked with their corporate recruiter a month ago about how they model their store after european pharmacies that provide herbs as well as pharmacological treatments. Their staff even includes acupuncturists, massage therapists, and other alternative medicine specialists.
The topic that we are delving into in clinical pharmacy class is Tobacco cessation. The program basically trains us about the importance of encouraging patients to quit, review of the physiological effect of nicotine and smoke on the body, how to counsel them about lifestyle changes that can improve rates of quitting, and pharmacologic treatments that can ease the withdrawal symptoms. I think this is the best series in the whole course since the instructors did a really thorough job on everything that we need to know about understanding how these treatments work, how to talk to a smoker, and the goals of how ending this behavior can decrease their chances of cardiovascular disease, stroke, asthma, COPD, and lung cancer.

They even did a shpeel on how the Tobacco industry has done everything they could to hook people on this drug for profit. For example, "Light" cigarrettes were marketed to be cleaner than regular cigarrettes. They were designed with ventilation holes to allow smoke to emit without entering the body, but they contain almost the same amount of nicotine and people inhale the same amount of smoke by covering the ventilation holes with their mouths when the take a puff. It is designed to be addictive since the nicotine reaches the brain to increase release of dopamine in the brainstem under 11 seconds, faster than most drug delivery systems developed today. Therefore this fast delivery of pleasure immediately after smoking a cigarrette reinforces the behavior of smoking.

Post 2nd Round of Midterms

This week was as busy as ever with another round of midterms and flurry of various club meetings. We took our last physical chemistry midterm, which was the most challenging out of the three that we have taken in terms of the material. Ever since we switched professors from Voigt to Schaffer, our lectures and homeworks have become increasingly complex. Part of the difficulty comes from Schaffer using calculus-based explanations of the material, for example understanding equilibrium between a pure liquid with its vapor as a discontinuity between two chemical potential curves, but mostly it is the result of shifting the focus of the class from understanding the concept of state functions to thermodynamics applicable to protein binding and pharmacodynamic studies. I enjoy this second half of the course much more because it is conceptually challenging while still keeping the problem solving understandable (basic calculus and algebra).

We also took our second biopharmaceutics midterm, which went ok. I could have done better since this class is really a simplified version of the pharmacology class that I took in undergrad at UCSD. Our curve was exceptionally high, with about 85% of the class getting an A. This is somewhat intimidating coming from undergrad classes where the curve was 50-60% which allowed you to make mistakes. But I suppose the expectations in biopharm and clinical pharmacy are a lot higher since the material is relatively easier and absolutely applicable to your future career. Every time I make a mistake I think about what a miscalculated dose could do to a patient. I wonder if this burden will ever go away (probably not).

As for extracurriculars….Here are a few out of many…

APhA is having its annual Patient Counseling Competition and a whopping 70 pharmacy students signed up to compete! This is about three times the number in previous years and can only be attributed to a growth of participation in my fellow classmates. I went to the info night and watched the video of last year’s national winner of the competition, also UCSF pharmacy student Eric Ip, counsel a patient in the national competition. He was so thorough when it came to knowing any side effects, customizing his responses to the patient’s needs, and reviewing proper dosage instructions. I still can’t believe he only had 5 minutes to prepare for the session. I realize that I have a lot to learn before I can reach his level.

Last week, we turned in our pledge cards for which fraternity we would pledge for. There are only two pharmacy fraternities at UCSF: Kappa Psi and Phi Delta Chi. From talking to the members, my impression is that Kappa Psi is more social (work hard play hard mentality) while PDC is like a low-key sorority. Pharmacy is already severely polarized (our class with about 100 females and 20 males), so it doesn’t really help the integration of the class when most of the males, non-asian ethnicities, and other minorities all pledged Kappa Psi. The break down this year was 75 pledged KY and only 20 pledged PDC (it was about 50:50 last year). They surprised us this week with breakfast and carnations in the morning before class. I never joined a frat in undergrad, so having such an intense frat presence in my school experience is very different for me. It is nice to have organizations that bring different class levels together.

We had a mandatory meeting for the California Society of Health Pharmacists information session about the conference in Anaheim Dec. 3^rd through 7^th. A large number of our class is interested, especially since the school will reimburse up to 184 dollars of the registration fees.

Also, there have been a series of talks given by some of the major experts in the developments in Medicare Part D. I am really happy that I came to UCSF so that I can hear some of these professors and 4^th year pharmacy students give these really informative talks about what a donut hole is, how late sign-ups for Part D can result in penalties, how benzodiazepines/barbiturates are not covered under the formularies, differences between this program and state run insurance plans, etc.

Summary of October

Let me first say that my experience here at UCSF Pharmacy School is just one voice and not representative of the diverse opinions about the curriculum and student life here. I have a lot of respect for the vast majority of my classmates because they are really genuinely caring, intelligent, and dedicated individuals. The first month is a flurry of orientations, social events, exploration of the city, and food food food!! Our biggest event was the White Coat Ceremony where we donned our new white coats and pledged our duty to the profession of pharmacy.

I attended this AIDS forum on October 13-14th as a one-unit elective class. It was pretty interesting to hear lectures about everything from the most recent research in AIDS treatment, epidemiology of the disease on an international scale, to real life anecdotes about what it was like to live with the disease. Since I did not have a strong grasp on the molecular biology of the disease, I learned that a patient's CD4 Helper T-cell count, the number of infected cells that spread the virus, can be used to measure the progression of the disease. New research suggests that CD8+ Killer T-cells may serve as a treatment solution to suppress CD4's. I learned a little about protease inhibitors, non-nucleoside reverse transcriptase inhibitors, and these new integrase inhibitors that are coming out. Apparently HiV clinics have this 20 minute blood test for HIV, but it's ridiculous cuz there's a 99% chance that it tests positive when you don't have it.

In terms of classes...
I was stressing this whole weekend about this clinical pharmacy midterm that's coming up on tuesday. So far, we covered gas, hemmorhoids, diarrhea, and constipation. The major source of anxiety that I sense among the class is condensing all the important information we need to work in a pharmacy into a "self-study" format. In conference, we analyze two cases per class. But we barely have enough time to cover the first case before we can thoroughly discuss the second one. I feel like I'm being immersed in this task of memorizing all the condraindications of drugs, side effects, mechanisms of action, and brand v. generic names, and therapeutic classes without understanding how they really work. I think taking a crash course in physiology would have given us the foundation to understand and retain why drugs work a certain way. For example, if our professor would have explained in lecture that Ca2+ influx into Ca2+ channels into heart muscle cells leads to heart contraction, then many more people would understand why Ca2+ channel blockers like Amlodipine can lower cardiac output and blood pressure.

Biostats is just like undergrad statistics that I took in UCSD. The tests are more difficult though, but our professor is an excellent lecturer. The compilation CD that a Pharmacy Frat (Phi Delta Chi) made is absolutely essential for preparing for tests.

I have taken physical chemistry in undergrad, but this class is still challenging nonetheless because our professor expects us to know and have equivalent problem solving skills as chemical engineers. This class is not particularly necessary to pursue a career in pharmacy, but understanding thermodynamics, colligative properties, phase changes, equilibrium of chemicals may be an advantage in a compounding pharmacy or pharmacological research.

I think I was stressed out because I had this interview for a pharmacy internship position at Walgreens the day before my Physical Chemistry midterm. It was random because I had to take the 34 to Laguna Honda Hospital and switch to metro L to meet my interviewer at Walgreens. I passed through the more expensive houses west of downtown until I reached 40th and Tarval. Not only was my interviewer half an hour late, but I was worried cuz I planned this study session at later that night. I got so bored that I started passing down the aisles and studying the drug facts on the OTC drugs, since I needed to know them for my midterm.

The interview went pretty well. Since I volunteered at a homeless clinic before, he asked me my opinion of the growing number of people without adequate health insurance in california. Since I was taking this health insurance elective CP198, I pulled out a common theme that the professor kept reiterating, which was that pharmacists have this essential role in educating the patient about redeeming benefits of government-sponsored health insurance like medical or medicare Part-D. The pharmacist can play a key role in deciphering the world of formularies, co-payments, premiums, and quarterly changes to insurance policies that lead to a lot of confusion for people.

It was basically like going through another pharmacy school interview, but somewhat less formal. He said that I could start as a script writer even though I did not have my intern license yet, so I told him that I could start training in december.