Pharmacy

Materia medica

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Pharmacy is the science and technique of preparing and dispensing drugs. It is a health profession that links health sciences with chemical sciences and aims to ensure the safe and effective use of pharmaceuticals. Since pharmacists know about the mode of action of a particular drug, and its metabolism and physiological effects on the human body in great detail, they play an important role in optimization of a drug treatment for an individual.

The scope of pharmacy practice includes more traditional roles such as compounding (reformulating) and dispensing medications, and it also includes more modern services related to health care, including clinical services, reviewing medications for safety and efficacy, and providing drug information. Pharmacists, therefore, are the experts on drug therapy and are the primary health professionals who optimize use of medication for the benefit of the patients.

An establishment in which pharmacy (in the first sense) is practiced is called a ‘pharmacy’ (this term is more common in the United States) or achemist’s (which is more common in Great Britain). In the United States and Canada, drugstores commonly sell drugs, as well as miscellaneous items such as confectionery, cosmetics, office supplies, and magazines and occasionally refreshments and groceries.

The word pharmacy is derived from its root word ‘pharma’ which was a term used since the 15th–17th centuries. However, the original Greek roots from ‘pharmakos’ imply sorcery or even poison. In addition to pharma responsibilities, the pharma offered general medical advice and a range of services that are now performed solely by other specialist practitioners, such as surgery and midwifery. The ‘pharma’ (as it was referred to) often operated through a retail shop which, in addition to ingredients for medicines, sold tobacco and patent medicines.

Often the place that did this was called an ‘apothecary’ and several languages have this as the dominant term, though their practices are more akin to a modern pharmacy, in English the term apothecary would today be seen as outdated or only appropriate if herbal remedies were on offer to a large extent. In its investigation of herbal and chemical ingredients, the work of the pharma may be regarded as a precursor of the modern sciences of chemistry and pharmacology, prior to the formulation of the scientific method.

The field of pharmacy can generally be divided into three primary disciplines: Pharmaceutics (the science of dosage form design), Medicinal Chemistry and Pharmacognosy (the study of medicinal drugs derived from plants or other natural sources), and Pharmacy Practice (e.g. disease-state management, clinical interventions). The boundaries between these disciplines and with other sciences, such as biochemistry, are not always clear-cut. Often, collaborative teams from various disciplines (pharmacists and other scientists) work together toward the introduction of new therapeutics and methods for patient care. However, pharmacy is not a basic or biomedical science in its typical form. Medicinal chemistry is also a distinct branch of synthetic chemistry combining pharmacology, organic chemistry, and chemical biology.

Pharmacology, the study of the effect of chemicals on living organisms is sometimes considered as the fourth discipline of pharmacy. Although pharmacology is essential to the study of pharmacy, it is not specific to pharmacy. Both disciplines are distinct. Those who wish to practice both pharmacy (patient oriented) and pharmacology (a biomedical science requiring the scientific method) receive separate training and degrees unique to either discipline. Pharmacoinformatics is considered another new discipline, defined by the use of information technology for systematic drug discovery and development with efficiency and safety.

In the United States, specializations in pharmacy practice recognized by the Board of Pharmacy Specialties include: cardiovascular, infectious disease, oncology, pharmacotherapy, nuclear, nutrition, and psychiatry. The Commission for Certification in Geriatric Pharmacy certifies pharmacists in geriatric pharmacy practice. The American Board of Applied Toxicology certifies pharmacists and other medical professionals in applied toxicology.

Pharmacy technicians support the work of pharmacists and other health professionals by performing a variety of pharmacy related functions, including dispensing prescription drugs and other medical devices to patients and instructing on their use. They may also perform administrative duties in pharmaceutical practice, such as reviewing prescription requests with medics’s offices and insurance companies to ensure correct medications are provided and payment is received. They are not generally allowed to perform the role of counseling patients on the proper use of their medications.

Compounding is the practice of preparing drugs in new forms. For example, if a drug manufacturer only provides a drug as a tablet, a compounding pharmacist might make a medicated lollipop that contains the drug. Patients who have difficulty swallowing the tablet may prefer to suck the medicated lollipop instead. Another form of compounding is by mixing different strengths of capsules or tablets to yield the desired amount of medication indicated by the physician, physician assistant, Nurse Practitioner, or clinical pharmacist practitioner. This form of compounding is found at community or hospital pharmacies or in-home administration therapy. Compounding pharmacies specialize in compounding, although many also dispense the same non-compounded drugs that patients can obtain from community pharmacies.

The earliest known compilation of medicinal substances was the ‘Sushruta Samhita,’ an Ayurvedic (holistic Indian medicine) treatise attributed to ancient Indian physician Sushruta in the 6th century BCE. However, the earliest text as preserved dates to the 3rd or 4th century CE. Ancient Egyptian pharmacological knowledge was recorded in various papyri such as the ‘Ebers Papyrus’ of 1550 BCE, and the ‘Edwin Smith Papyrus’ of the 16th century BCE.

In Ancient Greece, Diocles of Carystus (4th century BCE) was one of several men studying the medicinal properties of plants. He wrote several treatises on the topic. The Greek physician Pedanius Dioscorides is famous for writing a five volume book in his native Greek 1st century CE. The Latin translation ‘De Materia Medica’ (‘Concerning medical substances’) was used a basis for many medieval texts, and was built upon by many middle eastern scientists during the Islamic Golden Age. The title coined the term ‘materia medica,’ a medical term for the body of collected knowledge about the therapeutic properties of any substance used for healing.

The earliest known Chinese manual on materia medica is the ‘Shennong Bencao Jing’ (‘The Divine Farmer’s Herb-Root Classic’), dating back to the 1st century CE. It was compiled during the Han dynasty and was attributed to Shennong (lit. ‘Divine Farmer’), a mythical sage ruler of prehistoric China also known as the ‘Emperor of the Five Grains.’ Earlier Chinese literature included lists of prescriptions for specific ailments, exemplified by a manuscript ‘Recipes for 52 Ailments,’ found in the Mawangdui tomb, sealed in 168 BCE.

In Japan, at the end of the Asuka period (538–710) and the early Nara period (710–794), the men who fulfilled roles similar to those of modern pharmacists were highly respected. The place of pharmacists in society was expressly defined in the Taihō Code (701) and re-stated in the Yōrō Code (718). Ranked positions in the pre-Heian Imperial court were established; and this organizational structure remained largely intact until the Meiji Restoration (1868). In this highly stable hierarchy, the pharmacists—and even pharmacist assistants—were assigned status superior to all others in health-related fields such as physicians and acupuncturists. In the Imperial household, the pharmacist was even ranked above the two personal physicians of the Emperor.

In Baghdad the first pharmacies were established in 754 under the Abbasid Caliphate during the Islamic Golden Age. By the 9th century, these pharmacies were state-regulated. The advances made in the Middle East in botany and chemistry led medicine in medieval Islam substantially to develop pharmacology. Abu al-Qasim al-Zahrawi (‘Abulcasis’) (936–1013) pioneered the preparation of medicines by sublimation and distillation. His ‘Liber servitoris’ is of particular interest, as it provides the reader with recipes and explains how to prepare the ‘simples’ from which were compounded the complex drugs then generally used. Sabur Ibn Sahl (d 869), was, however, the first physician to initiate pharmacopoedia (the authoring of official books containing directions for the identification of compound medicines).

Al-Biruni (973–1050) wrote one of the most valuable Islamic works on pharmacology, entitled ‘Kitab al-Saydalah’ (‘The Book of Drugs’), in which he detailed the properties of drugs and outlined the role of pharmacy and the functions and duties of the pharmacist. Avicenna, too, described no less than 700 preparations, their properties, modes of action, and their indications. He devoted in fact a whole volume to simple drugs in ‘The Canon of Medicine.’ Of great impact were also the works by al-Maridini of Baghdad and Cairo, andIbn al-Wafid (1008–1074), both of which were printed in Latin more than fifty times, appearing as ‘De Medicinis universalibus et particularibus’ by ‘Mesue’ the younger, and the ‘Medicamentis simplicibus’ by ‘Abenguefit.’ Peter of Abano (1250–1316) translated and added a supplement to the work of al-Maridini under the title De Veneris.

Al-Muwaffaq’s contributions in the field are also pioneering. Living in the 10th century, he wrote ‘The foundations of the true properties of Remedies,’ among others describing arsenious oxide, and being acquainted with silicic acid. He made clear distinction between sodium carbonate and potassium carbonate, and drew attention to the poisonous nature of copper compounds, especially copper vitriol, and also lead compounds. He also describes the distillation of sea-water for drinking.

In Europe pharmacy-like shops began to appear during the 12th century. In 1240 emperor Frederic II issued a decree by which the physician’s and the apothecary’s professions were separated. The first pharmacy in Europe (still working) was opened in 1241 in Trier, Germany. In Europe there are old pharmacies still operating in Dubrovnik, Croatia, located inside the Franciscan monastery, opened in 1317; and in the Town Hall Square of Tallinn, Estonia, dating from at least 1422. The oldest is claimed to have been set up in 1221 in the Church of Santa Maria Novella in Florence, Italy, which now houses a perfume museum. The medieval Esteve Pharmacy, located in Llívia, a Catalan enclave close to Puigcerdà, also now a museum, dates back to the 15th century, keeping albarellos from the 16th and 17th centuries, old prescription books and antique drugs.

Since about the year 2000, a growing number of Internet pharmacies have been established worldwide. Many of these pharmacies are similar to community pharmacies, and in fact, many of them are actually operated by brick-and-mortar community pharmacies that serve consumers online and those that walk in their door. The primary difference is the method by which the medications are requested and received. Some customers consider this to be more convenient and private method rather than traveling to a community drugstore where another customer might overhear about the drugs that they take. Internet pharmacies (also known as online pharmacies) are also recommended to some patients by their physicians if they are homebound.

While most Internet pharmacies sell prescription drugs and require a valid prescription, some sell prescription drugs without requiring a prescription. Many customers order drugs from such pharmacies to avoid the ‘inconvenience’ of visiting a doctor or to obtain medications which their doctors were unwilling to prescribe. However, this practice has been criticized as potentially dangerous, especially by those who feel that only doctors can reliably assess contraindications, risk/benefit ratios, and an individual’s overall suitability for use of a medication. There also have been reports of such pharmacies dispensing substandard products.

Of particular concern with Internet pharmacies is the ease with which people, youth in particular, can obtain controlled substances (e.g., Vicodin, generically known as hydrocodone) via the Internet without a prescription issued by a doctor/practitioner who has an established doctor-patient relationship. There are many instances where a practitioner issues a prescription, brokered by an Internet server, for a controlled substance to a ‘patient’ s/he has never met. In the United States, in order for a prescription for a controlled substance to be valid, it must be issued for a legitimate medical purpose by a licensed practitioner acting in the course of legitimate doctor-patient relationship. The filling pharmacy has a corresponding responsibility to ensure that the prescription is valid. Often, individual state laws outline what defines a valid patient-doctor relationship.

Canada is home to dozens of licensed Internet pharmacies, many of which sell their lower-cost prescription drugs to US consumers, who pay one of the world’s highest drug prices. In recent years, many consumers in the US and in other countries with high drug costs, have turned to licensed Internet pharmacies in India, Israel and the UK, which often have even lower prices than in Canada. In the United States, there has been a push to legalize importation of medications from Canada and other countries, in order to reduce consumer costs. While in most cases importation of prescription medications violates Food and Drug Administration (FDA) regulations and federal laws, enforcement is generally targeted at international drug suppliers, rather than consumers. There is no known case of any US citizens buying Canadian drugs for personal use with a prescription, who has ever been charged by authorities.

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