Transcript From God to Druggist and Beyond

From God to Neighborhood
Druggist and Beyond… Sako Ikegami, PharmD
Part-time lecturer
～The Pharmacist～ Kyoto Pharmaceutical
University
Clinical communication expert
**Note to the conference attendees**
My apologies for the delay in making this file available (and the fact
that my talk differed somewhat from the summary provided on the
website). The history was far more intriguing than I had imagined,
and I wound up revising it until the morning of the conference, so I
am afraid that it was less than polished.
Your extremely insightful questions and feedback have allowed me
to identify some holes in the continuity and logic, so I’ve taken the
liberty of brushing it up a little bit before having this posted. There
are still a few things that need to be tied together to make it a
comprehensive whole, and I hope to eventually put it together into a
paper for publication in the society’s journal.
Thank you again for giving me the honor of addressing you at length
on such a niche topic.
It was truly a great pleasure.
Sako
Outline
•
History of Pharmacy’s Roots
Shennong
• Anesthesia as example
•
•
History of Pharmacy in Japan
Shinno-san
• Doshomachi
• Tanabe
•
•
Clinical Pharmacy and PharmDs
•
•
•
US overall
Asian countries and Japan
Future Vistas
History of Pharmacy
• Roll
back the hands of
time to 2700 BC, China
• An
eminently wise
emperor, Shennong or
Divine Farmer--the father
of pharmacy as we know
it.
Shennong, or Shinno-san*
• Hunter/fisher gatherer Nomadic
tribes
• Life unstable
• Often dangerous
• Shennong provided his people with
the things they needed for a more
stable existence
• Tools (the plow)
• Techniques (field burning)
• Knowledge (classification of plant life)
Shennong’s special powers
•
His red whip
•
Sampled several dozen
plants every day
•
Drank a special antidote tea
to counteract all effects
•
Tea (brewed medication
refreshing beverage)
•
See-through body—could
see which part of the body
was affected by the plant
•
Death ???
Shennong Ben Cao Jing
Content
•
Volume 1: 120 "noble" or "upper
herbs" (上品) harmless with
"stimulating properties": reishi,
ginseng, jujube, the orange, Chinese
cinnamon, Eucommia bark, cannabis,
or the root of liquorice (Glycyrrhiza
uralensis)
•
Volume 2: 120 "human," "commoner,"
or "middle herbs" (中品): therapeutic,
treat the sick, but with toxic, or
potentially toxic properties: ginger,
peonies and cucumber.
•
Volume 3: 125 "low herbs" (下品):
strong or violent action on
physiological functions or poisonous:
Rhubarb, different pitted fruits and
peaches
Tea (Camellia sinensis)
•
Tea is also a part of
Shennong’s heritage
•
First documented
mention is second C BC by
Han emperor
•
Probably from at least
1000 years BC
•
Came to Japan in 6-7 th C,
AD via Buddhist priests,
cultivated at monasteries
Practice of drinking tea
•
All cultures have a custom of
boiling water, steeping
fragrant leaves, and offering
the beverage to a guest
•
Medicinally, green tea
contains catechins and
caffeine
•
Herb teas contain other
compounds, many are
medicinal
•
Kampo medications are
taken as teas
•
Kissa Yōjōki (喫茶養生記?,
How to Stay Healthy by
Drinking Tea) by Zen priest
Eisai (brought tea seeds to
Kyoto in 1191)
Chinese medicine
entered Japan via Korea
in the 5th C Ad.
Missions sent to China
in the 7th C AD, by
Prince Shotoku brought
plants from China, later
cultivated in Japan and
becoming the source of
Kampo 漢方
Father of anesthesia: Hua Tuo 華佗
•
According to the
Records of the Three
Kingdoms (三国志), in
2nd C AD China, Hua
Tuo 華佗 (c. 140–208)
used máfèisàn (麻沸散),
a mix of wine and
medicinal herbs to
induce general
anesthesia.
His knowledge was lost
with his death.
Attempts to recreate his formulation
failed
•
This formula is believed to have
contained yang jin hua (Flos daturae),
cao wu (Radix aconiti kusnezoffii), bai zhi
(Radix angelicae dahuricae), dang gui
(Radix angelicae sinensis) and chuan
xiong (Rhizoma chuanxiong), among
others.
•
Hua Tuo : “The cause of disease is
physical inactivity”  Developed Wu Qin
Xi (Five Animal Frolics), an exercise that
imitates the physical movement of tigers,
deer, monkeys, bears and birds.
Seishu Hanaoka, Japan’s father of
anesthesia
•
In 1804, Hanaoka
successfully used 通仙散
Tsu-sen-san to anesthetize
and remove a breast
tumor from a 60-year-old
woman.
•
Performed over 150 breast
cancer surgeries over his
career.
Fictionalized by Sawako
Ariyoshi in The Doctor’s
Wife.
通仙散 Tsu-sen-san, the formulation
Take 8 parts of Datura alba 曼荼羅華 (Korean morning
glory), 2 parts of Aconium japonicum (Japanese
aconite), 2 parts of Angelica dahurica (Chinese
angelica), 2 parts Angelica decursiva (Norwegian
angelica), 2 parts of Ligusticum wallichii and 2 parts
Arisaema japonicum. The mixture is ground to a paste,
boiled in water, and orally ingested while still warm.
After 2 to 4 hours one will become impervious to pain
and subsequently fall unconscious. Depending on the
dosage, this effect will last 6 – 24 hours. Active
ingredients: scopolamine, hyoscyamine/atropine,
aconitine and angelicotoxin.
Combined, these give rise to anesthesia, sleep and
paralysis—mainly atropine and scopolamine—both of
which act to inhibit the transmission of stimuli
between neurons (as acetylcholine antagonists).
Current general anesthesia involves use of multiple
drugs to induce reversible muscle relaxation,
analgesia, amnesia, and depression of consciousness.
Shinno-san in Japan
• The
3 main importers of
medicinal herbs and
products from the Asian
continent Takeda, Tanabe,
Shionogi, a total of 124
merchants dealing in
pharmaceutical products
from the time of Toyotomi
(16C).
• Pharmacognosy 
Western medications
Tanabe (now Tanabe Mitsubishi)
•
Established in 1678, 2nd oldest
Pharma company in the world after
Germany’s Merck (1668).
•
Documents show Tokugawa
Shogunate granted Tanabe’s great
grandfather the right to travel to the
Philippines and Thailand to trade for
medicinal herbs as early as 1604
•
田邊屋振出薬 Tanabe-furidashi-kusuri
was a huge hit. *
*Tidbit: Early R&D in Japan: Tanabe is rumored to have gotten this formula from the
Shimadzu clan-jinchu-gusuri. It was a special formula that healed wounds and enhanced cure
rates.
Westernization of Doshomachi
•
With the start of Meiji
restoration in 1868,
Western medicine entered
Japan and Pharma
companies began
importing chemically
synthesized drugs from
the West. By 1877,
Tanabe Gohei decided to
manufacture drugs within
Japan.
•
In 1916, Tanabe opened
its first factory. Others
soon followed.
Osaka’s Doshomachi
～The Street of Pharmaceuticals
～
Doshomachi, Osaka
Kigusuri (生薬)
Shinno-san 少彦名神社
Sukunahikona shrine and the Tiger
•
Tiger and Medicine
•
Tiger Bones prescription against
cholera
Texts have listed it as having antiinflammatory properties
Also sedative properties—easing
fears and stress of the epidemic?
Hariko--「薬」 on tummy
Tiger Head Bones
•
Kotou-sakkiuouen pill
(Tiger’s head kills
demon ???) in 1822.
•
Blessed at the shrine and
handed out to the public
as a cure for cholera,
commonly referred to as
三日亡(korori=cholera),
meaning “Goner in 3
days”
•
The tiger figure was a
talisman to ward off
disease.
Efficacy of Tiger Bones…
•
Strengthens bones and muscles
•
Relieves pain and stress with sedative properties
•
Chinese texts suggest efficacy against forgetfulness and
anxiety.
•
In use for about 1500 years.
•
Mix of image, mythology, and actual effects—similar to
dragon bones (fossilized mammal bones).
•
Leopard, bear, wolf, dog, and deer bones have similar
effects.
神虎 Godly Tiger
From Kampo to Modern Pharmacy
•
Kampo 漢方 is a form of traditional Japanese medicine
founded in Chinese Traditional Medicine and imported into
Japan in the 5-7 th century AD alongside Buddhism (famous
Buddhist priests were often its first proponents).
•
Currently, it has developed into something quite distinct from
its origins. Kampo is generally known to cause fewer adverse
effects than western drugs.
•
Chief among its characteristics is its highly individualized
form of treatment. The practitioner conducts a thorough
physical exam and based on the patient’s unique “type” and
“condition”, recommends an appropriate mix of crude plantand animal-based ingredients that are then brewed into a
“tea” specific to that patient alone.
•
Although mostly abandoned at one time in favor of more
“scientific” western medication, Kampo has become
increasingly more popular over the past few decades.
What is a Doctor of Pharmacy
(PharmD) degree?
Similar to the MD (Doctor of Medicine) degree
•
Minimum requirement in the US to take the NAPLEX
board exams to practice as a pharmacist is a
PharmD degree.
•
Length: Undergraduate (2-4 years) + Graduatelevel Professional (3-4 years) = 7-8 years
•
OR entry-level 6-year accelerated program
(originated in 1950 @ USC Los Angeles)
Why clinical pharmacy?
•
Tailor-made medicine, individualized medicine has now
become fairly commonplace, but even in the mid-20 th C,
they recognized the limitations of the one-prescriptionfits-all formula.
•
The idea, to create a pharmacist better attuned to the
individual needs of patients in a clinical setting.
•
The 6-year PharmD program was originally an
undergraduate program and graduates wishing to
practice clinical pharmacy were encouraged to undergo
hospital residencies to bolster their actual experience.
Content of the post-BS PharmD
•
The Massachusetts College of Pharmacy program in
the 1980s was a post-BS PharmD program. The
undergraduate BS Pharmacy program was 5 years.
An additional 2 years of clinical training (0.5 years
didactic + 1.5 years of clinical rotations, including a
10-week teaching rotation and 5-week ambulatory
rotation).
Currently, there are no longer any BS in Pharmacy programs in the US,
and thus no post-BS PharmD programs.
PharmD programs around the world
•
Japan currently has no PharmD programs per se, but
they do have “clinical certifications” with impressive
requirements for clinical pharmacists.
•
India, Nepal, and Pakistan: Governments and Pharmacy
Councils have moved to begin professional programs
that started 6-8 years ago
•
The Philippines and Thailand each have 1 university
each offering a PharmD degree
•
Hong Kong, Singapore, Taiwan are fairly advanced in
clinical pharmacy and have some PharmD programs.
PharmD or Clinical Pharmacist?
• Confusion
• Let’s
Reigns!
call it clinical pharmacy for
convenience’s sake
Do all pharmacists need to become
Clinical Pharmacists?
• Length
of education and training
• Cost–effectiveness:
• Job
Extra healthcare costs?
satisfaction: Most pharmacist jobs do
not involve any clinical component
What is a Clinical Pharmacist?
Clinical pharmacists:
•
work directly with physicians, other health professionals, and patients to ensure
that the medications prescribed for patients contribute to the best possible health
outcomes.
•
practice in health care settings where they have frequent and regular interactions
with physicians and other health professionals=better coordination of care.
•
educated and trained in direct patient care environments (e.g. medical centers,
clinics, and other health care settings).
•
frequently granted patient care privileges by collaborating physicians and/or health
systems that allow them to perform a full range of medication decision-making
functions as part of the patient’s health care team.
•
has demonstrated knowledge of medication therapy and record of clinical
experience for these privileges. (Earned trust)
•
Specialized knowledge and clinical experience is usually gained through residency
training and specialist board certification.
•
From the ACCP (American College of Clinical Pharmacy)
Clinical pharmacists:
•
Assess patient status  determine whether medications are optimally meeting
the patient’s needs and goals of care.
•
Evaluate the appropriateness and effectiveness of the patient’s medications.
•
Recognize untreated but (medically) treatable health problems.
•
Follow patient progress to determine the effects of the patient’s medications
on his or her health.
•
Consult with the patient’s physicians and other health care providers in
selecting the medication therapy that best meets the patient’s needs and
contributes effectively to the overall therapy goals.
•
Advise the patient on how to best take his or her medications.
•
Support the health care team’s efforts to educate the patient on other
important steps to improve or maintain health, such as exercise, diet, and
preventive steps like immunization.
•
Refer the patient to his or her physician or other health professionals to
address specific health, wellness, or social services concerns as they arise.
Clinical pharmacist Roles:
•
Provide a consistent process of patient care that ensures the
appropriateness, effectiveness, and safety of the patient’s
medication use.
•
Consult with the patient’s physician(s) and other health care
provider(s) to develop and implement a medication plan that can
meet the overall goals of patient care established by the health
care team.
•
Apply specialized knowledge of the scientific and clinical use of
medications, including medication action, dosing, adverse effects,
and drug interactions, in performing their patient care activities in
collaboration with other members of the health care team.
•
Call on their clinical experience to solve health problems through
the rational use of medications.
•
Rely on their professional relationships with patients to tailor their
advice to best meet individual patient needs and desires.
Emerging pharmacist roles
• MHLW
Policies : Tighten our belts
• Community
pharmacies central to
dissemination of accurate,
accessible healthcare information
Why Pharmacists?
•
People feel Pharmacists are easier to talk to
•
More accessible (walking into a pharmacy is easier,
faster, and cheaper than walking into a doctor’s
office)
•
Informal setting and fewer time restraints (no
patients waiting out in the hallway) make it easier
to open up about medication-related concerns
•
Fear of insulting the MD who prescribed the drug
The Pharmacy in Society (until late
20 th century)
Re-created pharmacy
Pharmacies of Old (@Naraijuku,
Nagano)
Why individualized therapy is so vital
Three profoundly destabilizing scientific ideas
ricochet through the twentieth century,
trisecting it into three unequal parts: the atom,
the byte, the gene.
The gene is the fundamental unit of heredity
and the basic unit of all biological information.
Disease is itself diverse and individual (i.e., numerous gene-types have
already been identified), so tailor-made healthcare is essential if we hope
to achieve acceptable outcomes, esp. in life-threatening conditions.
Canada’s Success Story
•
In-depth state-funded counseling of patients with chronic
diseases (Hypertension, diabetes mellitus, etc.) by
pharmacists in community setting
•
Patient health outcomes improved by
60% !!
Requirements for successful embedment
•
Clinical competence
•
Time for both sides to accept clinical
pharmacist roles
•
Time to build trust
•
Not overstepping
•
Proving effectiveness and usefulness
•
Communication Skills
About Kyoto Pharmaceutical
University
•
Second oldest school of pharmacy in Japan
•
Established in 1884 by students of Dr. Rudolf Lehmann
Careers at KPU
Goals for 2016 and beyond?
TEACH PROFESSIONALISM
Read and Assess
•
Better ability to assess and use scientific/medical literature and
info
Communicate (Verbal and Written)
•
Communicate unbiased, evidence-based information
Improve Attitudes
•
Enhance confidence and delivery
What, ultimately is necessary?
• Professionalism
• Awareness
of self as a healthcare
worker, a member of a helping
profession
• Clinical
sense
Who will teach the students?
• Professors
• Professional
• Patients
Mentors
What traits must clinicians acquire?
•
Understanding
•
Empathy
•
Communication skills
•
•
•
Common sense
•
•
The ability to LISTEN
The ability to share
Gauge patient capabilities, offer reasoned solutions
Experience
So… the answer?
Touch
Thank You!