Herbal remedies gain in acceptance: Doctors' top concern is drug interaction
By Ralph Jimenez, Globe Staff, 6/29/97
CONCORD -- Last week, the pharmacy was out of St. John's wort, used to
combat mild depression, and evening primrose, the hot new product to alleviate
post-menstrual syndrome.
But hawthorn berries, milk thistle, ginko biloba, wild yam root, Dong quai,
bilberries, Gotu kola herb, and grapeseed extract could still be found on the
large racks of herbal medicines for sale in the pharmacy of Concord's
Hitchcock Clinic.
Until fairly recently, medicinal roots, bark, berries, and herbs in
capsules, tablets, tinctures, and teas could rarely be found outside health
food stores.
Now, in an expansion of what has become a $1.5 billion business nationally,
medicines whose usage predates writing itself are for sale in chain drug
stores, supermarkets, and discount stores. Yet when they buy an herbal
medicine, consumers have no sure way to know whether it will do good, ill, or
nothing at all. They cannot with certainty know how strong a dose of active
ingredients they are getting, how much to use, or even whether they got what
they paid for at prices of $10 or $20 per bottle.
Because herbal medicines are considered a food product, not a drug product,
by the federal Food and Drug Administration, no regulations exist governing
quality control. This month, the New Hampshire Department of Public Health
issued a warning about a dietary supplement sold primarily in health food
stores that led to a recall from three outlets.
The supplements contained plantain -- a variety of the noxious lawn weed
and not the relative of the banana -- commonly found in herbal teas. A bulk
supply of plantain used to make the teas had been contaminated with leaves
from Digitalis plants. Before the drug digitalin was synthesized, the leaves
were the primary source of the powerful heart stimulant whose ingestion can
cause a host of symptoms ranging from nausea to cardiac arrest.
Nor does medical science even know how many herbal medicines act when taken
in concert with over-the-counter pharmaceuticals or prescription drugs.
Yet the business is growing.
``A lot of these herbal medicines have a very active pharmacology. They can
be as chemically potent when it comes to altering our physiology as some of
the normal prescriptions we take,'' said Dr. Dale Gephart, a Dartmouth Medical
School professor who offers herbal medicines to some patients and teaches a
course in medical botany.
``Where I practice in Windsor, Vermont, not everybody wants or is
interested in herbal medicines,'' Gephart said. ``Perhaps one in 10 would want
me to prescribe something herbal.''
Patients in most areas, however, are more receptive to alternative
medicine. According to a study published this spring in the Archives of Family
Medicine, primary care doctors were shocked to learn that half of their
patients had or were using some form of alternative medicine. Only 53 percent
of those doing so, however, told their physician about it.
The array of herbal medicines in the Concord clinic is largely the doing of
chief pharmacist Greg (Cyclone) McCrone, said a colleague helping to fill in
for McCrone, who is spending two months canoeing near the Arctic Circle.
McCrone has also traveled to the Amazon to collect medicinal herbs. He is
one of two pharmacists in the state to whom his peers turn when they have
questions about alternative medicines that are not studied in pharmacy school,
said Norman DeWolfe, president of the state's Board of Pharmacy.
``He is our expert and resource on this,'' DeWolfe said of McCrone.
Another pharmacist who has in-depth knowledge of this is Rich Katz, a
free-lance pharmacist who works at drugstores across southern New Hampshire.
He uses a variety of herbal medicines, watches his diet, and has learned to
shed stress whenever possible. At 55, he remains an athlete who works out
intensely for two hours every morning and has never felt better.
By law, Katz said, pharmacists have to consult with patients when filling
standard prescriptions, counseling them about how to take the drug, and asking
questions about other medications they may be taking. Those rules, however, do
not apply to herbal medicines. Though generally safe, they must be used with
care and caution, Katz said.
``Actually, if people ask my advice on things, my mind goes first to our
herbal nutrition rack,'' Katz said. ``There are many times where I'll
recommend herbal medicines over patent medicines. There is a woman I know
going through menopause who was on all these hormone replacement therapies.
She switched to Dong quai and her hot flashes disappeared in two months. I can
repeat stories like that with different herbal medications. Echinacea [for
colds] is extremely effective. It boosts the immune system and lets your body
do the fighting.''
Katz calls St. John's wort ``enormously effective for mild to moderate
depression,'' but says diagnosing depression has rigid guidelines and
parameters that make self-diagnosis chancy. Some risk exists that people who
really should seek professional help quickly for a problem will worsen while
inexpertly trying herbal remedies. They may also misuse what can be a potent
drug.
``The immediate danger I see with herbal medicines is that people think
it's only a leaf or a root or a plant, so how much trouble can I get into?
They can get into enormous amounts of trouble,'' Katz said.
It is for that reason the Brooks drugstore chain does not sell herbal
medicines despite the money to be made, said DeWolfe, the district manager for
the chain's 23 stores in New Hampshire and Vermont. But like Katz, DeWolfe
believes that herbal medicine is expanding so rapidly and showing enough
benefits that it will become a standard component of pharmacy.
``Brooks will get into it, but only when we get to the point where our
pharmacists have been properly trained so they can educate the consumer,''
DeWolfe said.
Pharmacists now rarely have the answers. Ditto with doctors. Proper,
clinically controlled scientific studies are rare. Popular magazines offer
answers but they may or may not be true. The Internet abounds with
information, but much of it is wrong, said Gephart.
``The information you get on Andrew Weil's Web site is fairly well
moderated,'' Gephart said of Weil, a Harvard Medical School professor and
renowned expert on the use of alternative medicine. ``He is being fairly
reasonable. But if you type in the genus and species of an herb on the World
Wide Web, you will get 20 or 30 sites for any one of them.''
Good information is important. Goldenseal can irritate the stomach. Herbs
like ephedra, found in a concoction known as Mormon tea, contain ephedrine and
can also cause high blood pressure or in rare cases lead to a heart attack or
death, Gephart said.
The best answers, Gephart said, come from naturopaths, licensed graduates
of the handful of colleges that offer extensive training in disciplines that
include herbal medicine. But there are only about 10 naturopaths in the state.
Their services, while not expensive compared to the costs of traditional
medicine, are not cheap and only a few insurance companies will pick up the
tab. Pamela Herring, a Concord naturopath and chairman of the Naturopathic
Board of Examiners, generally charges $150 an hour for her services.
``A great part of the naturopathic profession's study is the toxicology of
herbs, and they are well-trained in what herbs to use for what and which ones
are contra-indicated for pregnancy. But most herbs have yet to be studied
sufficiently and there is no licensure for people who claim to be trained in
herbal medicine,'' Herring said.
Licorice root may be fine in candy, for example. But in herbal form it can
be quite potent and should be avoided by anyone with high blood pressure,
Herring said. Nor can purity be assured unless you purchase herbal medicines
from exceptionally reliable sources, she said.
``There is not strict enough regulation to know what potency and
concentration really is going to be. I have a friend in Canada who assays
everything he imports and uses,'' Herring said of a fellow naturopath. ``He
has found that often products don't have in them what they say is in them and
he has also found mineral products on the market with lead, arsenic, aluminum,
and other things you don't want to be consuming in them.''
Herbal medicines are not cheap. And many of the people using them are not
wealthy. ``I don't think that the people I find coming into Wal-Mart to buy
them are paying for their advice,'' Katz said. Unless you consult an expert or
at least read a good book or two on the subject before dosing yourself with
herbal medicines, he advised.
Dr. Susan Hadley, who studied herbal medicine with Weil, agrees. Hadley,
who has also taught Dartmouth Medical School students some of the basics of
herbal medicine, believes herbal medicines should come in standardized doses
and be guaranteed in purity.
``I don't want to discourage people from using them because most of the
herbs are safe,'' said Hadley, who prescribes herbal medicines routinely as
part of her practice. ``But I strongly discourage people from walking into
health food stores and saying, `Here's a premenstrual formula, I need some of
that and I'll buy that and take a couple of capsules of that.' That can be
dangerous,'' Hadley said.
Herbs must be used with caution, but they often work as well as standard
drugs and have fewer side effects, she said. Few physicians and pharmacists
know much about herbs, but they will have to learn if they want to serve
patients well.
``The first thing Andy Weil tells you in class is that if he gets hit by a
car he wants to be taken to the nearest trauma center and not to an
herbalist,'' Hadley said. But herbal medicine, along with acupuncture,
mediation, techniques of Chinese medicine, and other forms of alternative
medicine are becoming popular because they work, she said. They are not fads.
``I think it is the way medicine is going,'' Hadley said. ``We are starting
a task force now at Dartmouth Hitchcock Hospital to see how we can actually
use some of these herbs in a hospital setting along with massage therapy and
acupuncture.''
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Herbal remedies gain in acceptance
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