The Role of the Pharmacist on an Integrative Medicine Healthcare Team

Introduction

Pharmacy has existed since the beginning of humanity. The concept that plants could be used as medicine can be traced as far back as c. 30 000 BCE and dosage forms that were developed by the Babylonians, such as pills, enemas, suppositories, washes, and ointments, continue to be used today. ¹ The term pharmacognosy was developed by the Austrian physician J.A. Schmidt in 1811 and is the specific branch of pharmacy that studies drugs of natural origins. ²

Pharmacy has evolved considerably over the years but continues to be an important pillar in communities. Embedded within communities, pharmacists are one of the most accessible and trusted health care professionals. ³ Community pharmacies supply numerous over the counter (OTC) products including dietary supplements (DS) making these pharmacists important access points for the public to gain information about which supplements might be beneficial to them, considerations related to supplement-drug (SDI) or supplement-food interactions, and knowledge about the quality of available DS products. In addition to working in community pharmacies, many pharmacists work in ambulatory care practice settings and health systems. A large portion of these pharmacists are clinical pharmacists.

Clinical pharmacy is defined by the American College of Clinical Pharmacy (ACCP) as, “an area of pharmacy concerned with the science and practice of rational medication use.” ⁴ ACCP elaborates to indicate that clinical pharmacists optimize medication therapy and promote health and disease prevention. Clinical pharmacists have generally completed 1-2 years of post-graduate training after a 4-year Doctor of Pharmacy degree. A core part of clinical pharmacists’ responsibilities is medication reconciliation. Medication reconciliation is an opportunity to add DS and OTC products to a patients’ electronic health record (EHR). A study by Bouwmeester et al suggests that physicians do not always ask about or document patient use of DS emphasizing the importance of pharmacists in this process. ⁵ A thorough medication reconciliation by a clinical pharmacist will lead to safer and more efficacious care for patients. The addition of DS and OTC products to a patients’ EHR also ensures that prescribers can review any SDI and/or disease-supplement interactions as changes are made to patients’ prescription medications.

Pharmacists have established themselves as the medication experts within the healthcare system and have become a critical part of interprofessional teams. The Good Pharmacy Practice (GPP) standards published by the World Health Organization and the International Pharmaceutical Federation as well as numerous publications evaluating the perspectives of patients, pharmacists, and other stakeholders, support pharmacist involvement in managing traditional medicine/complementary medicine, defined as medications, complementary medicine, complementary and alternative medicine products, dietary supplements, herbal medicine, health supplements, vitamins, minerals, and natural products.^6-13 Within this publication we will summarize published literature highlighting unique and essential skills that pharmacists provide to enhance the safety, effectiveness, and coordination of care within integrative medicine teams.

Methods

This manuscript was developed as a narrative review with the aim of synthesizing published literature on the role of the pharmacist within integrative medicine teams. A targeted literature search was conducted in Embase (via Elsevier interfacing) using the following search strategy: (‘role playing’/exp OR role*:ti,ab,kw) AND (‘pharmacist’/exp OR pharmacist*:ti,ab,kw) AND (‘integrative medicine’/exp/mj OR ‘yoga’/exp/mj OR ‘alternative medicine’/exp/mj OR ‘mindfulness’/exp/mj OR ‘dietary supplement’/exp/mj OR ‘herbal medicine’/exp/mj OR ‘meditation’/exp/mj OR ‘acupuncture’/exp/mj OR ‘aromatherapy’/exp/mj OR ‘lifestyle modification’/exp/mj OR ‘exercise’/exp/mj OR ‘wellbeing’/exp/mj OR ‘guided imagery’/exp/mj OR ‘biofeedback’/exp/mj OR ‘massage’/exp/mj OR ‘hypnosis’/exp/mj OR ‘tai chi’/exp/mj OR ‘qigong’/exp/mj OR ‘integrative medicine*’:ti,ab,kw OR ‘alternative medicine*’:ti,ab,kw OR ‘complementary medicine*’:ti,ab,kw OR yoga:ti,ab,kw OR ‘non pharmacologic*’:ti,ab,kw OR ‘mind body’:ti,ab,kw OR mindfulness:ti,ab,kw OR meditation:ti,ab,kw OR ‘dietary supplement*’:ti,ab,kw OR botanical*:ti,ab,kw OR ‘herbal medicin*’:ti,ab,kw OR acupuncture:ti,ab,kw OR aromatherap*:ti,ab,kw OR ‘lifestyle change*’:ti,ab,kw OR ‘lifestyle modification*’:ti,ab,kw OR exercise:ti,ab,kw OR wellness:ti,ab,kw OR ‘guided imagery’:ti,ab,kw OR biofeedback:ti,ab,kw OR massage:ti,ab,kw OR hypnosis:ti,ab,kw OR ‘tai chi’:ti,ab,kw OR qigong:ti,ab,kw OR ‘qi gong’:ti,ab,kw OR ‘whole health’:ti,ab,kw). The search was first run on 14 April 2022 and updated on 12 June 2023. A total of 740 records were screened for inclusion. Articles were considered for inclusion if they (1) described pharmacist involvement in integrative or complementary care, (2) highlighted interprofessional collaboration, or (3) provided relevant context on pharmacist roles in patient-centered models of care. Priority was given to peer-reviewed articles, systematic reviews, and unique models of pharmacist practice published in English. Additional references were identified through citation tracking of included articles. Findings were synthesized thematically to highlight pharmacist roles, opportunities, and challenges in integrative practice rather than to provide a comprehensive systematic evaluation of outcomes. Building on this thematic synthesis of the literature, findings were organized according to key practice settings in which pharmacists contribute to integrative medicine.

Community Pharmacy

Community pharmacy represents a highly visible and accessible setting where pharmacists frequently engage patients in discussion related to holistic health approaches. The following section focuses on the role of community pharmacists, with a particular emphasis on their involvement in dietary supplementation and patient-centered care.

Dietary supplementation is often closely associated with integrative medicine in both public and professional perception. Within the community pharmacy setting, pharmacists are uniquely positioned to guide the safe and evidence-informed use of DS, given their accessibility, medication expertise, and frequent patient interactions. The following section summarizes the literature highlighting pharmacists’ impact in this area, including their roles in counseling, identifying SDI, and supporting patient-centered decision making.

In the United States, 33 to 50% of adults use DS,^14,15 while in the United Kingdom, 45% of survey responders from a small pilot exercise reported use of complementary and alternative medicines (including vitamins, minerals, and DS) within the last year. ¹⁶ These products also contribute to significant expenditure in Canada, Asia, and Australia.^17-21 DS use is high in the US and other nations; therefore, guidance for safe and efficacious use by a healthcare provider (HCP) is critical. Pharmacists in the community pharmacy setting are well positioned to serve as the HCP expert on DS use.

In a systematic review by Ung et al, ⁶ publications evaluating the community pharmacist’s responsibilities related to DS were evaluated. A total of 7 major themes were identified from a review of 41 publications. These themes are to acknowledge and ask about use of DS products, to be knowledgeable about DS products, to ensure safe and appropriate use of DS products, to document the use of DS products by consumers and patients, to report suspected adverse drug events involving DS products, to provide education, and to collaborate with other health care professionals. Evidence suggests that pharmacists, consumers, patient groups, and other stakeholders are generally positive about the role pharmacists can play in providing professional advice on DS.^8-11,13 In 2006, the National Academy of Medicine highlighted the importance of pharmacists in medication therapy management for all prescription and OTC medications that patients may be taking, ²² while a 2004 position statement from the American Society of Health System Pharmacists (ASHP) encouraged pharmacists to not only become more aware of patients’ DS use, but to increase efforts to reduce the risk of SDIs. ASHP extended their guidance further by urging pharmacists to gather patient medication histories, educate patients, and assign formulary inclusion or exclusion to these products. ²³ Such guidance is not unique to the United States; similar position statements have been issued in other countries as well. For example, in Australia, professional pharmacy organizations have developed a roadmap to encourage the extension of pharmacists’ practice to include management of DS. ²⁴ The National Center for Complementary and Integrative Health includes DS as a ‘complementary health approach’. ²⁵ It is evident that major professional organizations are recognizing the role of pharmacists in this area, as this discipline is readily available and accessible at the point of DS decision making, making pharmacists uniquely poised to assist in this setting.

A primary reason for pharmacists’ involvement in this area is to improve patient safety. Risk associated with DS use include adverse drug reactions (ADR), SDIs, and disease-supplement interactions. Health organizations worldwide, such as the World Health Organization – Uppsala Monitoring Center, United States Food and Drug Administration, and Therapeutic Good Administration of Australia are making efforts to create a culture of reporting DS-associated ADRs. Unlike conventional medicines, DS do not undergo clinical trials in which ADRs are most frequently discovered; therefore, pharmacovigilance and ADR reporting for these agents are of particular importance.

A multicenter quasi-experimental study by Lopez-Carmona et al demonstrates how the role of the community pharmacists aimed at improving the use of vitamin D supplementation. ²⁶ Community pharmacists in the Lopez-Carmona et al study enrolled a total of 210 patients with vitamin D deficiency. Provision of education and monitoring services by community pharmacists resulted in increased adherence to vitamin D supplementation from 24.1% to 90.6% and adequate vitamin D levels in 60.3% of enrolled patients.

Beyond the safe and effective use of DS, the pharmacist’s role is now evolving to include a focus on health and wellness. In the study by Simmons-Yon et al, patients seek community pharmacy advice for DS and also value pharmacists for their expertise on self-care and the use of complementary and alternative treatments, such as yoga and acupuncture. ¹¹ ASHP recognizes that community pharmacists’ role in the care continuum is vast, with “health and wellness initiatives” defined as a major focus area of pharmacist care. This may range from counseling on DS to providing guidance on smoking cessation or weight management to administration of immunizations. ²⁷

Community pharmacies are not the only setting in which pharmacists can make a difference in the safe and efficacious use of DS. Shawahna et al demonstrated a high level of consensus among various practitioners in Palestinian healthcare facilities about the importance and need for pharmacist involvement in inpatient facilities to provide education and improve the safe and efficacious use of DS. ²⁸

Oncology Practice

In addition to their general involvement in integrative medicine, pharmacists play a particularly critical role in oncology care, where studies report that up to 80% of patients may use integrative medicine modalities.^29-31 Chemotherapy regimens can be complex with a high rate of drug-drug interactions, narrow therapeutic index, and significant adverse event profiles. Given the characteristics of medications used in the treatment of oncologic conditions, it is particularly critical to have an accurate medication list that is inclusive of DS. Interestingly, studies in this patient population demonstrate that 40-50% of oncology patients do not disclose their use of DS to a healthcare provider either because they did not think it was relevant or because the treating physician did not ask and concern that the physician would discourage use and/or be unable to provide information related to the DS. ³² In a study by Lee et al, a large number of oncology physicians (70%) reported not having adequate knowledge to address questions and concerns related to concurrent DS use with chemotherapy regimens. ³³ A case series by Mellor et al ²⁹ demonstrates how pharmacist drug information skills can help to advise cancer patients interested in using DS to avoid interactions and worsening adverse events with concurrent chemotherapy. Together, these findings highlight the essential role of pharmacists in ensuring safe, informed and coordinated use of DS among oncology patients receiving complex chemotherapy regimens.

Cardiometabolic Management

As with other specialty areas, examples of integrative medicine within cardiology practice are multifaceted, emphasizing patient education, medication management, and interprofessional collaboration. Pharmacists provide counseling to enhance patient understanding of cardiovascular disease (CVD) risk factors, medication adherence, and lifestyle modifications, such as dietary changes and stress management. They are instrumental in monitoring the safe use of DS by ensuring these do not adversely interact with conventional cardiology treatments ³⁴ and by recommending dose adjustments to reduce risk for adverse effects. Pharmacists also bridge communication between patients and healthcare teams, fostering informed decision-making and supporting clinical trials to establish evidence-based practices, including DS. ³⁵

Pharmacists utilizing integrative approaches have been shown to improve medication adherence after myocardial infarction. ³⁶ Beyond structured medication counseling prior to discharge, reinforcement of key non-pharmacologic recommendations such as dietary and lifestyle changes, smoking cessation, physical activity, and moderation of alcohol help to ensure patients understand their full treatment plans. Incorporating this type of education has bolstered adherence and contributed to significant reductions in blood pressure, total cholesterol, blood glucose, and hospital readmissions. ³⁶ Pharmacists implementing blood pressure management approaches have achieved positive outcomes by enhancing awareness and behavioral change support in unique settings.^37,38 Tailored advice from pharmacists for individual patients with cardiometabolic risk in a community setting has led to significant behavior change, highlighting the pharmacist’s role in preventive care and early disease state management.^38,39 In collaboration with other members of the interprofessional team, pharmacists play a unique role in fostering self-management behaviors and empowering patients to take active roles in their health^38,40

The establishment of a consultation clinic involving pharmacists and nutritionists consulting with patients, 24% of whom had a major cardiovascular condition, has been reported to be of value within a Japanese hospital system. ⁴¹ Aiming to provide evidence-based information about DS to patients without directly offering alternative therapies, the clinic also facilitated communication among patients and providers. Most patients had not discussed their DS use with their physicians, leading to potential safety risks due to unmonitored interactions with standard treatments.

By offering tailored interventions and promoting adherence to both evidence-based pharmacologic and non-pharmacologic therapies, pharmacists significantly improve patient outcomes, reduce blood pressure levels, and minimize CVD risks, cementing their role as integral members of the care team when serving patients with cardiovascular risk.

Obesity/Metabolic Syndrome/Diabetes Management

One in every three adults in the United States meets obesity diagnostic criteria, defined as a body mass index (BMI) of greater than 30 kg/m2. ⁴² As obesity is a precursor for many chronic diseases, the pharmacist is in a unique position to offer health counseling earlier in the disease course. One study investigated the role of pharmacists in screening and managing metabolic syndrome in a community pharmacy setting. ⁴³ The objectives included implementing a comprehensive screening program, determining the prevalence of metabolic syndrome, assessing the 10-year risk of coronary heart disease (CHD), and evaluating the effectiveness of pharmacist-led education on lifestyle modifications. The study, conducted in a Pennsylvania community pharmacy between February 2006 and August 2007, screened 239 participants aged 18 years or older with no history of CHD. During 20-minute appointments, pharmacists collected data on cardiovascular risk factors, measured blood pressure and waist circumference, and analyzed blood samples for glucose and lipid profiles using point-of-care testing. The Framingham Risk Assessment was employed to estimate the 10-year CHD risk for participants with metabolic syndrome. Of the participants, 36% were identified as having metabolic syndrome, a prevalence higher than the national average of 31.9%. The most common risk factors included abdominal obesity, elevated blood pressure, and abnormal glucose levels. Pharmacists educated participants on lifestyle changes such as increasing fiber intake, reducing saturated fat consumption, and engaging in regular physical activity. Follow-up surveys revealed that 87% of participants with metabolic syndrome self-reported making lifestyle changes. The study highlighted the importance of pharmacist-led interventions in identifying and addressing risk factors for metabolic syndrome. Participants expressed high satisfaction with the program, and most were willing to return for follow-up screenings. Therefore, community pharmacists can play a critical role in public health by raising awareness, providing screenings, and encouraging lifestyle changes to mitigate risks associated with metabolic syndrome.

Counseling by pharmacists in community practice has been perceived as effective, including obesity management, diet and exercise, and food choices. ⁴⁴ The integration of food choices and exercise counseling favors the role of a pharmacist as a health coach. The role of the pharmacist as a lifestyle coach within a rural health, family medicine center was noted to be successful with weight goals after 6 months’ time. ⁴⁵ Common healthy weight management services noted by pharmacists in one survey of 563 international community pharmacists included BMI measurements (n = 447), advice on healthy eating (n = 515), and supply of weight loss products (n = 481). ⁴⁶

Combining obesity-related weekly health visits with a pharmacist in patients using GLP-1 = /- GIP agonists led to significant improvements in weight management, glycemic control, and cardiovascular risk factors in one 50-patient cohort. ⁴⁷ In this model, pharmacists were responsible not only for dose titration, but for advice related to diet, exercise, protein requirements and managing side effects from the obesity medication. Pharmacist management influenced discontinuation rates and improved other cardiometabolic outcomes such as prediabetes and metabolic syndrome.

Other innovative practice models in the literature include pharmacists integrated into hepatology clinics who manage obesity in patients with metabolic dysfunction-associated fatty liver disease (MAFLD). ⁴⁸ The pharmacist enrolls patients, recommends therapy, and monitors patient success via in-person and telephonic visits. Beyond medication assessment, the pharmacist is also responsible for group patient education classes. In this model, collaborative practice agreements and protocols for addressing evidence based metabolic risk reduction position the pharmacist to intervene early in the disease process.

A recent systematic review revealed improvements in hemoglobin A1C through pharmacist intervention in 24 of 26 trials. ⁴⁹ Involving 5761 participants with diabetes in various countries and health care facilities, the impact of pharmacist involvement in diabetes care influenced A1C, systolic and diastolic blood pressure, LDL and HDL cholesterol, and BMI. Several studies have demonstrated improvements in self-care through pharmacist education, not related to medication related interventions alone.^49,50 Further, using innovative counseling techniques such as motivational interviewing has helped to empower behavior change. ⁵¹

A randomized controlled prospective study of 150 patients demonstrated significant improvement in knowledge scores after pharmacist-initiated education ⁵² while the control group showed no meaningful change. In addition, a more positive attitude toward diabetes management, including regular exercise and adherence to controlled diet was adopted in those receiving pharmacist education. Fasting blood glucose in the pharmacist-led group decreased significantly (173.23 to 136.45 mg/dl, P < 0.000), whereas no significant changes were observed in the control group. Further impact on diabetes outcomes provided by pharmacists in federally qualified health centers has been described. ⁵³ In a small study of 99 patients, pharmacists provided direct care, including medication optimization, education on lifestyle modifications, and management of other comorbid conditions like hypertension and dyslipidemia. The pharmacist-driven care model demonstrated significant reductions in A1c (9.8 to 8.4%, P < 0.05), increased number of patients achieving A1C <9% (from 39% to 62%, P < 0,05) and <7% (from 16 to 26%, P = 0.096), and improvement in the use of ACE inhibitors/ARBs (from 68-78%, P < 0.05) and statins (46-64%, P < 0.05). Both patients and referring providers were highly satisfied (73%) with pharmacist’s care, particularly in education and accessibility. Given that even a single pharmacist-led education session can lead to meaningful improvements in A1C and weight, ⁵⁴ continuous pharmacist involvement in diabetes care has the potential for best possible outcomes.

Limitations

This review is limited by its narrative design and by the availability of publications describing pharmacists’ roles in integrative medicine. Existing literature may underestimate the scope of pharmacist contributions, which likely extend beyond the disease states and settings highlighted here. In addition, the publications included in this review demonstrated substantial heterogeneity in study design, practice location, and outcome measures, which limits the ability to draw consistent conclusions. Much of the survey data on DS and integrative medicine use derives from older publications, though these were supplemented with more recent sources where possible. Lifestyle counseling was included as a pharmacist contribution within integrative medicine, but it should be noted that this is not integrative medicine per se. Rather, lifestyle modification is an important component of patient-centered care that is often incorporated into integrative medicine approaches. Several publications we reviewed identified lifestyle counseling as a pharmacist role within the broader context of integrative medicine, particularly in relation to chronic disease management and wellness promotion. Together, these limitations highlight important opportunities for future research to more fully characterize and evaluate the breadth of pharmacists’ contributions to integrative medicine.

Conclusion

Pharmacists’ accessibility, expertise in medication management, and frequent patient interactions uniquely position them to contribute to integrative medicine approaches, especially in chronic disease management. Their involvement with patients using traditional and complementary medicine is essential to ensuring the safe and effective integration of these therapies with prescribed pharmacotherapy, while also facilitating interprofessional communication. Evidence from diverse practice settings highlights pharmacists’ contributions to improved outcomes through patient education, disease prevention and screening, lifestyle counseling, and collaboration within multidisciplinary teams. These findings underscore the expanding role of pharmacists in integrative medicine and highlight the need for continued research and implementation efforts to fully realize their potential within interprofessional care models.