Original Articles Use of Herbal Therapies to Relieve Pain: A Review of Efficacy and Adverse Effects

yyy James H. Wirth, BA,* J. Craig Hudgins, BA,† and Judith A. Paice, PhD, RN‡

y ABSTRACT: To find holistic treatment with effective pain relief and few side ef- fects, Americans spend billions of dollars annually on complementary and alternative medicine, including herbal therapies. Despite exten- sive use, the lack of regulatory scrutiny of these herbal supplements contributes to the paucity of reliable clinical data assessing their effi- cacy and safety. This review summarizes the existing studies investi- gating the efficacy of herbal therapies as a treatment for pain. Possi- ble side effects, potential drug–herb interactions, and information about common herbal therapies are also summarized. MEDLINE, AMED, and the Cochrane Library databases were searched for the pe- From the *Department of riod from January 1966 to June 2005. Uses, dosages, routes of admin- Psychology, Purdue University, istration, and side effects were summarized. Strength of empirical evi- West Lafayette, Indiana; dence also was evaluated. This review found few well-controlled †Department of Medicine, Division of Hematology/Oncology Feinberg clinical studies. Furthermore, these studies documented limited effi- School of Medicine, Northwestern cacy of herbal therapies to treat pain. The information presented here University and the Robert H. Lurie may be used to further educate nurses and patients on the use of Comprehensive Cancer Center of Northwestern University, Chicago, herbal therapies as well as direct future research efforts. Illinois; ‡Department of Medicine, © 2005 by the American Society for Pain Management Nursing Division of Hematology/Oncology, Feinberg School of Medicine, Northwestern University and the BACKGROUND Robert H. Lurie Comprehensive Patients experiencing pain may try numerous therapies, including conventional Cancer Center of Northwestern University, Chicago, Illinois. and alternative approaches, for relief. Pain relief is the most frequently cited reason that people seek complementary and alternative medicine (CAM) (Astin, Address correspondence and reprint 1998). CAM encompasses therapeutic treatments such as relaxation, meditation, requests to Judith A. Paice, PhD, RN, biofeedback, hypnosis, imagery, chiropractic, acupuncture, massage, aroma- FAAN, Division of therapy, and herbal therapies. A 2002 study conducted by the National Center Hematology/Oncology, Northwestern University; Feinberg School of for Complementary and Alternative Medicine surveyed 31,044 adults and found Medicine, 676 North St. Clair Street, that 36% of respondents used some form of CAM therapy during the last 12 Suite 850, Chicago, IL 60611. E-mail: months (Barnes, Powell-Griner, McFann, & Nahin, 2004). These therapies might [email protected]. be chosen because other conventional therapies were previously ineffective or produced side effects that were intolerable. Therefore, clinicians must be aware 1524-9042/$30.00 © 2005 by the American Society of CAM therapies used to treat pain to answer questions from patients effec- for Pain Management Nursing tively and to avoid possible interactions with medical (drug) therapies pre- doi:10.1016/j.pmn.2005.08.003 scribed for patients.

Pain Management Nursing, Vol 6, No 4 (December), 2005: pp 145-167 146 Wirth et al.

REASONS FOR USING quently no more dissatisfied or distrustful of conven- COMPLEMENTARY AND tional practitioners and hospitals than nonusers (Astin, ALTERNATIVE MEDICINES 1998). Most complementary therapies are used in con- junction with conventional medicine (Eisenberg et al., CAM users choose alternative therapies so their health 2001). In a national survey, 79% of respondents be- care is more congruent with their personal values, lieved that the combination of conventional and alter- beliefs, and overall philosophic orientation toward native therapies is more effective than either approach health and life (Astin, 1998). This philosophical orien- alone (Eisenberg et al., 2001), and presumably this tation may result from personal values, past health desire for a more holistic approach to health care is care experiences (i.e., disillusionment with conven- what accounts for $21.2 billion in U.S. consumer tional therapies because of their lack of efficacy or side spending in 1997 on CAM professional services (Rees, effects), or desire to have control over health care 2001), including massage, acupuncture, chiropractic matters (Astin, 1998; Barnes et al., 2004). treatment, and herbal therapies. Many herbal therapy users have a chronic disease. A study by Boon and colleagues (2000) reported that some patients with breast cancer chose CAM to boost HERBAL THERAPY USE FOR PAIN their immune system, increase quality of life, prevent Herbal therapies are more likely to be used by those recurrence of cancer, provide a feeling of control over with a better education, poorer health status, and a life, aid conventional medical treatment, or treat breast holistic orientation to health; those wanting relief cancer. The most frequently cited health problems from symptoms or seeking improvement in their gen- that lead to CAM use are anxiety, back problems, eral condition; and those who had a transformational chronic pain, and urinary tract disorders (Astin, 1998). experience that changed their world view (Astin, According to studies by Barnes et al. (2004) and 1998; Kimby et al., 2003; Oldendick et al., 2000). The Kimby, Launso, Henningsen, and Langgaard (2003), most commonly used natural products are echinacea, women and older adults are most likely to seek CAM ginseng, ginkgo biloba, and garlic supplements (Bar- therapy, and CAM users generally perceive the treat- nes, et al., 2004). In the United States, approximately ments have fewer side effects than do conventional $4 billion per year is spent on herbal products, with an medicines (Eisenberg, et al., 2001). annual growth of more than 30% (Rees, 2001). During Unfortunately, those who use CAM face potential the 1990s, there was an estimated 380% increase in adverse side effects, including drug–herb interactions. the sale of herbal substances. In 2002, a survey found Thus, clinicians in the pain field should be familiar 19% of adults had used natural products such as herbal with the uses and potential risks associated with CAM. medicine, functional foods (garlic), or animal-based More than half of patients first seek information re- supplements (Barnes, et al., 2004). Approximately $76 lated to CAM therapies from their primary physician million was spent in 2002 for just three of these sup- (Eisenberg et al., 2001). Hyodo and colleagues (2003) plements alone: androstenedione, kava, and yohimbe found that 93% of Japanese clinical oncologists sur- (Dangerous Supplements: Still at Large, 2004). veyed in 2002 had been asked about CAM options. In The use of herbal therapies comes with potential this study, 80.2% responded they were unable to ad- risks that are worth noting to consumers of herbs for vise their patients appropriately about the use of CAM medicinal purposes. Active ingredients in herbal ther- products. Similarly, Eisenberg, Kessler, Foster, Nor- apies or drugs may produce herb/herb or herb/drugs lock, Calkins, and Delbanco (1993) reported that phy- interactions that have undesirable side effects (Ernst, sicians do not discuss the use of unconventional ther- 1998; Fugh-Berman & Ernst, 2001). For example, apies because they lack adequate knowledge of these when combined with levodopa, kava can cause an techniques. Other barriers to discussion regarding increase in the number and duration of “off” periods; CAM exist, including patients perceiving that clini- St. John’s wort taken with sertraline (Zoloft) may pro- cians lack interest (Verhoef, Hilsden, & O’Beirne, duce nausea, vomiting, or anxiety (Fugh-Berman & 1999), are closed-minded, lack knowledge (Eliason, Ernst, 2001). Herbal therapies and drugs are often Huebner, & Marchand, 1999), and would not under- made of more than one active element. This further stand or would not approve of the alternative therapy complicates what pharmacologic ingredient is causing (Eisenberg et al., 2001). the interaction or undesirable side effect (Izzo & Ernst, Surprisingly, negative attitudes toward or experi- 2001; Fugh-Berman & Ernst, 2001). ences with conventional medicine do not predict CAM A lack of standardization of herbal remedies also use (Astin, 1998), despite one stereotype that CAM makes it challenging to understand what causes ad- users are disgruntled patients. CAM users are fre- verse interactions. Contamination, misidentification of Use of Herbal Therapies to Relieve Pain 147 an herbal plant, or an incorrectly substituted plant all gerously misleading, because potentially uneducated raise issues of quality (Drew & Myers, 1997; Ernst, health food store employees may freely give advice about 1998) and can result potentially in an unwanted side treatment for life-threatening illnesses (Phillips, Nichols, effect. Of 400 users of complementary medicine sur- & King, 1995). Likewise, prominent herbal therapy prod- veyed, Abbot, White, and Ernst (1996) found 8% of uct web sites often convey incorrect information (Morris those who tried herbal remedies had an adverse reac- & Avorn, 2003). A review of Internet web sites found tion. 273 (81%) of 338 sites made one or more health claims Incorrect preparations, incorrect dosages, lack of that may or may not be proven. standardization, substitution, or improper processing Labels on herbal products also are not a reliable of plants can result in unwanted combinations of in- source of information, often missing important details gredients in herbal therapies (Drew & Myers, 1997; such as product’s safety, effectiveness, or possible side Ernst, 1998). The pharmacologically active compo- effects (Zuk, 2000). This lack of information runs con- nent may not necessarily be known, making it difficult trary to what the general population believes is in- to understand how the therapies work (Ernst, 2000). cluded on herbal product labels. In a study of knowl- Unwanted ingredients may lead to contamination, for edge of regulations and labeling of food supplements, example, when bovine spongiform encephalopathy 68% of survey respondents believed the government from bovine organs was found in dietary supplements requires label warnings on potential side effects or (Department of Agriculture, 2000; Scott et al., 1999). dangers (Widespread Ignorance of Regulation and Cassileth and Deng (2004) contend that herbs are Labeling of Vitamins, Minerals and Food Supple- diluted natural drugs that contain scores of different ments, According to a National Harris Interactive chemicals that may not have been documented. A Survey, 2004). Ultimately, relaxed regulation places CAM user may not anticipate the potential interactions the onus on clinicians to educate and protect patients. with other medications or herbal preparations. As people with pain frequently turn to CAM for relief, A lack of strict government regulation diminishes pain management nurses must be aware of the risks efforts at prevention of potentially harmful results of and benefits of CAM for pain control. herbal remedies. In 1994, Congress passed the Dietary Supplement Health and Education Act (DSHEA) to set regulation standards of herbal therapies for medical METHODS benefit. DSHEA relieved pressure from the U.S. Food Literature Search and Drug Administration (FDA) on herb manufacturers To identify articles on the use of herbal therapies to to prove health benefits of herbal therapies, thereby reduce pain, a literature search of MEDLINE (January permitting them to make it to the marketplace without 1966 to June 2005), AMED (Allied and Complementary demonstrating any benefits (Larsen & Berry, 2003). Medicine, January 1985 to June 2005), and the Co- This creates a difficulty, because 59% of respondents chrane Library (November 2003 to June 2005) data- to an Internet survey believe herbal products must be bases was conducted. Reference lists of articles iden- approved by a government agency similar to the FDA tified from the initial search were also reviewed for (Widespread Ignorance of Regulation and Labeling additional articles. Research conducted with humans of Vitamins, Minerals and Food Supplements, Ac- or animals was reviewed. Only English language pub- cording to a National Harris Interactive Survey, lications were considered. Search criteria comprised 2002). the term painwith the common name, Latin name, DSHEA also allows herbal manufacturers to make and common synonyms for the herb in question (e.g., three types of claims without FDA approval: (1) nutri- for Black cohosh, search criteria pain and baneberry, ent content claims, (2) health claims, and (3) nutrient cimicifuga, and bugbane each were used). Most arti- support or structure-function claims (Kurtzweil, 1998; cles were identified using the herb’s common or Latin Overview of Dietary Supplements, 2001). Limited fed- name. eral authority has led to animal products being in- cluded in dietary supplements, increasing the possibil- Inclusion Criteria ity of contamination. Consumers need to be wary of All English-language titles and abstracts, from January false claims, insufficient labels, and the potential for 1966 to the present, were evaluated for inclusion in animal products to be included in the herbal therapy. this review. The first articles on herbal therapies to Those individuals considering herbal therapy use for reduce pain were published in 1990. All pain syn- pain control also may struggle to find credible sources of dromes were considered for this review. Publications information. A recent U.S. investigation suggests that written in English in which an herb was studied to information provided by health food stores can be dan- determine its effect on reducing pain or investigated in 148 Wirth et al.

TABLE 1. Strength of Evidence (Jacox et al., 1994)

Types of Evidence

I. Meta-analysis of multiple, well-designed controlled studies a. Studies of patients with cancer b. Studies of other clinical populations II. At least one well-designed experimental study a. Studies of patients with cancer b. Studies of other clinical populations III. Well-designed, quasiexperimental studies such as nonrandomized controlled, single group pre-post, cohort, time series, or matched case-controlled studies a. Studies of patients with cancer b. Studies of other clinical populations IV. Case reports and clinical examples a. Studies of patients with cancer b. Studies of other clinical populations Strength and consistency of evidence A. There is evidence of type I or consistent findings from multiples studies of types II, III, or IV. B. There is evidence of types II, III, or IV, and findings are generally consistent. C. There is evidence of types II, III, or IV, but findings are inconsistent. D. There is little or no evidence, or there is type V evidence only.

a human or rodent trial were included. The review man Commission E Monographs: Therapeutic Guide resulted in a range of articles addressing several types to Herbal Medicines,1998; Koenig, 2003). Several web of pain syndromes treated with the use of herbal sites were identified, and content from them was in- therapy. corporated into the review. These are listed in Table 2.

Strength of Evidence Methodologic quality of the studies reviewed was eval- RESULTS uated using a scientific evidence scale published by In our search of herbal therapies, 34 publications de- the U.S. Department of Health and Human Services scribing the use of 24 herbal therapies to treat pain were (Jacox et al., 1994). The type of evidence and the identified (Table 3). Ten of the 24 (42%) herbal therapies strength and consistency of the evidence were re- had research evidence available investigating the ability corded for all of the studies included in this review. of the herbal therapy to manage pain. For the remaining Types of evidence were (1) meta-analysis, (2) at least 16 herbal therapies (58%), no known research on their one well-designed experimental study, (3) well-de- use in pain management was identified at the time of this signed quasi-experimental studies, (4) well-designed review. The herbal therapies that were proven effective nonexperimental studies, and (5) case reports and were useful when specifically treating arthritis (Brzeski, clinical examples (Table 1). Strength and consistency Madhok & Capell, 1991; Deal et al., 1991), polyneurop- of evidence were (1) consistent findings from multi- athy (Low, Opfer-Gehrking, Dyck, Litchy, & O’Brien, ples studies, (2) findings that are generally consistent, 1995), postmastectomy pain syndrome (Dini, Bertelli, (3) findings are generally inconsistent, (4) little or no Gozza, & Forno, 1993; Watson & Evans, 1992), neurop- evidence (Table 1). athy (Scheffler, Sheitel, & Lipton, 1991), or low-back pain (Chrubasik, Eisenberg, Balan, Weinberger, Luzzati, & Possible Uses and Safety Information Conradt, 2000; Frerick, Keitel, Kuhn, Schmidt, Brede- This review of commonly used herbal therapies used horst, & Kuhlmann, 2003). The quality of the identified to treat pain includes information about possible studies ranged from a meta-analysis of multiple studies known uses, dosages, and routes of administration. It producing consistent findings (Type I, A) to case reports also includes safety and adverse effect information. that had generally consistent findings (Type V, B; Table This information was collected primarily from the Nat- 1). Overall, most of the research had at least one well- ural Medicine Comprehensive Database (2003) and designed experimental study that produced evidence several other published sources (Nutrition in Cancer that was generally consistent. This review found only Care, 2004; Skidmore-Roth, 2004; The Complete Ger- four double-blind, randomized, controlled trial studies Use of Herbal Therapies to Relieve Pain 149

TABLE 2. CAM-Related Informational Web Sites

Organization Web Site

American Botanical Council http://www.herbs.org Centers for Disease Control and Prevention, Public Health Services, U.S. http://www.cdc.gov Department of Health and Human Services Memorial Sloan-Kettering Cancer Center www.mskcc.org/aboutherbs National Center for Complementary and Alternative Medicine http://nccam.nih.gov/ Office of Complementary and Alternative Medicine http://www3.cancer.gov/occam/ Office of Dietary Supplements, National Institutes of Health http://dietary-supplements.info.nih.gov Society of Integrative Oncology http://www.integrativeonc.org/ U.S. Food and Drug Administration, Public Health Service, Department http://www.fda.gov/ of Health and Human Services U.S. National Library of Medicine, National Institutes of Health http://www.nlm.nih.gov

CAM, Complementary and alternative medicine. Data from Larsen & Berry, 2003

(Deal et al., 1991; Low et al., 1995; Jeffrey & Belcher, women (Natural Medicine Comprehensive Database, 2002; Sindrup, Madsen, Bach, Gram, & Jensen, 2001). 2003; Nutrition in Cancer Care, 2004; Skidmore-Roth, Studies for only 10 of 24 herbs used to manage pain 2004; The Complete German Commission E Mono- successfully were reviewed for efficacy. Of these 10 graphs: Therapeutic Guide to Herbal Medicines, 1998). herbals, several studies used a placebo-controlled study A review conducted by Fugh-Berman and Ernst methodology to investigate the herbal therapy’s effec- (2001) of suspected interactions of herbal therapies tiveness (Altman & Marcussen, 2001; Brzeski, Madhok, & and other treatments found warfarin was the drug Capell, 1991; Chrubasik et al., 2000; Deal et al., 1991; most likely to be involved in adverse interaction with Dini et al., 1993; Ellison et al., 1997; Frerick et al., 2003; an herbal therapy, and St. John’s wort was the herbal Low et al., 1995; Scheffler, Sheitel, & Lipton, 1991; therapy most likely to cause an adverse interaction. Watson & Evans, 1992). In addition, several studies found Although many herbs have potential side effects, sev- that herbal therapies were no more effective at managing eral herbal therapies reviewed have a status of “Gen- pain compared with a placebo or general pain medica- erally Recognized as Safe” for food use in the United tion (Bliddal et al., 2000; Ernst & Pittler, 1998; Kaziro, States (chamomile, cinnamon, cloves, ginger, mustard) 1984; Paice, Ferrans, Lashley, Shott, Vizgirda, & Pitrak, (Natural Medicine Comprehensive Database, 2003). 2000; Sindrup et al., 2001).

Adverse Effect and Interactions DISCUSSION Many of the herbal therapies had significant adverse side The use of herbal therapies is an increasingly popular effects that should be considered when using these treat- method to treat pain, either alone or as a complement to ments. For example, Arnica is considered poisonous if traditional medical approaches. Unfortunately, research injected and may also cause liver damage (Skidmore- demonstrating the efficacy of herbal therapies to treat Roth, 2004). In 2004, Ephedra was banned because of its pain is limited. The strongest evidence identified in this increased risk for heart palpitations, tremors, and insom- analysis was Type I, A, found in only one study. For the nia. This was the first time U.S. officials blocked the sale majority of the herbal therapies reviewed, there was no of an over-the-counter herbal supplement (Government empirical evidence for the analgesic efficacy of these Announces Ban on Ephedra, 2004). Overall, common compounds. Questions still remain about their underly- side effects caused by the investigated herbal therapies ing mechanisms to provide analgesia (Ernst, 2000). As included nausea, vomiting, burning sensations, gastroin- the use of herbal therapies grows, empirical research testinal irritation, intestinal blockage, and insomnia. Ad- demonstrating their benefits in pain control lags. The verse interactions with numerous drugs and the possibil- establishment of the National Center for Complementary ity of worsening medical conditions were common to and Alternative Medicine supports research of herbal many of the herbal therapies we investigated. For exam- therapies and other CAM. ple, herbal therapies may worsen diabetes for some pa- In regard to the safety of herbal therapies, several tients or estrogen-sensitive hormone disorders in some possible drug and herbal interactions were identified. 150

TABLE 3. Herbal Therapies for the Relief of Pain

Agent Possible Uses Dose/Routes Studies Safety/Adverse Reactions

● Arnica* (Arnica ● Used for general ● Topically: Used as a ● Arnica gave rise to greater pain than● Considered poisonous if injected (Data montana) counterirritant, anti- cream, 15% arnica a placebo and caused more from Skidmore-Roth, 2004) ● Also known as: inflammatory, and pain oil (Natural Medicine swelling when used to treat ● Serious liver and kidney damage can Arnica flos, reliever (Data from Comprehensive impacted wisdom teeth (Data from occur (Data from Skidmore-Roth, 2004) Leopard’s bane, Koenig, 2003) Database, 2003) Kaziro, 1984). Type III, B** ● Interacts with antihypertensive drugs Mountain tobacco, ● Topically, to decrease ● Typical strength is ● Topical application of Arnica (Data from Skidmore-Roth, 2004) Wundkraut inflammation in bruises, 2 g of flowerheads in montana gel was a safe, well- sprains, wounds, acne, 100 mL water tolerated, and effective treatment of boils, and rashes (Data mild to moderate osteoarthritis of from Skidmore-Roth, the knee (Data from Knuesel, 2004) Weber, & Suter, 2002). Type II, B ● Significant reduction of pain experienced by patients who underwent hand surgery (Data from Sindrup et al., 2001). Type II, B

● Analysis of eight trials found, on al. et Wirth balance, homeopathic arnica is no more effective than placebo (Data from Ernst & Pittler, 1998). Type I, B ● Black Cohosh ● It is a smooth-muscle ● Oral: 300-2000 mg of ● No published research related to ● Likely safe when used orally and (Cimicifuga relaxant, an the dried rhizome or pain appropriately, safe in studies lasting up to racemose) antispasmodic, an root three times daily 6 months (Natural Medicine ● Also known as: antitussive, a diuretic, (Natural Medicine Comprehensive Database, 2003) Baneberry, an antidiarrheal, and an Comprehensive ● Adversely interacts with hormone Cimicifuga, Bugbane antiarthritic (Data from Database, 2003) sensitive cancers/conditions, but has no Skidmore-Roth, 2004) known drug interactions (Natural Medicine Comprehensive Database, 2003) ● Camphor ● Applied topically as an ● Topically: ● No published research related to ● Likely safe when used topically in low (Cinnamomum analgesic and an 0.1%–0.3%, 3 to 4 pain concentrations short-term. Unsafe when camphora) antipruritic (Natural times daily (Natural used orally (Natural Medicine ● Also known as: Medicine Medicine Comprehensive Database, 2003) Camphora, Comprehensive Comprehensive ● Orally, camphor can cause significant Cemphire, Camphor Database, 2003) Database, 2003) toxicity, symptoms can occur rapidly tree ● Muscle rheumatism, ● Inhalation: starting with nausea and vomiting, oral respiratory tract diseases, tablespoon of and intestinal burning, feeling of warmth, circulatory regulation solution per quart of and headache (Natural Medicine disorders (The Complete water, medicated Comprehensive Database, 2003) German Commission E vapors are breathed ● Oral preparations are no longer available Monographs: Therapeutic (Natural Medicine in the United States (Natural Medicine Guide to Herbal Comprehensive Comprehensive Database, 2003) Medicines, 1998) Database, 2003) ● Capsaicin (Capsicum ● Stimulate digestion ● Oral: Capsicum fruit ● Systemic capsaicin is effective for ● Likely safe when used orally in amounts frutescens) when used orally, as an is usually in doses of short-term treatment of Burning typically found in food (Natural Medicine ● Also known as: antiflatulent, for colic, 30–120 mg, 3 times Mouth Syndrome but with major Comprehensive Database, 2003) African Chillies, diarrhea, cramps, to daily (Natural gastrointestinal side effects (Data ● May cause gastrointestinal irritation, African Pepper, improve peripheral Medicine from Petruzzi et al., 2004) Type II, B sweating, and flushing of the head and Capsaicin Fruit, circulation, reducing Comprehensive ● Topically applied capsaicin cream neck when taken orally (Natural Medicine Garden Pepper, blood clotting Database, 2003) may decrease subjective neck pain Comprehensive Database, 2003) Sweet Pepper, tendencies, and ● Topical: For pain (Data from Mathias et al., 1995) ● Interferes with the activity of acid- Mexican Chilies, preventing heart disease syndromes, creams Type IV, B inhibiting drugs, antihypertensive drugs Grains of Paradise (Natural Medicine can be applied 3–4 ● Capsaicin is ineffective in relieving (Natural Medicine Comprehensive Comprehensive times daily (Natural pain associated with HIV-associated Database, 2003) Database, 2003) Medicine peripheral neuropathy (Data from ● May increase the effects of antiplatelet ● Topically to reduce pain Comprehensive Paice et al., 2000). Type II, B drugs, barbiturates, cocaine, and drugs Database, 2003) ● Topical 0.075% capsaicin cream with sedative properties (Natural Medicine ● Available in 0.075% appeared to be more effective than Comprehensive Database, 2003)

and 0.025% creams the vehicle cream in relief of ● Topically, may increase pain, may cause Pain Relieve to Therapies Herbal of Use postmastectomy pain syndrome in a burning of the eye or mucous membrane double-blind study (Data from if accidentally applied Watson, 1994). Type II, B ● Open-label trial where 68.4% of patients received good pain relief from 0.025% capsaicin administered to treat postmastectomy pain syndrome (Data from Dini et al., 1993). Type III, B ● Double-blind, 8-week trial found topical capsaicin 0.075% cream is safe and effective in managing painful diabetic neuropathy (Data from Scheffler, Sheitel & Lipton, 1991). Type II, B ● Analysis of several trials found topical capsaicin is generally not satisfactory as a sole therapy for chronic painful conditions; it may serve as an adjuvant (Data from Watson, 1994). Type I, B ● Long-term, open, nonrandomized study might indicate that the analgesic effect of capsaicin in post-herpetic neuralgia is mediated by both interference with neuropeptide metabolism and morphologic changes of nociceptive afferents (Data from Peikert, Hentrich, & Ochs, 1991). Type II, B 151 152

TABLE 3. Herbal Therapies for the Relief of Pain (Cont’d)

Agent Possible Uses Dose/Routes Studies Safety/Adverse Reactions

● After 2 weeks, 80% of capsaicin- treated patients with osteoarthritis or rheumatoid arthritis in a double- blind randomized study experienced a reduction in pain (Data from Deal et al., 1991). Type II, B ● A two-arm, double-blind, placebo- controlled, crossover study found topical capsaicin cream decreases postsurgical neuropathic pain to a 3 to 1 margin over placebo. There were some toxicities (Data from Ellison et al., 1997). Type II, B ● A vehicle-controlled, double-blind, multicenter study found 0.075% it tal. et Wirth capsaicin cream is safe and effective in treating painful diabetic neuropathy (Scheffler, Sheitel, & Lipton, 1991). Type II, B ● In a 12-week, double-blind, placebo- controlled randomized study of capsaicin cream on distal painful polyneuropathy found no difference between capsaicin cream and the placebo (Data from Low et al., 1995). Type II, B ● In a double-blind, randomized, placebo-controlled multicenter parallel group study, treatment of low back pain with capsicum plaster was statistically and clinically beneficial compared with a placebo (Data from Frerick et al., 2003). Type II, B ● Meta-analysis found capsaicin cream to be effective in easing pain associated with diabetic neuropathy and osteoarthritis. Capsaicin’s effectiveness may be attributed to placebo effects (Data from Zhang & Li Wan Po, 1994). Type I, A ● Chamomile ● Skin and mucous ● Oral: 2–8 g of the ● Chamomile extract spray does not ● Has a Generally Recognized as Safe (matricaria recutita) membrane dried flower head significantly ameliorate pain status for food use in the US (Natural ● Also known as: inflammations, irritations (Natural Medicine associated with postoperative sore Medicine Comprehensive Database, 2003) Cammilla, Kamillen, of the respiratory tract Comprehensive throat (Data from Kyokong et al., ● Generally safe when consumed in Pin Heads, (The Complete German Database, 2003) 2002) Type II, B amounts commonly found in foods Camomilla, Commission E ● Topical: Used as a (Natural Medicine Comprehensive Allemande, Monographs: rinse. No known Database, 2003) Manzanilla Therapeutic Guide to typical dosage ● Theoretically, large doses may increase Herbal Medicines, 1998) ● Tea: Steep3gin150 the risk of bleeding when used with ● Reduces gastrointestinal mL boiling water for anticoagulants (Nutrition in Cancer Care, spasms and 5–10 minutes 2004) inflammatory diseases (Natural Medicine ● Theoretically, may increase additive and of the gastrointestinal Comprehensive side effects of benzodiazepines (Nutrition tract (The Complete Database, 2003) in Cancer Care, 2004)

German Commission E Pain Relieve to Therapies Herbal of Use Monographs: Therapeutic Guide to Herbal Medicines, 1998) ● Antispasmodic for menstrual cramps (The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines, 1998) ● Cinnamon ● Improve appetite (The ● Oral: 2–4 g of ● No published research related to ● Has a Generally Recognized as Safe (Cinnamomum) Complete German cinnamon bark pain status for food use in the US (Natural ● Also known as: Commission E (Natural Medicine Medicine Comprehensive Database, 2003) Cinnamon bark, Monographs: Comprehensive ● Likely safe when consumed in amounts Batavia cassia, Therapeutic Guide to Database, 2003) commonly found in foods and possibly Ceylon Cinnamon, Herbal Medicines, 1998) ● Topical: No known safe when used orally and appropriately Panang Cinnamon, ● Treat dyspepsia, typical dosage in amounts slightly greater than those Saigon Cinnamon abdominal pain, nausea, ● Tea: 0.5–1 g of the found in food (Natural Medicine and other digestive bark in 150 mL of Comprehensive Database, 2003) complaints (Data from boiling water, for 5– ● Might interfere with antacids (Natural Koenig, 2003) 10 min, then strain Medicine Comprehensive Database, 2003) ● Thought to be, (Natural Medicine antispasmodic, Comprehensive antiflatulent, Database, 2003) antidiarrheal, antimicrobial, and anthelmintic (Natural Medicine Comprehensive Database, 2003) 153 154

TABLE 3. Herbal Therapies for the Relief of Pain (Cont’d)

Agent Possible Uses Dose/Routes Studies Safety/Adverse Reactions

● Cloves (Syzgium ● Used for gastrointestinal ● Oral: 120–300 mg, ● No published research related to ● Has a Generally Recognized as Safe status aromaticum) upset, including limit ingestion to 3.6 pain for food use in the US (Natural Medicine ● Also known as: flatulence, nausea, and mg/kg clove oil per Comprehensive Database, 2003) Clove, Caryophylli, vomiting (Natural day (Natural ● Likely safe when consumed in amounts Caryophyllus, Clous Medicine Comprehensive Medicine commonly found in food and possibly de Girolfe, Flores Database, 2003) Comprehensive safe when taken orally in higher doses for Caryophyllum ● Reduces inflammatory Database, 2003) medicinal purposes (Natural Medicine changes of the oral and ● Topical: Commonly Comprehensive Database, 2003) pharyngeal mucosa (The used in mouthwash, ● May be irritating to respiratory tract when Complete German 15% clove tincture smoked (clove cigarettes) (Natural Medicine Commission E can treat athletes’ Comprehensive Database, 2003) Monographs: Therapeutic foot (Natural ● Concomitant use of anticoagulants and Guide to Herbal Medicine antiplatelets could theoretically increase Medicines, 1998) Comprehensive the risk of bleeding and the effects of ● Counterirritant for pain Database, 2003) these drugs (Natural Medicine (The Complete German Comprehensive Database, 2003) Commission E al. et Wirth Monographs: Therapeutic Guide to Herbal Medicines, 1998) ● Used for toothache or mouth and throat inflammation (The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines, 1998) ● Cod-liver Oil ● Used for hyperlipidemia, ● Oral: For lowering ● n-3 polyunsaturated fatty acids ● Likely safe when used orally and hypertriglyceridemia, triglycerides, 20 mL directly attenuate the neuronal and appropriately (Natural Medicine hypertension, coronary per day. For lowering glial processes that underlie Comprehensive Database, 2003) heart disease, blood pressure, 20 neuropathic and inflammatory pain ● Increased risk of bleeding when used with osteoarthritis, and mL per day (Natural (Data from Shapiro, 2003). Type II, anticoagulants/antiplatelet drugs (Natural systemic lupus Medicine B Medicine Comprehensive Database, 2003) erythematosus (Natural Comprehensive ● People with musculoskeletal pain ● Decreased effectiveness of antidiabetes Medicine Database, 2003) experience less pain if they take drugs (Natatural Medicine Comprehensive Comprehensive cod liver oil (Data from Eriksen, Database, 2003) Database, 2003) Sandvik, & Bruusgaar, 1996) Type ● May have additive effects on II, B antihypertensive drugs (Natural Medicine ● Cod liver oil as supplemental to Comprehensive Database, 2003) NSAID therapy in treating ● May cause nosebleeds, halitosis, and osteoarthritis showed no significant heartburn (Natural Medicine benefit vs placebo (Data from Comprehensive Database, 2003) Stammers, Sibbald, & Freeling, 1992) Type II, B Also known as: n-3 Fatty Acids, Cod Oil, Fish Oil, Liver Oil, Omega-3 Fatty Acids, Polyunsaturated Fatty Acids ● Devil’s Claw ● Used to treat joint pain ● Oral: To stimulate ● Devil’s Claw lacks the anti- ● Possibly safe when used orally and (Harpagophytum and inflammation (Data appetite, 1.5 g of inflammatory properties possessed appropriately for short term. Well procumbens) from Skidmore-Roth, root per day: 1–4.5 g by NSAIDS (Data from Whitehouse, tolerated for up to 16 weeks (Natural 2004) of root per day for Znamirowska, & Paul, 1983). Type Medicine Comprehensive Database, 2003) ● Loss of appetite, other uses II, B ● May decrease blood glucose levels in dyspepsia, supportive ● Tea: 4.5 g in 300 mL ● Devil’s Claw extract is effective in diabetes (Natural Medicine therapy of degenerative water boiled for 8 treating pain associated with Comprehensive Database, 2003) disorders of the hours arthrosis of the hip or knee (Data ● May increase bile production in patients musculoskeletal system from Wegener & Lupke, 2003), Type with gallstones (Natural Medicine Pain Relieve to Therapies Herbal of Use (The Complete German II, B Comprehensive Database, 2003) Commission E ● Effective in treatment of slight to ● Adversely effects acid-inhibiting drugs, Monographs: moderate muscular pain (Data from blood pressure therapy, and cardiac Therapeutic Guide to Gobel et al., 2001) Type II, B drugs (Natural Medicine Comprehensive Herbal Medicines, 1998) ● Effective in treatment of chronic Database, 2003) nonradicular back pain (Data from ● Orally, devil’s claw is well tolerated. Most Laudahn & Walper, 2001) Type II, B common adverse effect is diarrhea (Natural Medicine Comprehensive Database, 2003) ● Dong Quai (Angelica ● Used primarily for ● Oral: 3–4 g daily with ● No published research related to ● Orally, dong quai is well tolerated (Natural sinensis) gynecologic ailments meals (Natural pain Medicine Comprehensive Database, 2003) ● Also known as: including menstrual Medicine ● Theoretically, may increase effects of Chinese Angelica, cramps, irregularity, Comprehensive warfarin and may potentiate the effects of Dang Gui, Dong Qua, retarded flow, weakness Database, 2003) other anticoagulants and antiplatelet Dong-Quai, Tang during the menstrual ● Tea: Extract of dong drugs (Nutrition in Cancer Care, 2004; Kuei, Tan Kue Bai period, and symptoms quai in a dose of 1 Data from Paice et al., 2000) Zhi of menopause (Natural mL three times daily ● Interacts with hormone sensitive cancers/ Medicine (Natural Medicine conditions, especially for women with Comprehensive Comprehensive hormone sensitive conditions (Natural Database, 2003) Database, 2003) Medicine Comprehensive Database, 2003) ● It is also used orally as a “blood purifier” to manage hypertension, rheumatism, ulcers, anemia, and constipation (Natural Medicine Comprehensive Database, 2003) 155 156

TABLE 3. Herbal Therapies for the Relief of Pain (Cont’d)

Agent Possible Uses Dose/Routes Studies Safety/Adverse Reactions

● Echinacea (echinacea ● Supportive therapy for ● Oral: Varying ● No published research related to ● Orally, echinacea is usually well tolerated angustifolia) colds and chronic dosages for various pain (Natural Medicine Comprehensive ● Also known as: infections of the illnesses (Natural Database, 2003) American Cone respiratory tract and Medicine ● Has been used safely in trials lasting up Flower, Indian Head, lower urinary tract (The Comprehensive to 12 weeks when used topically and Purple Cone Flower, Complete German Database, 2003) appropriately (Natural Medicine Black Sampson, Commission E ● Topical: Semi-solid Comprehensive Database, 2003) it tal. et Wirth Kansas Snakeroot, Monographs: preparation ● Theoretically, may interfere with Red Sunflower Therapeutic Guide to containing at least immunosuppressive therapy (Nutrition in Herbal Medicines, 1998) 15% pressed juice of Cancer Care, 2004) ● Externally for poorly Echinacea purpurea ● May experience allergic reactions, fever, healing wounds and herb nausea, vomiting, unpleasant taste, chronic ulcerations (The ● Tea: Prepared by abdominal pain, diarrhea, sore throat, and Complete German pouring 8 oz of dizziness (Natural Medicine Commission E boiling water over a Comprehensive Database, 2003) Monographs: tea bag and steeping ● Theoretically may increase hepatotoxicity Therapeutic Guide to for 10–15 min risk when coadministered with Herbal Medicines, 1198) (Natural Medicine acetaminophen (Data from Paice et al., ● Also used for migraines, Comprehensive 2000) dyspepsia, pain, and Database, 2003) dizziness (Natural Medicine Comprehensive Database, 2003) ● Epsom Salt ● Used for treating and ● Oral, topical, or ● Infusion may be used as an adjunct ● Likely safe when used orally and (Magnesium) preventing parenteral for reducing analgesic consumption appropriately. ● Also known as: hypomagnesemia, may ● Dosages are very after spinal anaesthesia (Data from ● Parenteral magnesium sulfate is an FDA- Chelated Magnesium, also be used orally as a illness specific and Apan et al., 2004) Type II, B approved prescription product (Natural Magnesium Sulfate, laxative or for treating varies (Natural ● Use as an adjuvant analgesic in Medicine Comprehensive Database, 2003) Milk of Magnesia symptoms of asthma Medicine patients undergoing open ● Interacts with malabsorption syndromes, (Natural Medicine Comprehensive cholecystectomy resulted in better renal disease, Comprehensive Database, 2003) pain relief during first postoperative excretion-enhancing/reducing drugs, and Database, 2003) ● Tea: Steep 4.5 g of hour but did not significantly skeletal muscle relaxants (Natural ● Reduces swelling, root in 300 mL boiled decrease postoperative morphine Medicine Comprehensive Database, 2003) muscle ache, and pain water for 8 hours at requirement (Data from Bhatia et al., ● Orally, magnesium can cause resulting from bruised or room temperature 2004) Type II, B gastrointestinal irritation, nausea, Pain Relieve to Therapies Herbal of Use irritated tissues (Data and then strain ● In a rat model, magnesium amplifies vomiting, and diarrhea (Natural Medicine from Koenig, 2003) (Natural Medicine the analgesic effect of low-dose Comprehensive Database, 2003) ● Topically, used for Comprehensive morphine in conditions of sustained treating infected skin Database, 2003) pain (Data from Begon et al., 2002) ulcers (Natural Medicine Type II, B Comprehensive ● Found magnesium can be an Database, 2003) adjuvant for perioperative analgesic ● Reduce neuropathic and management to reduce other pain when pure perioperative pain (Data from Kara magnesium is used IV et al., 2002). Type II, B ● For patients with chronic limb pain, the addition of magnesium to a Bier’s block with lignocaine improves and prolongs pain relief (Data from Tramer & Glynn, 2002). Type II, B ● The addition of magnesium sulfate to the opioid fentanyl prolonged analgesia with no increase of side effects (Data from Buvanendran et al., 2002). Type II, B ● 500-mg and 1-g bolus doses of IV magnesium were well tolerated and potentially effective in patients with neuropathic pain due to cancer (Data from Crosby, Wilcock, & Corcoran, 2000). Type V, B 157 158

TABLE 3. Herbal Therapies for the Relief of Pain (Cont’d)

Agent Possible Uses Dose/Routes Studies Safety/Adverse Reactions

● Gamma Linolenic ● Rheumatoid arthritis, ● Oral: For rheumatoid ● Control group, placebo study found ● Appears safe when taken in oral doses of Acid (Octadeca- hyperlipidemia, heart arthritis 1.1 g daily, GLA may produce mild 2.8 g per day or less for up to a year 6,9,12-trienoic acid) disease, syndrome-X, for diabetic improvement in rheumatoid arthritis, (Natural Medicine Comprehensive ● Also known as: systemic sclerosis, neuropathy 360 to but the placebo, olive oil, may have Database, 2003) Gamolenic Acid, GLA diabetic neuropathy, 480 mg per day, for unrecognized benefits (Data from ● May interact with herbs that have and cancer prevention hyperlipidemia 1.5–6 Brzeski, Madhok, & Capell, 1991). coumarin constituents or affect platelet (Natural Medicine g daily (Natural Type II, B aggregation to theoretically increase the Comprehensive Medicine ● Meta-analysis of a small number of risk of bleeding (Natural Medicine Database, 2003) Comprehensive studies suggest that GLA is Comprehensive Database, 2003) ● Also used for ADHD, Database, 2003) effective treatment for patients with ● Taking with other anticoagulants or depression, postpartum rheumatoid arthritis (Data from antiplatelet drugs might increase risk of depression, chronic Rothman, DeLuca, & Zurier, 1995). bruising and bleeding (Natural Medicine fatigue syndrome Type I, B Comprehensive Database, 2003) (Natural Medicine ● A review of 11 studies found there Comprehensive is some potential benefit for the use Database, 2003) of GLA in rheumatoid arthritis. More it tal. et Wirth studies on dosage and duration are needed (Data from Little & Parsons, 2001). Type I, B ● Meta-analysis found moderate support for GLA for reducing pain, tender joint count and stiffness. In general, GLA herbal medicines were relatively safe to use (Data from Soeken, Miller, & Ernst, 2003). Type I, C ● Ginger (Zingiber ● Motion sickness, nausea, ● Oral: 550–1100 mg ● Extract as effective as placebo ● Generally Recognized as Safe Status in Officinale) dyspepsia, flatulence, three times daily during first 3 months of study, but the US (Data from Altman & Marcussen, ● Also known as: chemotherapy-induced (Natural Medicine at end of 6 months, extract group 2001) African Ginger, Black nausea (Natural Medicine Comprehensive experienced better relief from pain ● Usually well tolerated when used in Ginger, Gingembre, Comprehensive Database, 2003) associated with symptomatic typical doses (Data from Altman & Ginger Root, Database, 2003) ● Topical: No typical gonarthritis (Data from Wigler et Marcussen, 2001) Zingiberis rhizoma ● Can be used for treating dosage al., 2003) Type II, B ● Theoretically, may increase the risk of thermal burns (Natural ● Randomized, placebo-controlled, bleeding, or interfere with diabetic, Medicine cross-over study found no cardiac, therapy for heart conditions and Comprehensive difference between ginger extract acid-inhibiting drugs (Data from Altman & Database, 2003) and a placebo in treating Marcussen, 2001) ● The essential oil of ginger osteoarthritis of the hip or knee. is used topically as an Ibuprofen was significantly more anlgesic (Natural effective than ginger extract (Data Medicine Comprehensive from Bliddal et al., 2000). Type II, Database, 2003) B ● Randomized, double-blind, placebo- controlled, 6-week study found highly purified ginger extract had a statistically significantly effect of reducing pain in patients with osteoarthritis of the knee compared with a control group that received a placebo (Data from Altman & Marcussen, 2001) Type II, B ● Ginkgo Biloba ● Used as an antitussive ● Oral: 120–240 mg ● A study of rats looked at several ● May increase bleeding with NSAIDS (Data (Ginkgo biloba) and expectorant (Data ginkgo tablets or models of nociceptive pain, tail- from Abebe, 2002), acetaminophen (Data ● Also known as: from Altman & capsules in 2 or 3 electric stimulation assay, and from Abebe, 2002), dipyridamole, and Baiguo, Fossil Tree, Marcussen, 2001) divided doses (Data capsaicin-induced paw licking, warfarin (Nutrition in Cancer Care, 2004) Ginkyo, Yinhsing, ● Fatigue (The Complete from Altman & results suggest Ginkgo biloba ● Ginkgo fruit and pulp can cause redness Kew Tree, German Commission E Marcussen, 2001) extract may be of clinical value as of the mouth, rectal burning, and painful Monographs: an anti-inflammatory and analgesic anal sphincter spasms (Natural Medicine Pain Relieve to Therapies Herbal of Use Therapeutic Guide to alone or in conjunction with NSAIDs Comprehensive Database, 2003) Herbal Medicines, 1998) (Data from Abdel-Salam et al., 2004)● May increase blood pressure when used ● Thought to increase Type II, B with thiazide diuretics (Nutrition in Cancer blood flow to the brain Care, 2004) and to treat/prevent ● Reportedly causes seizures (Natural Alzheimer’s/dementia Medicine Comprehensive Database, 2003) ● Theoretically, might interfere with the effectiveness of anticonvulsants (Natural Medicine Comprehensive Database, 2003) ● Can cause coma when combined with trazodone (Data from Hu et al., 2005) ● Ginseng (Panax ● For symptomatic ● Oral: 0.25–0.5 g of ● No published research related to ● No adverse reactions have been reported quinquefolius) treatment of: memory the root 2 times daily pain specifically with the use of American ● Also known as: deficits, disturbances in (Natural Medicine ginseng (Natural Medicine Comprehensive American Ginseng, concentration, Comprehensive Database, 2003) Ren Shen, Sang, Red depressive emotional Database, 2003) ● Expected to increase risk of bleeding if Berry condition, dizziness, and taken with NSAIDS (Data from Abebe, headache (The 2002) Complete German ● Varying dosages for various illnesses Commission E (Natural Medicine Comprehensive Monographs: Database, 2003) Therapeutic Guide to ● May interfere with antipsychotic drugs, Herbal Medicines, 1998) hormones, MAOs (Nutrition in Cancer ● Increase physical Care, 2004) endurance and lessen ● Ginseng may diminish the effect of fatigue, to improve immunosuppressants (Data from ability to cope with Skidmore-Roth, 2004) stress (Data from ● May cause anxiety, insomnia, Skidmore-Roth, 2004) restlessness, headache (Data from

Skidmore-Roth, 2004) 159 160

TABLE 3. Herbal Therapies for the Relief of Pain (Cont’d)

Agent Possible Uses Dose/Routes Studies Safety/Adverse Reactions

● May reduce concentration of blood alcohol (Data from Lee, 1987; Data from Lee, 1993) and warfarin (Data from Hu et al., 2005) ● May reduce opioid-induced analgesia (Data from Abebe, 2002) ● May induce mania when used concomitantly with phenelzine (Data from Hu et al., 2005) ● Japanese Mint ● Orally to reduce ● Oral: 3–6 drops of oil ● No published research related to ● Possibly safe when the oil is used orally (Mentha arvensis) flatulence (Natural daily (Natural pain or topically and appropriately (Natural ● Also known as: Brook Medicine Medicine Medicine Comprehensive Database, 2003) mint, Chinese Mint Comprehensive Comprehensive ● May worsen bronchial spasms, Oil, Cornmint Oil, Database, 2003) Database, 2003) gallbladder conditions, or liver disease Minzol ● Topically, for ● Topically: Rub (Natural Medicine Comprehensive musculoskeletal or several drops of oil Database, 2003) neuropathic pain, on affected areas of ● No known interactions with drugs (Natural al. et Wirth pruritus, and urticaria skin (Natural Medicine Comprehensive Database, 2003) (Natural Medicine Medicine ● Can cause upset stomach when taken Comprehensive Comprehensive orally (Natural Medicine Comprehensive Database, 2003) Database, 2003) Database, 2003) ● Inhalation: 3–4 drops of oil in hot water (Natural Medicine Comprehensive Database, 2003) ● Kava Kava (Piper ● Treat anxiety disorders, ● Oral: 100 mg 3 times ● No published research related to ● Taken orally, may induce hepatotoxicity methysticum) stress, insomnia, and a day (Natural pain and liver failure (Natural Medicine ● Also known as: Ava, restlessness (Natural Medicine Comprehensive Database, 2003; Nutrition Ava Pepper, Awa Medicine Comprehensive in Cancer Care, 2004) Root, Kava, Yagona Comprehensive Database, 2003) ● Banned in Switzerland, Germany, and Database, 2003) ● Tea: 2–4 g in 150 mL Canada (Natural Medicine Comprehensive ● Orally, for depression, boiling water for 5–10 Database, 2003) headaches, common minutes, then strain ● Decreases platelets, lymphocyte, bilirubin, cold, cancer prevention, (Natural Medicine protein, increased red blood cell volume and musculoskeletal Comprehensive (Data from Skidmore-Roth, 2004) pain (Natural Medicine Database, 2003) ● Adverse interactions with alprazolam, he Comprehensive patotoxic drugs, and levodopa (Natural Database, 2003) Medicine Comprehensive Database, 2003) ● Given hepatotoxic effects, avoid concurrent use with acetaminophen (Natural Medicine Comprehensive Database, 2003). ● Expected to enhance CNS depression/ sedation caused by opioids (Natural Medicine Comprehensive, 2003) ● Ma Huang (Ephedra ● Used for weight loss ● Oral: 15–20 mg of ● No published research related to ● FDA recently banned ephedra (1/1/2004) distachya) and enhancing athletic ephedra taken up to pain ● Increases toxicity with beta-blockers, ● Also known as: performance (Natural three times daily monoamine oxidase inhibitors, caffeine, Ephedra, Cao Medicine (Natural Medicine and St. John’s Wart (Nutrition in Cancer Mahuang, Herbal Comprehensive Comprehensive Care, 2004) Ecstasy, Sea Grape Database, 2003) Database, 2003) ● Side effects—insomnia, motor ● Also used for allergies, ● Tea: 1–4 g in 150 mL restlessness, irritability, headaches, allergic rhinitis, boiling water for 5–10 nausea, vomiting, disturbances of respiratory tract minutes and then urination, tachycardia; in high doses, conditions, colds, flu, strain (Natural increase in blood pressure, cardiac Pain Relieve to Therapies Herbal of Use fever, headache, joint Medicine arrhythmia, herb dependency (The and bone pain (Natural Comprehensive Complete German Commission E Medicine Database, 2003) Monographs: Therapeutic Guide to Herbal Comprehensive Medicines, 1998) Database, 2003) ● Reports of serious life-threatening or debilitating adverse effects, psychosis, and hepatitis (Natural Medicine Comprehensive Database, 2003) ● Mustard (Brassica) ● Topically, used as a ● Topical: Prepare a ● No published research related to ● Has Generally Recognized as Safe status poultice for bronchial mustard plaster; pain in the US (Natural Medicine pneumonia, pleurisy, 100 g of mustard Comprehensive Database, 2003) arthritis, lumbago, flour mixed with ● Can irritate asthma and the GI tract aching feet, rheumatism, warm water to make (Natural Medicine Comprehensive and as a counterirritant a paste. Put mustard Database, 2003) (Natural Medicine paste into a linen and ● Orally, large amounts of black mustard Comprehensive apply for 10 min seed can lead to vomiting, stomach pain, Database, 2003) (Natural Medicine diarrhea, somnolence, cardiac failure, ● To treat inflammation Comprehensive breathing difficulties, coma, and possibly and joint pain (Data Database, 2003) death (Natural Medicine Comprehensive from Skidmore-Roth, ● Orally: No known Database, 2003) 2004) suggested dose (Natural Medicine Comprehensive Database, 2003) 161 162

TABLE 3. Herbal Therapies for the Relief of Pain (Cont’d)

Agent Possible Uses Dose/Routes Studies Safety/Adverse Reactions

● Oil of Wintergreen ● Topically, wintergreen ● Topical: Apply as ● No published research related to ● Symptoms of toxicity include tinnitus, (Gaultheria oil is used as a gels, lotion, or pain nausea, and vomiting (Natural Medicine Proxumbens) counterirritant for ointments 3–4 times Comprehensive Database, 2003) ● Also known as: musculoskeletal pain daily (Natural ● May aggravate gastrointestinal Boxberry, Canada and as an antiseptic Medicine inflammation, and increases INR and Tea, Deerberry, (Natural Medicine Comprehensive bleeding if used with warfarin (Natural Mountain Tea, Comprehensive Database, 2003) Medicine Comprehensive Database, 2003) Partridge Berry Database, 2003) ● Orally: No known ● Likely unsafe when used orally for ● May be useful in the suggested dose medicinal purposes (Natural Medicine treatment of neuropathic (Natural Medicine Comprehensive Database, 2003) pain (Data from Comprehensive Skidmore-Roth L, 2004) Database, 2003) ● St. John’s Wort ● Depressive moods, ● Oral: for mild ● Found no significant effect of St. ● Likely safe when used orally and (Hypericum anxiety and/or nervous depression, 300 mg John’s wort on painful appropriately, short term for up to 8 perforatum) unrest (The Complete times daily (Natural polyneuropathy or measures of pain weeks (Natural Medicine Comprehensive ● Also known as: German Commission E Medicine processing (Data from Sindrup et Database, 2003) Amber, Demon Monographs: Comprehensive al., 2001) Type II, B ● May cause serotonin syndrome when used al. et Wirth Chaser, Goatweed, Therapeutic Guide to Database, 2003) with some selective seratonin reuptake Tipton Weed, Herbal Medicines, 1998) ● For long-term inhibitors (Nutrition in Cancer Care, 2004) Hypericum, ● No studies have yet maintenance therapy, ● Increases the effects of triptans and Millepertuis, John’s examined the effects of 300–600 mg have opioids (Natural Medicine Comprehensive Wort St. John’s Wort on been used (Natural Database, 2003) chronic pain in the Medicine ● Decreases the effects of amitriptyline, absence of depression Comprehensive barbiturates, digoxin, irinotecan, and (Data from Koenig, Database, 2003) protease inhibitors (Natural Medicine 2003) Comprehensive Database, 2003) ● Also used for ● Increase side effects of antidepressants, dysthymia, exhaustion, cyclosporine, nefazodone, paroxetine, and fibrositis, headache, sertraline (Natural Medicine heart palpitations, Comprehensive Database, 2003) muscle pain, OCD, and ● Side effects can include insomnia, neuralgia (Natural restlessness, anxiety, irritability, fatigue, Medicine headache (Natural Medicine Comprehensive Comprehensive Database, 2003) Database, 2003) ● Avoid with all concurrent chemotherapy ● May decrease blood concentrations of cyclosporine, midazolam, tacrolimus, amitriptyline, indinavir, warfarin, phenprocoumon and theophylline (Data from Hu et al., 2005) ● May cause breakthrough bleeding and unplanned pregnancy when used concomitantly with oral contraceptives (Data from Hu et al., 2005) ● White Willow (Salix ● Diseases accompanied ● Oral: 1–3 g dried ● Willow bark extract may be a useful ● Possibly safe when used orally and alba) by fever, rheumatic bark 3–4 times daily and safe treatment for low back appropriately, short term (Natural ● Also known as: ailments, headaches (Natural Medicine pain (Data from Chrubasik et al., Medicine Comprehensive Database, 2003) Willow Bark, Bay (The Complete German Comprehensive 2000) Type II, B ● Theoretically, may interact with kidney or Willow, Reifweide, Commission E Database, 2003) ● No efficacy shown for use of willow liver dysfunction and an anticoagulant/ Violet Willow Monographs: ● Tea: 1–3 g bark in bark extract in treatment of osteo- antiplatelets and oral drugs (Natural Therapeutic Guide to 150 mL of boiling and rheumatoid arthritis (Data from Medicine Comprehensive Database, 2003) Herbal Medicines, 1998) water, then strain Biegert et al., 2004) Type II, B ● Salicylates are part of the compound that ● For pain caused by (Natural Medicine makes up aspirin inflammation, muscles, Comprehensive

and joint aches (Natural Database, 2003) Pain Relieve to Therapies Herbal of Use Medicine Comprehensive Database, 2003) ● Yohimbe ● Used to treat ● Oral: 15–30 mg daily ● No published research related to ● Not recommended because of insufficient (Pausinystalia impotence, fatigue, (Natural Medicine pain proof of efficacy and significant adverse yohimbe) hypertension, diabetic Comprehensive effects (The Complete German ● Also known as: neuropathy, and Database, 2003) Commission E Monographs: Therapeutic Johimbi, Yohimbehe, postural hypotension Guide to Herbal Medicines, 1998) Yohimbine (Natural Medicine ● Decreases effects of antidepressants, Comprehensive antihypertensives, hyperglycemic agents, Database, 2003) and monoamine oxidase inhibitors (Nutrition in Cancer Care, 2004) ● Can cause excitation, tremor, insomnia, anxiety, hypertension, tachycardia, dizziness, gastric intolerance, salivation, sinusitis, irritability, headache, urinary frequency, fluid retention, nausea, and vomiting (Natural Medicine Comprehensive Database, 2003) ● Higher doses have significantly more adverse effects (Natural Medicine Comprehensive Database, 2003)

NSAID, Nonsteroidal anti-inflammatory drug; FDA, Food and Drug Administration; ADHD, attention-deficit hyperactivity disorder; CNS, Central nervous system; GI, gastrointestinal; HIV, human immunode- ficiency virus; CAM, complementary and alternative medicine; INR, international normalized ratio. *This table includes only herbal supplements, dietary supplements or other forms of CAM therapy were not included. **Refer to Table 1 for study review criteria. 163 164 Wirth et al.

Understanding these interactions is complicated by also be suggested. To learn more about CAM, a list of the fact that the precise composition of many herbal educational web sites is included (Table 2). therapies is not fully known. Impurities and lack of quality testing may result in elements in herb mix- Limitations tures that are not intended to be included. Further- This study is limited by several methodologic con- more, patients may be lured into a false sense of straints. Publications were identified using only security believing that because herbal therapies are three search engines; more publications may have “natural” and are not regulated by the FDA, they are been identified through more diverse search means. inherently safe. These misconceptions may lead In addition, only publications written in English herbal therapy users to believe the therapies are were reviewed. There may be a larger body of re- safer than they really are. search in non-English speaking countries, where use of herbal therapies is more prevalent. Review and Patient Care Strategies translation of these articles were beyond our re- It is important for nurses to openly communicate sources. with patients who use CAM therapies. With use of herbal therapy on the rise, nurses are encouraged CONCLUSION when taking drug histories to routinely ask for in- The use of CAM, especially herbal therapies, to reduce formation about a patient’s use of CAM therapies pain has dramatically increased. Although use has in- ( Drew & Myers, 1997). It is important to be non- creased, scientific evidence of the efficacy of herbal judgmental and to keep in mind that patients may therapies to moderate pain is still limited. This review not consider “natural” substances in the same way summarized the empirical evidence available for 24 as pharmaceuticals. When addressing adverse drug herbal therapies and also detailed uses, dosages, routes reactions, question possible CAM use, do not dis- of administration, and side effects related to these count long-term use of CAM preparations as causing herbal therapies. This information will help pain man- side effects because there may be batch-to-batch agement nurses educate themselves about herbal ther- differences, and contact Drug and Poison Informa- apies to be better equipped to advise and treat patients tion Centers for information on CAM relating to a who use herbal therapies. suspected adverse drug reaction (Drew & Myers, 1997). Education on what is understood about herbal therapies may also greatly benefit the patient. Acknowledgments Education about alternative means to treat pain, The authors thank Randy Boston and Ronald Sims for their such as medication or another CAM therapy, may assistance.

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