Design and Implementation of an Elective on the Ethnopharmacology of Appalachia for the PharmD Curriculum

Rebecca S. Linger, PhD


Am J Pharm Educ. 2017;81(10):6100 

In This Article

Abstract and Introduction


Objective. To create and implement a class in ethnopharmacology that would educate student pharmacists on folk medicine, including home remedies and native plants that are used as alternative medicinal sources; active components of medicinal plants including toxicity issues and the mechanism of action of beneficial compounds, such as catechins and other flavonoids; and nutraceuticals and poisonous plants.

Methods. In this three-credit hour class, herbal remedies are investigated from the standpoints of medical efficacy, potential toxicities and drug interactions with prescribed medications. Class discussions are conducted on the usefulness of remedies, the attitudes of practitioners toward traditional remedy use and the risks of relying on herbal preparations. Each student prepares a 15-minute presentation on a disease state, which covers modern pharmaceuticals and herbal or folk remedy alternatives used in that disease. Special emphasis is given to drug-herb interactions.

Results. The class has gained popularity among students and consistently fills within the first hour of computerized registration. Students agree that being educated in the benefits and potential toxicities of herbal products will better prepare them to counsel their patients who use these remedies. The elective has been offered 10 times since 2007. Anecdotal comments from our alumni indicate that they have found the information to be very useful in their practice environments.

Conclusion. Providing our students with a greater understanding of herbal remedies is essential to prepare them for practice. By including both the uses and potential toxicities, the student pharmacist is able to counsel her patients from a standpoint of expertise on these self-administered remedies.


The popularity of herbal medicine and alternative remedies remains strong within the United States. The National Center for Health Statistics has conducted the National Health Interview Survey (NHIS) on complementary and alternative medicines nationwide since 1997. This survey, conducted every five years, asks adults living in the United States about their use of herbal preparations and dietary supplements. In 2012, the NHIS reported that 53.6 million Americans utilized herbal remedies and dietary supplements.[1] The sale of botanical dietary supplements was estimated at $11.5 billion in 2012.[2] A population-based survey of 2,982 respondents conducted by Emory University in 2004 indicated that while 20% of the population used medicinal herbs, over 33% admitted to daily use.[3] People who use dietary supplements report feeling an increase in general well-being and energy and feel that the supplements will help them fight or prevent various diseases.[4] As our nation continues its pursuit of healthier lifestyles, we can expect the use of herbal supplements to continue to rise. Thus, the education of our student pharmacists in the uses of herbal supplements is of utmost importance.

In a 1998 report on complementary and alternative medicine (CAM) education in U.S. pharmacy schools, Rowell and Kroll indicated that 60% of schools responding presented herbal medicine in their curriculum, either in standalone classes or as part of the core curriculum.[5] The guidelines they developed for CAM coursework for pharmacy schools stress the critical evaluation of the efficacy of the herbal remedies discussed. In 2003, Shields and colleagues found that 63% of schools responding had a specific course in natural products within their curriculum, with the majority of these classes offered as electives.[6] In 2013, Noureldin and colleagues reported that while the majority of students surveyed had a positive opinion of CAM, students who had "personal experience, pharmacy education and family background" with CAM had a more favorable attitude toward its use.[7]

The importance of educating student pharmacists in the use and risks of herbal remedies cannot be overstated. The study of commercially available herbal supplements and an understanding of the lax regulatory oversight in their production are essential. The Dietary Supplement Health and Education Act of 1994 was established to help regulate products to be used for nutritional supplementation, but does not require certification or registration of active ingredients or potencies.[8] Consequently, some commercially available nutritional supplements may contain insufficient quantities of active ingredients for efficacy, or competing brands may have significantly different concentrations of active ingredient leading to overdose or significant drug-herb interactions in the patient who is unaware that the concentration has increased from one brand to the next.

Given the large market for herbal supplements, it is interesting to note that many of the herbal remedies used today in Appalachia utilize foraged plants. The remedies have been passed down through oral tradition from ancestors who settled this area in the late 18th and early 19th century. For the uninitiated, descriptions of these remedies can be found in publications, such as almanacs, family medicine books and herbal texts, many of which date back to the homesteading period. Self-treatment with "tried and true" family remedies is part of the Appalachian spirit of self-reliance, which also includes the reluctance to seek outside medical attention.[9] Although many Appalachians will admit to a lack of medical knowledge, their faith in family remedies will foment their reliance on self-treatment. Economic issues also influence their choices; many families do not have adequate health insurance, or medical personnel and facilities may be too far away.[10] Pharmacy education in these rural areas should take these factors into account and include discussions of alternative remedies and practices of the local population.

According to Standard 12 of the "Accreditation Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree" (Accreditation Council for Pharmacy Education 2016),[11] "the didactic portion of the pre-APPE curriculum includes rigorous instruction in all sciences that define the profession" including "evidence-based evaluation of the therapeutic value, safety, and regulation of pharmacologically active natural products and dietary supplements. Cultural practices commonly selected by practitioners and/or patients for use in the promotion of health and wellness, and their potential impact on pharmacotherapy" (Appendix 1 of Standards 2016). Patient-centered care must consider the health-literacy of the patient as well as any cultural issues that might need to be addressed. Student pharmacists need to understand the cultural background of their patients and be able to describe prescribed therapies and potential interactions in terms that can be understood by the patient. In this course, we expose the students to the folk lexicon of Appalachian residents, such as "risings" for hives or boils, "piles" for hemorrhoids, dropsy for edema.[12] This sensitivity to the patient is also prescribed by the Center for the Advancement of Pharmaceutical Education (CAPE) 2013 Educational Outcomes, which describes within Domain 3 the need to advocate for the patients' best interests in a way that engages cultural sensitivity.[13]

This article describes the design and implementation of a class in ethnopharmacology. The University of Charleston resides in the heart of Appalachia. Approximately 70% of the students come from counties considered part of Appalachia by the Appalachian Regional Commission. Focusing on herbal supplement and folk medicine use following the traditions of Appalachia, this class adequately trains students to counsel their patients in a more culturally sensitive manner.