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Let’s Get This Straight – Greed is NOT Good.

greed stop signWhen greed gets involved, bad things happen. This seems to be a universal truth – whether we’re talking about the sub-prime loan fiasco in the financial industry, or the recent scandal in the world of compounding pharmacy where some pharmacies were overcharging insurance companies for customized medications for profit-driven motives.

From our experience as members of the compounding pharmacy community, the pharmacies that gamed the system were in a small minority. In fact, what has always inspired us about running a compounding pharmacy is the opportunity to help our patients achieve real health benefits from customized medications and to collaborate with colleagues who feel the same. In our own compounding pharmacy and in many others we know across the country, much care is taken to price compounds fairly.

We want to speak out as owners of one compounding pharmacy to say that greed, especially in our industry where people’s health is at stake, is never okay. The compounding industry has received a blow to its reputation due to the greed of a few. And the most unfortunate consequence is that patients are the ones who ultimately suffer. Many insurance plans now no longer cover certain compounded medications in response to the overcharging practices of a few pharmacies. Now if a patient is using a compounded topical cream with anti-inflammatory ingredients and ingredients that block nerve pain – a cream that precludes the use of oral opioids that we know can lead to addiction and other serious health problems – they probably need to pay four or five times what their previous co-pay was. And that’s a shame.

Compounding pharmacies now have to work to advocate for the reinstatement of insurance coverage for many customized medications. This is an important role for compounding pharmacies to play, for they see on a day-to-day basis how these medications can make a tangible, positive difference in people’s lives. Some of those real-life examples can be seen on  PCCA’s “Protect My Compounds” webpage.

We believe it is also important to be honest and forthcoming about the role greed played in the recent restriction in coverage of compounded medications, even though this truth is uncomfortable to talk about.

Ironically, the industry of compounding pharmacy was not so long ago on the other side of a story about greed, this time playing the role of the magnanimous alternative to a greedy pharmaceutical company. It was the case of a drug called 17 alpha-hydroxyprogesterone caproate, often prescribed to help lower the risk of pre-term births. Compounding pharmacies were able to make this medication for an affordable price of $20 per dose until KV Pharmaceutical got FDA approval for their own brand-name version of the drug, called Makena. Suddenly, the price of the same drug – 17 alpha-hydroxyprogesterone – went to $1,500. The reasoning behind the phenomenal increase in price from $20 to $1,500 was never convincingly argued by KV Pharmaceutical, and greed’s role in the controversy was easy to discern. (You can read a great recap of the Makena story in this blog article, “Pregnancy Woes: Why did the price of my progesterone skyrocket?”)

It’s easy to see greed in others. It’s harder to see in ourselves. It’s also hard to regulate greed. But if we’re more aware of its power to cloud judgment, we can be ready to recognize it and speak out against it when we first see it – especially in the very industries in which we work.

No one says it better than Sweet Honey in the Rock (click here to listen).

Krista Shaffer, Outreach Director, & Peter Koshland, PharmD

Koshland Pharm


6 Questions for Evaluating Scientific-Based Articles


When researching matters related to our own health, it can be daunting at times to wade through the massive amount of data available to us now through the internet. I recently saw a short article summarizing some key questions to keep in mind any time we read a scientific study.  This article with tips for evaluating scientific-based articles was written by Jane Houston and Robyn Correll Carlyle on the site

The six helpful questions they highlight are:

1. Does the study confuse correlation with causation?

2. What is the sample size of the study?

3. Is the study controlled or uncontrolled?

4. Are the results replicable?

5. Is there any conflict of interest for the authors?

6. Is the publication the study appears in peer-reviewed?


For more explanation of these questions, see this easy-to-read article at

–Krista Shaffer, Outreach Director at Koshland Pharm


Holistic Care Can Be For Pets, Too!

Rachael Feigenbaum, VMD

Rachael Feigenbaum, VMD

Did you know that pets can benefit from acupuncture just like humans can? We had a chance recently to interview Bay Area veterinarian Rachael Feigenbaum, VMD, about her holistic approach to treating animals.

How would you describe your practice approach?
Lotus is an integrative house-call practice, which means we combine acupuncture, Chinese herbs, and nutritional therapies along with more traditional western therapies to tailor the treatment to the individual animal. When I use the word “holistic” to describe my practice, I mean that I use everything at my disposal to give the animals the best quality care possible.

Acupuncture is one example of this. The Chinese performed acupuncture on horses dating back 5,000 years, but in terms of cat and dog acupuncture, it’s more recent. Anything that involves pain, such as arthritis or back pain, tends to respond well to this treatment. I also treat chronic illnesses (such as chronic renal failure), depression of the immune system, and behavioral issues with acupuncture. The animals enjoy it; while the needles are in, they feel really relaxed. There’s a spot on the top of the head that is an amazing calming point. Sometimes, I put a needle right into that point and you can see an immediate change in demeanor – they become ready for a nap. What people have typically told me is that the next day, their animal acts like a puppy, and they can see their energy level, mobility, and appetite have improved.

Another kind of therapy that we’ve recently added to Lotus is called “Cold Therapy,” which is a very specific frequency of light that penetrates into tissues. The laser can penetrate up to four centimeters deep and helps with pain and inflammation and promotes healing at the cellular level. For animals that are more sensitive to needles, we can use cold laser therapy with or instead of acupuncture, and often get a similar effect.

Another tool in my holistic approach is the use of Chinese herbs. The idea behind the herbs is to look for patterns that the animals display and then come up with a very specific formulation that’s going to address the specific problem. Chinese herbs allow me to decrease some western medicines, or to potentially reduce some of the side effects.

How do you use compounded medications in you practice?
Part of the whole picture of maximizing outcomes and using the best combination of all the tools at my disposal is to offer my clients medications that are customized to meet their individual pet needs. Compounding works especially well in animals because of the range in size. I see animals from three pounds to 160
pounds, so a dose formulation and a method that is going to work for that individual patient is key to having a successful outcome.

I’ve had good results with the KoshClear that Koshland Pharmacist Maryam Tabatabaei introduced me to. KoshClear is a bioadhesive gel that can include anti-fungal medications, antibiotics, and/or steroids. In addition to being a convenient way to treat otitis (ear infections) in a single application, I’ve found some even more creative uses for it. There’s a certain condition that we sometimes see in dogs which is a hematoma inside the flap of the ear. This can be hard to treat and oftentimes requires extensive surgery. What’s been working really well for me is to make an incision to open that pocket up and let the blood fluid out of it, and then inject the KoshClear into the flap. Having the bioadhesiveness of the KoshClear with steroids added is ideal because not only are you helping with the inflammation, but you’re coating the entire surface as well.

What is keeping you inspired in your work these days?
I see how much love my clients have for their animals, and how much the animals mean to them as family members. It brings me so much happiness to see their animals thrive and do well.

I also really value being able to volunteer for organizations that allow people and their animals to stay together. We’re fortunate in San Francisco because there are organizations dedicated to helping people who are low-income to be able to maintain the love and support they get from their pets. For example, Pets Are Wonderful Support is a non-profit that provides people who are low-income and have disabling illnesses with veterinary services, donated pet food, and other related aide. Allowing people to keep their pets throughout their illnesses is a core part of their healthcare delivery system. The other organization I volunteer with is the Veterinary Street Outreach Services, which provides free veterinary care to pets that belong to the homeless population. People really benefit from having that companionship; often it’s their best friend and their family. I see how animals contribute so much to people’s physical and emotional health. For me, having a role in nurturing the bond between people and their animals is deeply rewarding.

For more information about Dr. Feigenbaum and Lotus Veterinary House Calls, visit:

~Krista Shaffer & Lindsey Bourcier, Outreach Team at Koshland Pharm and Peter Koshland, PharmD

Interview with Integrative Pediatrician Dr. Julia Getzelman


Dr. Julia Getzelman, MD, FAAP

Did you hear the recent radio series on Human Media about integrative medicine, entitled “The Search for Well-Being?” We feel it’s well-worth a listen, available free on Human Media’s website.

There are many different names for an integrative approach to health – functional medicine, naturopathic medicine, slow medicine, holistic medicine. In our experience, this approach to health and healing prioritizes finding the root cause of symptoms, taking the whole person (not just a specific medical condition) into account when creating a treatment approach, and spending time educating and supporting patients in healthy living choices that can help prevent disease.

We recently had the opportunity to interview one Bay Area pediatrician, Dr. Julia Getzelman, who practices functional medicine in her pediatric practice, Getzwell Pediatrics. We find this kind of holistic care for children and families inspiring and hope you do, too!

~Krista Shaffer, Outreach Director at Koshland Pharm

Highlights of interview with Dr. Julia Getzelman, MD, FAAP

The Getzwell Approach: Functional Medicine

Functional medicine significantly informs our practice of pediatric care at GetzWell – both on a day to day preventive level and in more complex cases such as autoimmune illness, asthma and eczema. This approach distinguishes us from almost all other pediatric practices. Allopathic medicine, the model in which all MDs are trained, teaches doctors that the body is a collection of independently functioning organ systems and is premised upon symptom suppression, usually through the use of prescription medication. Some call this the “one ill one pill” paradigm.

Functional medicine, using the most current science, focuses on the interlocking physiologic systems that underlie all processes that lead to health and
illness. The idea is that the body’s organ systems are interdependent, like a wheel and its spokes. In order for the wheel to turn, the spokes must be present and in balance. If you remove or even slightly bend one of the spokes, the wheel can’t function as it’s meant to. The same is true
of the human body.

At GetzWell we don’t reject the allopathic model. We provide a more comprehensive approach to care, combining the best of allopathic, functional
and homeopathic medicine. By understanding and impacting underlying causes, instead of just suppressing symptoms, we support wellness and
the body’s innate healing abilities. Functional medicine influences my daily approach to care in a variety of ways. As an example, when a baby is
born by Cesarean section (C-section) and doesn’t have the opportunity to be coated with beneficial bacteria from the vaginal antibiotics for Group B streptococcus (strep), I typically recommend probiotics for the infant. This addresses the fact that in both of these birth scenarios the baby is deprived of important microbes which are fundamental to early gut colonization and subsequent immune functions.

In functional medicine the health of the intestinal tract is inextricably linked to overall health. About 70 percent of the immune system is in the gut. The ‘bugs’ in our guts and what we eat provide information to our immune cells. In a child with a developing immune system, we have the opportunity to quite literally educate those immune cells by what goes and grows in the intestines.

Relationship-Based Medicine

At GetzWell the foundation of the care we provide also rests on the relationships that we have with families. These relationships often begin shortly after the baby is born and in the baby’s home – we offer house calls. Transitioning to the role of new parent is challenging on many levels and we love supporting families during this time by providing an extra level of service and sensitivity. We also provide longer appointments and 24/7 access via email and phone. We’re like the old-fashioned doc but with all the modern accoutrements.

Compounding Success Story

We don’t practice cookie cutter medicine. What we do is much more individualized than is typical of most high volume practices. We also support
the entire family. We want our families to know that they can reach out to us about anything, even if it blurs the traditional lines between pediatrics and family medicine. We want parents, and moms in particular, to come to us if they have issues we can help with, like mastitis or breast feeding problems. If we can’t provide what’s necessary, we make thoughtful referrals.

An example of a customized, or compounded medication,  that we’ve had success with is all-purpose nipple ointment from Koshland Pharm. We use it when we think there might be a fungal or bacterial infection of the breast skin or when there are nipple complaints due to breastfeeding. It has
provided significant relief for many nursing mothers. The compounded ointment is a mixture of anti-fungals, anti-bacterials, topical steroids, and sometimes ibuprofen.

Current Inspirations

One of my convictions is that whole kid care starts before your baby is born. This is supported by the science of fetal origins of adult disease. The research in ‘fetal origins’ examines the factors (including nutrition, environmental toxins, stress, etc.) during pregnancy that can shape the physical,
mental and even emotional well-being of the developing baby for the rest of its life! I invite women into my practice early in their pregnancies, or even pre-conception along with their partners, in order to set the stage for the healthiest baby possible.

For more information about Dr. Getzelman and Getzwell Pediatrics, visit:

Map of the Spirit: Assessing and Addressing Spiritual Stress As a Component of Healing

Map-of-the-Spirit-Cover-smallDo you experience spiritual stress? Could this be a contributing factor to a health condition you are facing, and therefore an important area to address as a part of your healing process?

Dr. Michael Cantwell, an integrative physician who practices in San Francisco, sets out to answer these questions in his recently published book, Map of the Spirit. Dr. Cantwell gave a presentation this January at the Commonwealth Club, explaining this unique approach of looking at spirituality as one aspect of health and healing. He realized that the paradigm he had learned in his own medical training of looking at the role the mind and body can play in illness was  missing a crucial piece for some of his patients: taking into account one’s experiences with spirituality.

Dr. Cantwell defines spirituality very broadly – as a way people find meaning in their lives, or what they believe exists or doesn’t exist beyond human experience. This looks different for each individual – dualist theology (a belief in God such as in Christianity, Judaism, or Islam) might speak to some; non-dualism (a belief in the oneness of all, such as in Taoism or Buddhism) might speak to others; atheism (the belief that God does not exist) also represents an important belief system in this definition of a person’s spirituality.

What everyone has in common, Dr. Cantwell argues, no matter what form their spirituality takes, is that their health can potentially benefit from 1) determining their beliefs and 2) living out of those beliefs in their day-to-day lives. Dr. Cantwell proposes that people can experience spiritual stress, just as they can experience physical and mental stress. Because stress has a known negative impact on our health, and, it can even be argued, leads to the majority of diseases from which Americans actually die, it is important to take into account and attempt to remedy one’s level of spiritual stress if it proves to be high.

How does one assess spiritual stress? Dr. Cantwell provides a simple formula in his book: rank on a scale from one to ten how important spirituality is to you in your life. Next, measure on a scale of one to 10 how satisfied you feel spiritually. Then, subtract your satisfaction from your interest. If the resulting number is low, you are experiencing a low level of spiritual stress; if it is high, you might want to consider taking spirituality into account when making a plan for your path to wellness.

This is only the beginning of Dr. Cantwell’s theory he presents with both practical tools (such as a the measurement of spiritual stress) as well as real patient examples (patients form diverse spiritual backgrounds). For those interested to learn more, you will find in his book four different stages of spiritual development; examples of resistance that a person may experience moving from one stage to another; strategies for removing those blockages and increasing attention to spiritual development – all within the framework of thought that one stage is not inherently better than another. Rather, he suggests that the most important time for intervention in spiritual health is when, or if, spiritual stress is high.

What if, Dr. Cantwell asks, we put spirituality onto the map of what we look at when assessing overall health? Map of the Spirit provides a practical and thought-provoking approach for patients and doctors to consider when addressing health challenges.

For more information about Map of the Spirit, see Dr. Cantwell’s website

~Krista Shaffer, Outreach Director at Koshland Pharm

New Compounding Law H.R. 3204: One Pharmacist’s Perspective

Sacramento state house

Sacramento state house

A little over a year ago, an outbreak of meningitis cases caused by injectable steroid medications made by a compounding pharmacy in Massachussetts cast a national spotlight on the compounding profession. As a result of this tragedy, new legislation was signed into law in November, 2013. This new legislation, called “H.R. 3204,”” strives to create legal distinctions between traditional compounding pharmacies and a newly designated category of pharmacy called an “outsourcing facility.”

A traditional compounding pharmacy is defined as one that mostly dispenses customized medications on a case-by-case, patient specific basis. Outsourcing facilities, on the other hand, will more closely resemble drug manufacturers in that they make large quantities of medications that are not patient-specific and that can be shipped regularly across state lines.

Although outsourcing facilities are now being encouraged to officially register with the Food and Drug Administration (FDA), traditional compounding pharmacies (such as Koshland Pharm) will continue to be regulated by their individual state boards of pharmacy. The FDA has always had and will continue to have the authority to inspect any facility or business that stores medications, which means that it can inspect a traditional compounding pharmacy at any time. However, H.R. 3204 puts the FDA’s greatest attention on outsourcing facilities, and it clarifies state boards’ of pharmacy responsibility to regulate traditional compounding pharmacies in their jurisdiction.

There are many aspects of the new legislation that will only become clear once it begins to be enforced in the coming year. One question that remains is how the FDA will carry out its power to create a “do not compound” list for both traditional compounding pharmacies and outsourcing facilities alike. In the past, the FDA has written statements expressing concerns about certain kinds of commonly compounded medications, such as the hormone estriol, but without citing specific research that led them to have these concerns (see my past blog post on the FDA and estriol for further information). Up until now, the FDA has not prohibited compounding pharmacies from making estriol, even though it has had the power to do so. Although the FDA has not taken this action in the past, it could potentially do so in the future at their discretion.

Stay tuned for on-going updates about this recent law and how it is impacting the field of customized medications. Feel free to post questions here for a dialogue about this important topic for the future of customized medications.

~Peter Koshland, PharmD

Bioidentical Hormone Therapy Team: Patient, Doctor and Pharmacist

APatel photoWe are pleased to have a guest post this week on our blog. We welcome your comments and feedback.

~ Krista Shaffer, Outreach Director at Koshland Pharm

Many people want to know the process involved for bioidentical hormone replacement before starting treatment. There are Whos, Whats, Whens, and Whys involved before starting any therapy and being informed helps each person feel more confident of the care they are receiving. Bioidentical hormone therapy is typically a team approach including the patient, the doctor, and the compounding pharmacist. Let’s start at the beginning.

When you book an appointment with your doctor, he or she will ask you a full health history and questions that are specific to the symptoms you’re experiencing. They often seek to explore how the symptoms are connected, what makes the symptoms feel better or worse, and which underlying hormones may be deficient, excessive, or out of balance in the body. Hormones work best when they are in concert with one another at healthy levels and ratios. For example, the body needs enough progesterone hormone to balance estrogen levels.  (To see an example of a symptom checklist, click here.)

Once the doctor has collected important information about your symptoms, health history, and lifestyle, he or she may decide to order salivary or blood hormone testing for confirmation. Patients sometimes worry that the results from one single hormone test may be skewed if it’s a bad day. Don’t worry, your doctor should put your comprehensive health intake and lab results side by side to make sure there is a correlation before writing a prescription. In addition, many providers re-test hormone levels at 3 or 6 months to monitor treatment.

After your doctor detects patterns in hormone imbalances, and if she determines an individualized prescription would work best for you, she will contact a compounding pharmacy. The pharmacist speaks to the doctor and can help advise on dosing, route of administration (cream or pill, for example), and other important prescription considerations. The pharmacy staff knows that hormone prescriptions need to be tailored to the individual, and they are there to help make that happen.

Once the compounding pharmacy has your prescription, they’ll give you a call to arrange pick-up or shipping and to answer any questions you may have. Don’t be shy—ask any questions that come to mind about how to use your bioidentical hormones. I recommend working with accredited and quality compounding pharmacies, which can be found nation-wide through the website of the Pharmacy Compounding Accreditation Board.

After you get your bioidentical hormone prescription and start using it, try to pay attention to how your body adapts to the medicine for the first couple of months. A quick update to your doctor can let them know that the dose you’re on is working for you, or it can alert them that you may need an adjustment. Your body knows best, so your detective skills can help you, the doctor, and the compounding pharmacist arrive at the best dose for your symptoms and overall health. If needed, during the first few months your doctor may work with the compounding pharmacy to tweak the prescription until it fits just right.

Good communication among the patient, the doctor, and the compounding pharmacist helps maximize the benefits that bioidentical hormone replacement can provide to your health and your life. You have a team at your disposal on the road to better hormone balance, increased energy and vitality, and improved health!

~ Aarti Patel, ND, Guest Author
Inner Balance Natural Health
Connecting the dots in health

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