REVIEW ARTICLE Herbs as Medicines Lisa Corbin Winslow, MD; David J. Kroll, PhD erbs and related products are commonly used by patients who also seek conventional health care. All physicians, regardless of specialty or interest, care for patients who use products that are neither prescribed nor recommended. Some herbs have been exten- sively studied, but little is known about others. When a patient asks for advice regard- Hing the use of a particular herb, how should a physician respond? Similarly, how does a physician de- termine if a patient’s symptoms are caused by a “remedy”? This review attempts to answer these ques- tions by investigating pertinent definitions, the history of herbs in medicine, epidemiology and prevalence of herbal use, and relevant psychosocial issues. Arch Intern Med. 1998;158:2192-2199 While a complete review of specific herbs Md) in 1992. Worldwide, herbal use again is impossible in this setting (.20 000 herbal became popular; in 1974 the World Health and related products are used in the United Organization (Geneva, Switzerland) en- States),1 the potential benefits and hazards couraged developing countries to use tra- of some of the more popular herbal prod- ditional plant medicines to “fulfill a need ucts in use are examined (Table 1). unmet by modern systems.”5 Thirty percent of all modern drugs are HISTORY derived from plants.3 Some of the more fa- miliar ones are listed in Table 2.4,6,7 The earliest evidence of humans’ use of plants for healing dates back to the Nean- EPIDEMIOLOGY derthal period.3 In the 16th century, bo- tanical gardens were created to grow me- Estimates of the prevalence of herbal medi- dicinal plants for medical schools.4 Herbal cine use differ, with studies concluding that medicine practice flourished until the 17th between 3% and 93% of the US popula- century when more “scientific” pharma- tion uses herbs (Table 3).7-10 The vari- cological remedies were favored.5 ability of these estimates is due to discrep- In the United States, the history of ant definitions of herbs (Table 1) as well herbal use begins in the early colonial days as different inclusions of the length of use when health care was provided by women (ie, ever vs in the last 12 months). in the home. Initially, they used home- Internationally, the use of botanical made botanical remedies and later pur- medicines is generally higher. For ex- chased similar products as “patent medi- ample, 70% of “Western” doctors in Ja- cines.” In the early 19th century, scientific pan prescribe kampo drugs daily.11 Eighty methods became more advanced and pre- percent of the world’s population relies pri- ferred, and the practice of botanical heal- marily on traditional medicines for their ing was dismissed as quackery. In the health care needs.5,12 It is certain that phy- 1960s, with concerns over the iatrogenic sicians are seeing patients who are using effects of conventional medicine and de- herbs, and, as is discussed, this use can af- sire for more self-reliance, interest in “natu- fect the patient’s health problems and ef- ral health” and the use of herbal products fects of conventional treatments. increased.5 Recognition of the rising use of herbal medicines and other nontradi- ECONOMICS tional remedies led to the establishment AND REIMBURSEMENT of the Office of Alternative Medicine by the National Institutes of Health (Bethesda, The amount of money spent on herbal remedies is significant. Americans spent From the HealthONE Center for Health Sciences Education (Dr Winslow), the Division $553 million in 8000 health food stores of General Internal Medicine (Dr Winslow), and the School of Pharmacy (Dr Kroll), in 1994,13 and from all sources, the esti- University of Colorado Health Sciences Center, Denver. mate of US “medical” herb sales is $1.2 bil- ARCH INTERN MED/ VOL 158, NOV 9, 1998 2192 ©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 ter herbs are not; and German phy- Table 1. Definitions of Terms Used in This Article sicians are much more knowledge- able about their use.14 Physicians Herb (urb, hurb) n 1. A flowering plant whose stem above ground does not must become familiar with herbal become woody and persistent. 2. Such a plant when valued for its medicinal properties, flavor, scent, or the medicine, as more insurance com- like.2 A broader definition also includes fungi, fruits, roots, panies will expect their physicians vegetables, and all plants; occasionally, enzymes, to make referrals or suggest herbal minerals, and hormones are also included when referring products. to “herbal medicine.”1 For this review, an herb refers to any plant, plant product, or mixtures of plants or plant products, in any form WHY DO PEOPLE Herbalist One who prescribes plants for medicinal use USE HERBAL MEDICINES? Botanical, natural, herbal, All refer to the use of plants for medicinal purposes traditional, and plant medicine There are multiple reasons patients Alternative medicine Refers to herbal medicine, chiropractors, acupuncture, or reflexology, etc—ie, anything not taught in a medical turn to herbal therapies. Often cited school but used for health care is a “sense of control, a mental com- Conventional medicine The practice of medicine as taught in a western medical fort from taking action,”9 which helps school explain why many people taking herbs Kampo Japanese traditional medicine, including the use of herbs have diseases that are chronic or incur- Ayurdevic medicine Type of herbal medicine practiced in India able, such as diabetes, cancer, arthri- tis, or AIDS. In such situations, they often believe that conventional medi- Table 2. Conventional Medicines Derived From Plants cine has failed them. When patients use home remedies for acute, often Atropine (Atropa belladonna) Physotigmine (Physostigma venenosum) self-limited conditions, such as a cold, Digoxin (Digitalis purpurea) Senna (Cassia acutifolia) Colchicine (Colchicum autumnale) Ephedrine (Ephedra sinica) sore throat, or bee sting, it is often Quinine (Cinchona officinalis) Cocaine (Erythroxylon coca) because professional care is not imme- Codeine (Papaver somniferum) Salicylin (Salix purpurea) diately available, too inconvenient, Vincristine (Catharanthus roseus) Capsaicin (Capsicum frutescens) costly, or time consuming.9,18 Ipecac (Cephaelis ipecacuanha) Scopolamine (Datura fastuosa) In rural areas, there are addi- Taxol (Taxus brevifolia) Reserpine (Rauvolfia serpentina) tional cultural factors that encour- age the use of botanicals, such as the concept of an interplay between the lion in 1996.14 Sales of herbal medi- ture in 7 states, and naturopathy in environment and culture, a “man- cines are growing by 20% a year, and 2 states.17 Insurance plans that cover earth” relationship.12 Religious be- herbs are the largest growth area in alternative health care often re- liefs, which can be traced to the me- retail pharmacy, far exceeding quire physician referral for these ser- dieval doctrine of signatures, are also growth in the conventional drug cat- vices, highlighting the importance of prominent: “The good Lord has put egory.15 physician awareness. One man- these yerbs here for man to make his- Costs to the individual and aged care company, Oxford Health self with. They is a yerb, could we costs of individual products can also Plans, Norwalk, Conn, is planning but find it, to cure every illness be substantial, albeit variable. An epi- to cover alternative treatments, in- [sic].”19 People believe that where an demiological study10 of patients posi- cluding some that use herbal rem- area gives rise to a particular dis- tive for human immunodeficiency edies, basing their decision on a sur- ease, it will also support plants that virus found that the average herbal vey showing that 33% of its 1.5 can be used to cure it.5 user was spending $18 per month on million members had sought alter- Natural plant products are per- herbs (range, $0-$175). Individual native treatment in the last 2 years. ceived to be healthier than manu- products have variable costs, depen- American Western Life Insurance factured medicines.12 Additionally, dent on both the product and its Company, San Mateo, Calif, has a reports of adverse effects of conven- source (homegrown, imported, from “prevention plus” plan that covers tional medications are found in the a health food store, or from an herb- herbal medicines. Industry ana- lay press at a much higher rate than alist). In another study16 of herb use lysts expect many other insurance reports of herbal toxicities, in part among patients with the acquired im- plans to follow suit to compete for because mechanisms to track ad- munodeficiency syndrome (AIDS), this untapped multibillion dollar verse effects exist for conventional one product recommended by a market.17 Although reimburse- medicines whereas such data for self- health food store sold for almost $150 ment for herbal medicines is in its treatment is harder to ascertain. Even for a month’s supply. infancy, it is expected to grow tre- physicians often dismiss herbs as Insurance plans and managed mendously along with the contin- harmless placebos,10 and many con- care organizations are beginning to ued boom in sales of herbal prod- sumers and physicians alike mistak- offer reimbursement for alternative ucts and alternative health care in enly believe that anything in a pill treatments. In fact, coverage of chi- general. In Germany, herbs pre- form has been approved by the US ropractic treatment is mandated by scribed by