Saving Lives: The Role of The Pharmacist in HIV

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What you will learn

  • More about Homeopathy
  • How essential Oils work
  • What about Cannabinoids
  • What’s the deal with NAC
  • Role of Pharmacists in Integrative Medicine
  • Role of Pharmacists in Functional  Medicine
  • What’s the deal with NAC

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Transcription

Michelle:
This is Michelle Sherman, president of Michelle RX pharmacists consulting services and the host of the conscious pharmacist podcast, a proud podcast of the pharmacy podcast network. Welcome to today’s show. And we have a returning guest today who I am thrilled to have on our show today. Dr. Pam Tarlow, a pharmacist in LA who is so knowledgeable and extraordinary on supplements, homeopathy and the like, and it is a pleasure to have you back on the show, Dr. Tarlow, thank you so much. It’s a pleasure to be back here, and I appreciate all the efforts that you go through to bring these good podcast to us as pharmacists. No, my pleasure. And thanks for being on the show you know what I want your listeners to know that you are going to be one of the speakers at the Western pharmacy exchange in Palm Springs coming up in a couple of weeks.

Michelle:
Now, I know it’s coming up sooner rather than later. I know you, you, you and I are going to be sharing the time slot for our talks. And I know a lot of people will be at a WP in person and a lot virtually. So for those listening, you know, you can attend the conference without being physically present in Palm Springs, which is also going to allow you to attend all these incredible CE programs. And the one from Dr. Tollo interests me so much you know, it’s called demystifying the pharmacist’s role in homeopathy in homeopathic medicine and ensuring, you know, how to educate your patients. So you know, our audience out there, or some technicians, but mainly pharmacists. And, you know, we, we stayed in the pharmacy all day long. We filling prescriptions or providing clinical pharmacy consultations to our patients.

Michelle:
And so many of them are taking supplements homeopathic products, essential oils. And for me working in HIV, a lot of my patients use cannabinoids as well. How do we, as pharmacists discern the difference and what is the difference? Yeah, thank you for asking that. And it can’t be emphasized enough by me and others that are involved in education to know what these different natural products are. I don’t believe as pharmacists, we have to be experts in any of them are all of them just became essential in my practice to know what my patients were taking and how it fit into their drug regimes and their disease regimes, just their, their whole protocols for their conditions. So the topic I’m talking on at Western pharmacy exchange this year is homeopathy. And first distinction to make is that homeopathic medicines are not the same as dietary supplement that’s so, or essentially oils or herbs or vitamins or minerals, even though some homeopathic medicines can be made from minerals and from herbs and from a variety of things that occur.

Michelle:
Naturally homeopathic medicines are a whole healing system with their own vocabulary, their own principles, their own medicines, their own Pharmacopia actually ever own way of approaching homeopathic healing. And it is not necessarily in conflict with pharmacotherapy, although the principles are counter intuitive and don’t follow the same tenants that we have for Western pharmacotherapy. So I know I just said a lot, but I feel like I need to say that all in one breath to just introduce the idea because working at Santa Monica homeopathic pharmacy, we do a lot more than homeopathy. In fact, I’m just trained well enough to know the difference and be able to recommend some simple remedies rather than complex ones. We have homeopaths that work with us. We often get patients coming in calling or emailing saying they want something homeopathic for whatever their condition is. And a first thing to know is they may or may not be speaking of true homeopathy.

Michelle:
They may instead be asking for something natural and homeopathic medicines are one particular kind of natural medicine that’s available to anyone really. You can get homeopathic medications almost everywhere. So I hope that’s clear that distinction and that’s really the place to start when a patient asks about, or a colleague physicians call to other pharmacists. And if they’re asking about homeopathy, I first find out if that’s really what they mean that it’s a product homeopathically prepared according to FDA and Pharmacopia homeopathic pharmacopeia guidelines. They may also be talking about vitamins, minerals, probiotics, fish oils, all the last few things. I said, those are all dietary supplements and those are regulated differently. And their intended purposes are a little different.

Michelle:
Oh, that, that clears up a lot. One of the points you alluded to was the counter intuitiveness, you know, and as a pharmacist, you know, we, we always fill the prescriptions and looking at doses and many dosage forms come in, you know, one strengthen in highest strengths. What’s really fascinating to me with homeopathy is the dilutions and that the more diluted the product, the more powerful it is. Can you, can you speak a little bit to that? So our listeners can understand that more. Yes, I would be very happy to. That was one of the big stumbling points for me. There are many, many stumbling points that I had in my journey to be effective with, as a pharmacist with homeopathy and which doesn’t mean that I always recommend it. I think what is crucial and over and over in my presentation, I’ll be demonstrating how homeopathy is not always the answer for somebody.

Michelle:
It may be, and it may be good for us to know when it’s appropriate and when it isn’t, there are two main principles to homeopathy. There’s really three, but we’ll just talk about the two main ones. One is that substances are diluted and their effectiveness for helping the body turn around reverse or heal symptoms comes from their dilution. And I like to use the word dilution rather than potency and its tricky self. So all of everything I say about homeopathy, here’s my disclaimer. One of many is that it’s just herself limiting conditions. It takes somebody other than me to work with more serious indications. I’m working with self-limiting symptoms and conditions. And with the dilutions, we look to a lower dilution, more of the original substance when the symptom is more local, if you can point to it, if you’ve got a bug bite on your forearm and you can point to it and it’s itching and stinging, and you want relief from that, itching would, might give you a homeopathic medicine in a six or a six seat, which is a lower dilution.

Michelle:
If there’s more general symptoms, including emotional symptoms, then we would go to a higher dilution or a higher potency. And then it would be more effective to me. The most effective dilution is the one that matches the patient’s symptoms, the best that could be a lower or a higher. And I’ve seen that in action at work many, many times how the homeopaths and now I suggest a starting dilution. And then we see if the patient responds very, that’s like one of the most fascinating things about homeopathy to me really, and, you know, the way it works and, you know, growing up in South Africa we had a lot of that around and, you know, even growing up, you know, utilize some of those modalities and used homeopathy quite a bit as well. Can you also, you know, we get confused, like, like you say, homeopathy essential oils, supplements minerals and things like that, where do essential oils come in and what’s kind of the difference.

Michelle:
Sure, sure. And I just would like to also mention that you’re very fortunate that you grow up with it. I grew up with antibiotics and cocoa Krispies and mashed potato flakes. That’s how I grew up. And so and that’s how I got involved in all the natural medicine is my health needed something that would help me heal and cope to the causes of what was causing my conditions. Medications stopped being effective for me though. I’m a big proponent for medications when you correctly in the doses for the person or the condition that’s necessary homeopathy, dietary supplements, cannabinoid medicines, essential oils. They can be very helpful either in combination when safe with medications or as a standalone when there’s just a little bit of symptomatology or irritation. And so if we skip to essential oils, which are very different, there are no essential oils that are homeopathic essential oils.

Michelle:
I classify as a pharmacist, I’m always classifying things. I can’t really learn and communicate carefully unless I have a slot to put it in or know where this product overlaps different slots. So essential oils though, they are not regulated or considered dietary supplements. They’re closest to herbs. They are the fragrant volatile oils that a plant produces often in their flower in their bud, in their seeds in their leaves, think of eucalyptus. And that’s where you can live. This essential oil comes from the leaves of the pedals like Rose the bark or from frankincense ginger is from the root et cetera. So essential oils are a very concentrated extract of the volatile turpines and terpene light compounds that are fragrant. That was a pretty exciting moment. A few years ago for me, when I realized that some of the bioactive molecules in the cannabis sativa plant that give it, it characteristic aroma are turpines cause I’ve studied turpines for decades in essential oils.

Michelle:
And so that’s a connection there, but let’s go back to aroma therapy in general, aroma therapy is either used by smelling it through inhalation or it’s used diluted topically. It is very rarely if ever used orally and systemically. And it takes an expert, which I’m not to suggest essential oils that are taken internally. There are a few exceptions and those are exceptions, but I think for pharmacists, just beginning to explore the idea of their patients using aroma therapy, essential oils, they should keep it to just inhalation and topical application. And topical is almost always diluted in some kind of neutral carrier oil, like almond oil or hemp.

Michelle:
Totally fascinating. All the, all these different modalities. And, you know, as you were talking, I was thinking, you know, as pharmacists, you know, we, we faced with Western medicine and all the prescriptions that we feel and everything every day. But you know, we have to look at everything from like a three 60 degree look and look at not only those prescriptions that we’re filling, but everything else that our patients are doing and taking and what they want to do and take. And you know, as an HIV pharmacist, obviously the focus of everything is for my patients is their antiretrovirals and other drugs they’re taking for co-morbidities. But so many of them are also taking supplements all these other products and many, many, many of them are using cannabinoids as well. Can you speak to the, the cannabinoids and you know, where those fit in?

Michelle:
And what’s very fascinating to me is, is the research that you’ve published in the endocannabinoid journal. Yeah. Good. Could you let us know a little bit about that?

Pam:
Uh yeah, so I’m a little humbled with that question because it’s a very vast subject and a lot of us health care professionals are playing catch up. I only started studying cannabinoids about five or six years ago, and I wish I would have started many more years ago. I had some biases, some myths. I needed cannabinoid medicine to be demystified for me. And it is still becoming demystified. Previously I only knew about cannabinoid medicine, excuse me, from the recreational side for my work in addiction. What, what is paramount in all your questions is to be the kind of pharmacist that patients will talk to. I can’t help my patients. You can’t help your patients.

Pam:
The listener can’t help his or her patients unless we know what they’re taking. And most patients don’t feel comfortable talking to their pharmacist about some of these products. And so what we had a lab was a year and a half ago, approximately at the beginning of pandemic, don’t we really under think about things before, after or during a pandemic. We had some students from Western pharmacy school that came to do their four month research project with us. And we decided to see what the patient’s perception of CBD safety was and whether they talk to their pharmacist about it. And we found that patients thought it was automatically safe. They did not in general tell their pharmacist that they were on it. And they were not aware that there could be some important drug interactions. So I, our research was just on CBD and my knowledge really just has to do with CBD some minor cannabinoids and the terpenes.

Pam:
I am not an expert in THC because we don’t have any products in our pharmacy that have THC. They have to have less than 0.3% THC to be sold in our pharmacy. That’s due to the the hemp bill of 2018 agricultural bill. And so a lot of what I do based on that research and even before is become interested in why a patient is interested in cannabinoids, what they’ve tried, what their experience is. And also if it makes sense for me, for them to pursue that they also would like advice about whether they should have gummies or liquids or topicals. I find the topical CBDs much safer, much less a risk if patients are on a lot of medications, especially medications that have a narrow therapeutic index. And then very often I will decide to refer them out to a practitioner or a physician or pharmacist, some other experts that might be able to help them decide whether THC belongs in their regime too.

Pam:
So I do a lot of referring and then mostly talking to my patients to see what their experience is and how they might add cannabinoids CBD plus other things I know we, we all want the fix. Don’t wait, Oh, CBD did it for my friend. My friend’s sleeps with CBD. So it’s going to help my sleeping. I like to look that three 60 also, when anybody has insomnia, first thing I look at is their medications and then their lifestyle and their diet, rather than medicating for insomnia. Maybe there’s something that we can change in their life or in their medication regime that might help them sleep better.

Michelle:
No, absolutely. The three 60 is, you know, is essential. And I think everybody in our society wants that magic pill, the pill for everything where as, like you say, if you can help your patient make a few lifestyle adjustments, then that could maybe improve their sleep without adding another sleep Elliot or any other supplements or anything like that.

Michelle:
So it’s so important and you made a great point is firstly talking to our patients and then so important is to listen to when I’m with patients. I just let them talk because the more I listened to them, the more information I can glean to come up with a better plan for them. So listening and letting them talk. And I think engaging with our patients they’ll become more comfortable with us. So they will us what’s going on and what they’re really doing and really taking.

Pam:
It really adds to job satisfaction to do that patient outcome and job satisfaction. I have found that I’ve needed to educate myself at least a cursory education on all these different things so I can engage so I can listen if a patient or a colleague is presenting me with a lot of different things. I’ve never heard of.

Pam:
I find that my mind starts racing and I can’t really listen. But if I’ve heard about different, all the things that they’re talking or have some way of sort of at least initially classifying them in my mind, I’m much more present. And that is an exceptionally good reason why someone might benefit from learning an hour or two hours, three hours about homeopathy. I used to trip all the time in my mind, 20 something years ago about what do they mean homeopathic? And what’s a 30 C and what’s a, this, and will that interact with their medications? I don’t trip over that anymore. They have a pretty good general basis that it’s that medications and homeopathic medicines have very little chance of a pharmacokinetic interaction, very little chance. So that is not impinging on my listening ability when I’m hearing why they went with homeopathic, are they taking it with their medication?

Michelle:
Is their medication not working half of the time during a discussion about homeopathy? I find out the patient doesn’t want to take their medication, can’t afford it, or is getting side effects and I send them back to their pharmacist.

Michelle:
No, absolutely. You know, just to, to everybody listening today as, as, as we talking through this and where your role fits in you are literally the, the, one of the most important healthcare providers that our patients have as a resource and somebody to go with. So critically, critically important is, is, is your role Penn, I had another question that actually came up with one of my patients last week is like, what is the story about NAC you know, working with HIV patients for all these years. Um we actually had a provider in orange County many, many years ago who used to study nutraceuticals and, you know, do lab work or on his patients to check their levels and things like that.

Michelle:
And one of his protocols was to use L-carnitine in a C alpha lipoic acid and glutathione with his, with his patients. And many, many, many of them are still using that today. And one of my patients called me last week because he was buying his NAC all this time on Amazon. And Amazon’s no longer selling at what, what happened with NAC. And why did that happen?

Pam:
Good question. And, and really interesting supplements. You, you named, I think four dietary supplements that are intellectually fascinating for me as a pharmacist and a chemist, and they always get covered during my student rotations. We look at all of those and a lot of people are using them. So yes, and acetol system IEM, which is an amino acid has been regulated, has been, let me say this exactly right. And big on terminology has been available as a dietary supplement for many.

Pam:
And it’s used for a variety of intended purposes. Of course, it’s not approved for anything. FDA has not proved done any pre-marketing on any dietary supplements. That’s part of the differentiation between all these different classes of products. It is also a prescription product and has been available as in marketed as a drug since 1963. So that in itself creates a regulatory conflict. Part of the guidelines for being a dietary supplement is that there is no prescription drug that’s also available. And the FDA has not pursued the many dietary supplements that are also available as prescription drugs until I think it was last year that a few companies got a warning letter from FDA and the warning letter was not due to the safety of NAC. I really want to stress that it was due to the regulatory and also they had some false advertising because you cannot make any medical claims about dietary supplements.

Pam:
They are not intended to diagnose, treat anything like that. There’s a disclaimer that has to go on a dietary supplement. So social media is great. We get to find out about things and people panicked when they found out that Amazon was dropping their products that had NAC. I would like to include here that the professional distributors are not dropping those products and the professional companies are continuing to make them. We just have to wait and see their FDA is getting a lot of input from the industry I credit FDA for that they want to hear different opinions. There’s some pretty strong opinions that in AC should be available for consumers as a dietary supplement. Well, I think Michelle, we just have to wait and see it’s an important dietary supplement and it is possible that FDA could decide to quote grandfather it as an ingredient for dietary supplements.

Pam:
We’re seeing this in the cannabinoid realm. Also CBD is not considered a dietary supplement. Companies are including it in hemp products, hemp products can be dietary supplements. So it’s kind of a fine tuning of the regulations and the guidelines. I hope that made it more clear rather than more confusing.

Michelle:
Yeah, no, definitely, definitely. Well, I, I’m pleased to, to hear that the, the professional distributors of NAC are still going to continue and, you know, can then, you know, make referrals for, for my patients. Who’ve just been, you know, buying it off Amazon and things like that. So, absolutely. Wow. I mean, this conversation has, has, has been so interesting. You know, I feel like we can just go on and on and on and on and talk about this topic for hours before we, before we end. Is there anything else you’d like to highlight for the listeners and anything more about your talk or, or anything about homeopathy dietary supplements that people should know?

Pam:
Oh, there’s so much, I do want to correct an error that I said. So it’s the farm bill of 2018. And I think I said agricultural bill of natural medicine has increased my humility. It’s very challenging. I do want to say that it has been extremely challenging for me to try to understand the use, the safety, the science, the availability, the different formulations. We, we could have a whole discussion just on delivery systems. I’m very grateful for my pharmacy knowledge and pharmacy practice, to be able to have some kind of a professional patient centered, shared decision-making platform in order to learn about these and talk to people about it, listen to what they have to say, but also give them some guidance. Our patients really want guidance and they want guidance from us, especially if they’re taking medications.

Michelle:
Absolutely. You know, I probably eight out of 10 of the clinical consultations that I have with, with patients is reviewing the list of dietary supplements and things their friend told them to take and things that found online and how those, you know, interact with the HIV meds and other mates they taking. So this is such an essential topic for us as pharmacists to, to, you know, learn more about. And if we don’t know the answers to be able to find sources that we can refer our patients to, to get the answers they need.

Pam:
Yes, yes, yes. I do have a parting thought about homeopathy since it is so mysterious. Please consider for yourself as a professional. I don’t have to believe me. I hope if you come to my CE program that you will know after you finish it, it is my goal to really bring you to a place where you can professionally decide that there’s very little chance that patients taking true homeopathic medicines that are prepared according to guidelines, that they will have any unwanted effects or drug interactions. And that there is a possibility they will provide symptom relief from self-limiting symptoms. And that really counts a lot for patient care, very little chance of interactions, very little chance of unwanted effects, not very expensive readily available, and they provide relief can be taken concurrently with medications.

Michelle:
And it, and it’s, and it’s, and it’s huge because, you know, as a pharmacist, that’s always a concern that every everything that the patient’s taking and they add more things to their regimen is going to, you know, open the doorway for, for drug drug interactions. So it’s very comforting to know that.

Pam:
Now that’s true for dietary supplements that could be dietary supplements, may cause interactions and unwanted effects and add up. And we need to be concerned about liver function and hepatic function, but not so with homeopathic medicines,

Michelle:
Very, very interesting. Well, Pam, thank you so much for, for being on the show today, to all the listeners out there, we have some resources and things on Dr. Tarlow and for your, your parting comments Pam, what, how could people get in touch with you if they need to?

Pam:
Um if they can get in touch with me by my email, though, the best way to get in touch with me as LinkedIn, I do a lot of my networking on LinkedIn, as I know you do. We’re always looking at what each other is posting. And so really, I think that’s the best place to get ahold of me is through my LinkedIn account. And possibly we can leave that information in the show notes, or you can Google my name. I’m pretty active on LinkedIn. And I would love for everyone listening to be part of my network. I can be part of yours.

Pam:
Oh, absolutely. And in your LinkedIn will be in, in the show notes and in the resources. And again, it was an absolute pleasure having you on the show. I called wait for your WPE talk in a few weeks and, you know, thank you so much. This was so informative for, for me. And I’m sure for our listeners out there and to all of you pharmacists out there, thank you for all the great work you’ve done over the last year and the work that you do every day. Remember you all the change.

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