BACKGROUND: The use of alternative pharmacotherapies is rapidly increasing. Many persons who use purchased or prepared alternative medications are also cared for by family physicians. We describe patient usage of alternative pharmacotherapies and examine how family physicians handle this in medical practice.
METHODS: We recorded data from structured interviews of 178 patients in an academic family medicine practice in a midsized southern city. We then examined the medical records of each participant who reported using some form of alternative pharmacotherapy to determine whether there was discussion of this use with the physician.
RESULTS: Approximately one third of the patients reported using some form of alternative pharmacotherapy for 1 year or less, learning about alternative medications mostly from the media, and being generally satisfied with the results. Eighty-four percent of the patients reported not having been asked by their physician about their use of these drugs on the day of their office visit, and more than half reported never having been asked about their use of them. Medical record reviews indicated that for the most part physicians did not document having discussed or making recommendations about the use of alternative pharmacotherapies at any point in their relationship with the patient.
CONCLUSIONS: Since many of their patients are using alternative pharmacotherapies, family physicians are encouraged to learn more about what their patients use, to institute easy systemwide changes to facilitate discussion about this use with their patients, to document alternative drugs used, and to give recommendations regarding them.
Patient use of alternative medicine is increasing rapidly. The most common form of alternative treatment is self-medication with herbs (botanicals or phytomedicines), vitamins, or other pharmacologic or biologic substances.1-3 Data from family practice patients reflect that 28% to 50% use some form of alternative medicine, and at least one third also take some form of alternative pharmacotherapy, usually herbs.4,5 Alternative pharmacotherapy is now widely available in most supermarkets, drugstores, natural food shops, and from on-line stores. In early November 1999 we used a popular public Internet search engine to locate 505 Web sites for “alternative medicine,” 1100 sites for “herbs,” and more than 15,000 listings for individual herbs from 571 on-line stores.
Patients who self-medicate with herbs for preventive and therapeutic purposes may assume that these products are safe because they are natural; however, concerns about the safety of these products are well founded. Some herbal products can cause adverse side effects, such as nephropathy and hepatic toxicity, have the potential to interact with or potentiate prescription medications, and may contain high levels of contaminants, such as mercury, lead, and other toxic substances that can result in poisoning.6-16 Chemical analysis has shown that some herbal preparations contain heavy metals or other toxins, and some do not contain some of the desired chemicals they advertise.17 Many herbal or other alternative preparations are considered dietary supplements, so their manufacture and contents are not monitored by the Food and Drug Administration (FDA) or other regulatory bodies.18 Of the more than 1400 herbs promoted and sold as medicine, the FDA has approved only 9.17 Although these products have shown promise as treatments for health concerns ranging from depression and cholesterol management to fertility enhancement and immune system stimulation, more clinical information is warranted.
Greater knowledge is needed about the use of alternative pharmacotherapies and particularly about the practice patterns of family physicians with regard to their patients who use them.19-23 Although it is important for family physicians to be aware of and open to discussing their patients’ interest in these alternative approaches, it is also important to include documentation of their use in the medical history and record.2,24-28 Our study illustrates the use of common alternative pharmacotherapies in a sample of family practice patients. It also expands our understanding of family physician response to the increasing use of these therapies by their patients.
Methods
Adult patients were recruited from an academic family medicine clinic in the Southeast United States from June 1999 to August 1999. A total of 204 patients were approached following their scheduled clinic visit, and 197 agreed to talk with the interviewer. Of these, 178 complete records of demographic data (age, race, sex) were obtained. Patients were then asked: “Do you use any type of medications, herbs, vitamins, or other substances other than what your physician tells you to use?” One hundred twenty-three (69%) indicated they did not, and 55 (31%) indicated that they did. The study was briefly explained to these 55 patients, and informed consent was obtained from those who agreed to participate. Of those reporting use of alternative pharmacotherapy, 44 patients (80%) agreed to participate, and 11 (20%) refused. The participants included 18 men and 37 women; 60% were white, and 40%, African American. One participant was younger than 19 years; 31% were aged 20 to 40 years; 49% were aged 41 to 59 years; and 18% were older than 60 years. Chi-square analysis was used to test for differences among the groups. The participants responded to a brief series of questions regarding the purpose of their clinic visit, the name of the physician seen, their history of self-medication with a list of commonly used vitamins and herbs (Table 1), the names of other substances they used that were not listed, the source of their information about vitamins and herbs, and their judgment about the helpfulness of the vitamins and herbs. To determine the extent of physician-patient discussion about alternative medication use, we assessed 3 levels of interaction: (1) we asked whether the physician had inquired about their use of vitamins and herbs during that day’s visit, or ever, during the course of any clinic visit; (2) after all interviews were completed, we reviewed each patient’s medical record to determine if the physician had documented anything about alternative medication use at any time in the relationship with the patient; and (3) we examined the medical record to determine the presence of more extensive recommendations for past, present, or future alternative medication use.