Throughout most of mankind’s history, the earth’s forests and jungles have been our pharmacy, providing an incredible variety of roots, leaves, berries and barks with the power to soothe and, in some cases, cure our ills.

Today, nearly all of our medicines come in bottles and tubes. They are manufactured in vast quantities under sterile conditions and, more often than not, contain no ingredients found in nature. In fact, most modern drugs bear little or no resemblance to the plant juices that served as medicine a thousand years ago—except in one fundamental respect: They all work, because of the interaction between the chemicals in the drug and the chemicals in the patient’s body or the chemical make-up of organisms that invade the body.

Figuring out those chemical relationships is the key to modern drug development. And understanding how and when to use those drugs is a fundamental part of being a physician.

Physicians couldn’t very well practice medicine without, well, medicine.

There are now more than 50,000 medicines available to treat just about every known disease. Community hospitals such as FirstHealth Richmond Memorial and FirstHealth Montgomery Memorial typically stock about 2,500 different drugs. FirstHealth Moore Regional, which treats patients with a wider range of problems and more serious problems, carries about 2,700 drugs.

Know your prescription label

“Physicians and pharmacists cooperate to keep the number of drugs we have on hand at a minimum, while making sure we have all the drugs our patients are likely to need,” says John Walker, R.Ph., Pharmacy director at Montgomery Memorial. “Many drugs, like antibiotics, are used for the same purpose, and some of them are very expensive. So we stock a minimum of these drugs to treat a particular organism rather than stocking every medication that’s made, because that would be cost-prohibitive.”

Of course, if a patient really needs a particular drug that isn’t in stock, a hospital can get it in a matter of hours.

Jason Joyce, Pharm.D., Pharmacy director at Richmond Memorial, says hospital pharmacists are continually looking to see if the list of drugs they stock—called their formulary—needs to be changed.

“When a new drug comes out, we evaluate it and, along with our physicians, decide if it’s something we should have,” he says. “If we put it on the formulary, we might take off an older drug in the same category.”

Drugs for pneumonia, heart disease, high blood pressure and diabetes are the ones that hospitals in this area use most often. Community pharmacies also fill large numbers of prescriptions for heart and blood pressure medicines, as well as for antidepressants and antibiotics.

“The primary care practice upstairs sees children,” says Angela Elkins, R.Ph., the chief pharmacist at FirstHealth Standard Drug in Troy. “So we dispense a lot of antibiotics for strep throat and ear infections.”

Pharmacy education and training Pharmacy students typically spend at least one year outside the classroom, learning as they work alongside experienced pharmacists in hospitals and community pharmacies. Carolina pharmacy student from Rockingham, spent part of last spring in the Pharmacy at FirstHealth Richmond Memorial Hospital. She chose to become a pharmacist, she says, because she wanted to work in the health care field and, having had summer jobs in a local drug store, she liked what she saw of the profession. “It’s a good feeling when people ask your advice and rely on you,” Ammons says. “That means there’s a lot of pressure on you; you’ve got to stay up to date. So learning doesn’t stop once you graduate; it continues on forever, because new things are coming along every day. But that’s one of the reasons I like pharmacy.” Becoming a pharmacist requires two years of pre-pharmacy courses in a community college, four-year college or university and then four years of pharmacy school. There are three pharmacy schools in North Carolina: at the University of North Carolina at Chapel Hill, at Campbell University in Buies Creek and at Wingate University near Charlotte, which will graduate its first class next spring.

The role of the Pharmacist Every time Jason Joyce looks at the antique wooden cabinet on a table in his office, it reminds him of how far his profession has come. Joyce, Pharm.D., is director of the Pharmacy at FirstHealth Richmond Memorial Hospital, and the cabinet is one of his most cherished possessions. Built early in the last century by the McCourt Label Cabinet Co. of Bradford, Pa., it was used to dispense labels for medicine bottles. The labels came on rolls, like postage stamps do today. The ends of the rolls could stick through slots on the front of the cabinet so the labels were easy to peel off. Jason Joyce, Phar.D. For Joyce, the label cabinet is a symbol of a time when, as he says, “just about the only thing pharmacists did was lick, stick and pour.” They licked labels, stuck them on bottles and poured medicine into the bottles. “It was strictly a dispensing function,” Joyce says. Today, dispensing medicine accounts for less than half of what many pharmacists do. Some of them spend a lot of time educating and counseling patients. They also provide information and advice to physicians and nurses, who recognize that pharmacists are the experts on how drugs work, how they should be used and what if any risks they pose. “Various factors can make one drug better than another for a given patient, and our job is to help make sure the medication regimen is optimum,” says Lisa Cutrell, Pharm.D., a pharmacist at Richmond Memorial. “For example, we can look at whether a certain drug a patient is taking for a specific condition may be exacerbating another health problem they may have such as heart disease, asthma or diabetes.” John Walker, R.Ph., Pharmacy director at FirstHealth Montgomery Memorial Hospital, says physicians rely on the expertise of pharmacists much more than they did just 20 years ago. “Now, when physicians come out of medical school, they expect a pharmacist to be available to give them information and answer their questions,” he says. Hospital pharmacists also have a big role in training new nurses, and nurses frequently call them with questions. Years ago, nurses mixed all IV medications and were trained to administer only medications that they had mixed. Now, a hospital’s pharmacy mixes all medications in a sterile environment. Ensuring medication safety—and making absolutely sure that every patient gets the right dose of the right drug at the right time—is one of the most critical aspects of the hospital pharmacist’s job, according to Walker. “Because we use so many different drugs and there are so many points at which errors can be made, medication safety is something we are working on all the time,” he says. “It is a primary focus for all clinical staff.” Pharmacists who work in retail pharmacies are valuable resources for physicians, as well. For example, physicians sometimes call to make sure a drug they are about to prescribe won’t interact in a negative way with a drug the patient is already taking. Lisa Cutrell, Pharm.D. Federal law requires pharmacies to offer counseling to every customer who gets a prescription filled. Angela Elkins, R.Ph., the chief pharmacist at FirstHealth Standard Drug in Troy, says that instead of offering to counsel a patient, she often just goes ahead and does it. “Especially when I’m dealing with children’s medications, I want to make sure the parents understand the proper dosing,” she says. Elkins also spends a lot of time educating and counseling adult patients. She talks with them about any drug side effects they should look for and about the importance of taking the correct dose at the proper time. Patient compliance with those instructions is especially important with what are called “maintenance medicines.” “Those are the ones you take on a regular basis, like blood pressure medicine, as opposed to antibiotics, which you are only going to take for a week or two,” she says. Most pharmacists now spend a great deal of time—far more time than they would like, quite frankly—on the phone with insurance companies and the Medicare drug benefit program. Often, they are trying to resolve a problem with the patient’s coverage. “Dealing with insurance companies is by far the biggest and most time-consuming challenge we have,” Elkins says. The best part of being a community pharmacist, she says, is getting to know her customers. “I have known a lot of them for years, and I know their children or their parents,” she says. “I love the one-on-one contact with people.”

John Walker, R.Ph.

The nation’s medicine cabinet

On any given day, there is an excellent chance that some of the drugs dispensed by local hospitals and community pharmacies were developed or manufactured in North Carolina or tested by a company based in the state.

North Carolina ranks fourth in the nation in pharmaceutical production and first in contract research organizations, which conduct clinical trials of new drugs. With pharmaceutical company scientists often working in collaboration with faculty members at the state’s large research universities, North Carolina has become a world leader in biomedical research and pharmaceutical research and development.

GlaxoSmithKline, the world’s largest pharmaceutical company, has major research and manufacturing facilities in the state, and one of its two U.S. headquarters is in Research Triangle Park. Other global pharmaceutical companies with North Carolina facilities include Merck, Bayer, Novo Nordisk and Wyeth.

North Carolina has the world’s largest vaccine production plant, the world’s largest intravenous solutions plant, the world’s largest plasma-based products plant and one of the largest insulin plants.

The North Carolina Department of Commerce estimates that the state’s life science industry, led by pharmaceutical and biotechnology companies, generates more than $7 billion in revenues each year. That means medicine is supporting the health of North Carolina in more ways than one.

The last time you sprained your ankle, did your doctor prescribe leopard’s bane?

If your cholesterol is too high, do you have a prescription for red yeast rice?

What about noni juice to relieve pain and clean your liver?

According to the label on the noni bottle, “Islanders in the South Pacific have used noni for over 2,000 years for its natural analgesic and anti-inflammatory properties.” The label also states that noni juice “cleanses the liver” and “helps maintain a healthy digestive system.”

Sounds like great stuff, doesn’t it? And, indeed, it might be. But in fine print on the label, there is this disclaimer: “These statements have not be evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease.”

That probably explains why your doctor doesn’t tell you to take leopard’s bane or noni or most of the other products you’ll find in health food stores and the natural remedies section of your neighborhood drug store.

It isn’t that these products don’t work. In fact, some of them might work quite well. But most of them have not been subjected to the same rigorous tests—including clinical trials—that prescription drugs and most over-the-counter medications have to pass before they can be sold in this country.

“We can’t say that these natural products work or don’t work, because we don’t require them to undergo evidencebased testing,” says Jason Joyce, Pharm.D., Pharmacy director at FirstHealth Richmond Memorial Hospital. “You will rarely see a physician prescribe a natural remedy, because there is little or no scientific evidence that they are effective and safe.”

Because these products contain only natural ingredients such as roots and leaves, they are not considered drugs but dietary supplements. For that reason, there are few restrictions on how they are produced, marketed and sold. There is also no economic incentive for pharmaceutical companies to spend money researching and testing them, Joyce says.

“Natural products cannot be patented, so there is no way for drug companies to recoup the cost of research,” he says.

The largest companies that process and sell natural remedies have their products independently evaluated to verify that the ingredients listed on the label are actually in the bottle. But if you buy a dietary supplement from a friend or your next-door neighbor or via the Internet, you might not get what you’re paying for.

According to Joyce, anybody can make and sell dietary supplements and, unlike regulated drugs, they don’t have to meet any standards of purity.

“The biggest marketplace for natural remedies these days is the Internet, where you have no idea whether what you’re buying was made in somebody’s kitchen or in a sterile lab,” he says. “The problem with some of these natural products is that, along with the beneficial ingredient, you might be getting a lot of other chemicals that aren’t very good for you.”

Pharmacists and physicians also caution that natural remedies should not be taken along with prescription drugs, because certain combinations can result in a trip to the emergency room. Aside from that—and aside from whether a particular natural remedy actually does any good—most of them probably don’t do any harm, Joyce says, especially if you buy from a reputable company.

So you can take pulverized shark cartilage to strengthen your bones and joints, ginkgo biloba to make your mind sharper, fish body oil to support your cardiovascular system and yohimbe bark to increase male potency. You can take lutein for your eyes, colostrum for your immune system, and maca to improve sexual function and relieve the symptoms of menopause.

For all the miserable symptoms of the flu, you can take a pill made from aconite (a poisonous plant), yellow jasmine, wind flower, malabar-nut, blood root, lungwort and red onion.

If you are really stressed out and need to relax, you can try Bach’s Rescue Remedy, which is made from the essence of five flowers: cherry plum, clematis, impatiens, rock rose and star of Bethlehem. But be careful: Rescue Remedy is 27 percent alcohol.