The “What I Wish I Knew” series of articles is a service of AAPP’s Resident and New Practitioner Committee. Articles are intended to provide advice from experts for students, residents, and new practitioners. Articles are not intended to provide in-depth disease state or pharmacotherapy information nor replace any peer-reviewed educational materials. We hope you benefit from this “field guide” discussing approaches to unique problems and situations.
Richard J. Silvia, PharmD, BCPP
Professor of Pharmacy Practice
MCPHS School of Pharmacy, Boston, MA
Dr. Silvia graduated from the University of Rhode Island College of Pharmacy in 1999, and then completed a two-year residency/fellowship in psychiatric pharmacy through the Institute of Living and the University of Connecticut School of Pharmacy. Since then, he has taught future pharmacists at the MCPHS School of Pharmacy in Boston. During this time, Dr. Silvia has held clinical positions in a variety of psychiatric settings, most recently at the Codman Square Health Center in Boston. At the center, he maintains a collaborative practice in psychiatric pharmacy within the primary care clinics of the center. Seeing patients in primary care, he prescribes psychotropic medications for a variety of psychiatric indications, including depression, anxiety, ADHD, and others.
Patients will often come to a clinic appointment asking if there is any way to use over the counter (OTC) products in addition to- or rather than- prescription medications to treat their illnesses, including anxiety. While there have been some OTC and herbal products that have been used and sometimes studied for treating anxiety, they may not be as well studied as prescription medications. As pharmacists, we have an opportunity to educate patients about appropriate use of OTC products, including questions about treatment for anxiety disorders.
Most patients work under the impression that if a medication is OTC, then it must be safer than prescription medications. Patients often perceive that because an herbal product is natural, and not made in a lab, then it must again be safer. While we all know that prescription medications carry their risks of adverse effects, OTC and herbal products do as well. Explaining to patients that most OTC products were once prescription-only medications, and many still are, and therefore can cause adverse effects and drug interactions like their prescription counterparts. Herbals, while natural products, can affect many of the same processes in the human body that medications do. With prescription medications, we generally have a good notion of what potential adverse effects might occur, something we may not understand as well for an herbal product. I often have patients ask about herbal teas for “calming” for their anxiety. In looking over the ingredients, they often have a mixture of various herbal products, making it very difficult to determine what effects occur. Many of these products contain either chamomile or lavender, which are purported to have some calming qualities.
The other concern of course is “will the product work” in treating the patient’s anxiety. A number of OTC medications are similar pharmacologically to prescription anxiety meds. For example, with diphenhydramine and hydroxyzine there is a reasonable chance the OTC will help. For herbals, this may not be as easy or clear to determine. While many herbal products have been studied, including in direct comparisons to prescription medications, there are often still questions about how well they might work for treating anxiety. Valerian root, for example, is a product commonly used for insomnia and/or anxiety, but its benefits for true anxiety are not fully proven or accepted. If the patient is ultimately set on taking an OTC or herbal product for their anxiety, our role is to help guide them to an appropriate product.
This can be a difficult task, especially for herbal products. While OTC products may have various manufacturers, the drug and dose within them is consistent among brands. They are also subject to the same manufacturing and quality regulations as prescription medications. This is not always the case with herbals. Take a walk through the herbal section of a pharmacy or a health food store and literally dozens of products all containing the same herbal product can be found, but not always with the same dose and/or concentration of product. A 100mg dose of a 0.1% concentration product will actually contain less active ingredient that a 10mg 2% product, but this might not be apparent from a casual review of the label. This may make determining a “dose” rather difficult. In clinical studies of herbal products, a specific brand is usually used and mentioned; however, that product may not be widely commercially available.
To help a patient in selecting an herbal product, try to find one that complies with the FDA’s Good Manufacturing Practice (GMP) guidelines. This might appear right on the product label. In addition, try to find a manufacturer that is a member of the American Herbal Products Association (AHPA). The AHPA is an organization of herbal manufacturers that agrees to abide by ethical quality standards in their products. Determining a dose for a patient might be complicated, again based upon the myriad of dose forms available, but similar to selecting a prescription medication, employing a “dose escalation” strategy might be prudent, starting with a low dose and increasing based upon patient response.
As mentioned above, the AHPA is a good source of information; their website is http://www.ahpa.org. They have information for consumers on common herbal products and what they are used for, how to select a product, and so forth. They have also added in some information regarding CBD supplements on their site which could be useful. AAPP also has information on CBD available through its website at https://aapp.org/resource/patients/cbd. One of the better quality websites available is the Natural Medicines database at https://naturalmedicines.therapeuticresearch.com/. It provides monographs on individual products, including a review of studies, adverse effects, and potential drug interactions. While it is subscription-based there may be some info available for a product without a subscription. Another potentially useful site for selecting a specific product is https://www.consumerlab.com. Unfortunately this too is a subscription site, but it does provide reviews of commercially available herbal products to help choose between multiple manufacturers of the same product. If you’re having a difficult time selecting among various manufacturers, it might be worth looking into this resource. The federal government also maintains several websites with herbal product information, although they may be more patient-oriented rather than practitioner-oriented. One is the National Center for Complementary and Integrative Health (https://www.nccih.nih.gov/health/herbsataglance) through the National Institutes of Health, and another is through the National Agricultural Library of the U.S. Department of Agriculture (https://phytochem.nal.usda.gov/).
A patient might elect an OTC product over prescription medication for anxiety, or the patient might not be appropriate for prescription treatment due to a relatively low acuity of anxiety symptoms. In these instances, try to approach the patient as if they were taking prescription medications. Provide the patient with non-pharmacologic counseling for anxiety: avoiding caffeine and other stimulants, relaxation techniques, avoiding stimuli that might trigger their anxiety, and so on. You could try to recommend meeting with a therapist for counseling about their anxiety. Try to determine what OTC agent they intend to take, and then check this product against any prescription medications they are already taking, if that is possible. Performing a drug interaction check with their existing prescription medications is highly recommended to help avoid any unexpected problems. Finally, if follow-up visits are to be done, assess the patient’s anxiety to determine if the OTC product is helping. Adverse effects should also be monitored, and if seen then a re-evaluation of the appropriateness of the product should be performed.
