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Home , Herbal medicine

Complementary and Alternative (CAM): A Review for the Primary Care

Janet Onopa MD

It/s difficultto find a satisfactory titlefor this review, because both treatments, such as or spinal manipulation, in the event the word “complementary” and “alternative” are not very politically of an . correct currently. Itis probable that there is no fullypoliticallycorrect This review will briefly introduce some of the most common word, except for “non-allopathic,” which is unfamiliar to many MDs. alternative practices likely to be seen in Hawaii communities: Accurately used, the term “allopathic” is as opposed to “homeo , , , Chinese Medicine and Acu path/c,” so from its origms, “aiopathic medicine” should include puncture, and and spinal manipulation, and a brief medicine. Howe vet inpractice, herbal and many other non- discussion of Dr. Eisenberg ‘s recent position paper on advising homeopath/c treatments are cailed ‘on-allopathic, “ whereas con patients about alternative practices. ventional medicine is called “allopathic.””Complementary” usually would include practices that are used with conventional western Homeopathy medical treatments, and “alternative”would include those practices Homeopathy was invented by Samuel Hahnemann, a physician that are used instead of western medical treatments. For most of who lived from the mid-l700s to the late 1800s. He was alarmed by this review, the terms “non-allopathic,” ‘alternative, “and “comple mentary” could be used interchangeably. the rather toxic of medical treatment of his day: it was This topic has gained interest, and received some allopathic common to treat by purging or bleeding, and it seemed to him that legitimacy, inpart because ofan article that David Eisenberg, M.D., the doctors were often doing harm in their treatments. (This is a published in the New England Journal.’ In 1990, he performed a recurring theme among the founders of alternative methods.) He telephone survey of about 1,500 adults in the U.S. and asked them wanted to find some treatment method which was gentle, and which about the use of treatments and practices that were “alternative,” would cause no harm. which he defined as not generally being taught in the U.S. medical In the early I800s, he revisited an old idea which Hippocrates had schools and not being readily available in U.S. hospitals. From his sample, he extrapolated that in 1990, about 60 millionAmericans promoted, that of the “Law of Similars”: si,nila similibus curentur used alternative medical treatments, at an estimated cost of $13.7 (like cures like). The idea occurred to him after he took an overdose billion. There were more visits to alternative healers than to primary of ( bark) and became ill with it. He noticed that care MOs that year, and over two-thirds of people who did use when he got sick, his symptoms were similar to those of . At alternative medical treatments did not tell their doctors about it. the time, knew that quinine cured malaria, though they Now that third party figures are becoming interested inpaying for did not know the cause for malaria. Hahnemann surmised that alternative medical practices (especially naturopathic, chiroprac perhaps it is because quinine mimics malaria that it is capable of tic, and acupuncture services), allopathic physicians will be in creasing in the position of being able to refer people to alternative curing malaria, if taken in lower doses. It is taking a “simillimum,” providers, and insurers willpay for services that MDs approve. a substance that can mimic the illness, which will cure the illness. Therefore, it willbecome increasingly important for physicians to Hahnemann thought that the similar drug would activate some vital have a degree of familiarity with alternative treatments (including force in the body to react against the illness. efficacy and risks). So far, to date, there have been no cases of He advanced his idea to his colleagues, and together they set about malpractice for giving advice about the use of alternative medical the task of”proving” drugs: identifying what symptoms they caused treatments, but liability willcertainly exist to anyone who delivers in high doses, in order to match them up with illnesses, after which they would be diluted down to non-toxic doses. Hahnemann chose “reliable observers” (including himself), who would take a large dose of a medicine, usually herbs and minerals that were used medicinally at the time, and note down what the symptomatic results were. They pooled several observers’ findings and identified what each drug’s signature symptoms were. This process is called “prov

Correspondenceto: ing” a remedy. Janet OnopaMD They tried to identify the minimum dose of each drug that would UniversityofHawaii be effective as a cure. To Hahnemann’s surprise, he discovered that DepartmentofMedicine 1356LusitaniaSf,7th Floor no matter how far he diluted the drugs, they still seemed to work as Honolulu,Hawaii96813 cures for illnesses. The explanation for this was that the method of

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a a placebo or standard medical treatment, Of these, 81 indicated have done a little bit better than the U.S. in crafting legislation. positive results (homeopathy is likely to be effective), and 24 found Currently, the U.S. is following the Health and no evidence of effect. Most trials had relatively poor quality meth Education Act of 1994. Senator Oren Hatch of the state of Utah ods but there were some that were that were well designed. The (which has an active herbal products industry) introduced this law. authors considered it likely that some publication bias existed. It permits the marketing of “dietary supplement” with no required Publication bias can work in favor of. or against publication, approval of any government agency, so long as there is a label on the depending upon the orientation of the editors. Alternative medical product that states that (I) no Food and Drug Administration (FDA) journals would theoretically be more likely to want to publish items evaluation of that product has occurred, and (2) the product “is not that had positive results for alternative treatments, but conventional intended to diagnose, treat, or prevent any disease.” When these medical journals would be more likely to want to publish negative criteria are met, the burden of proof about the product’s safety, or results. However, review of the outcomes does not reveal any lack of it, would rest entirely on the FDA, and not on the manufac correlation between the orientation of the journal (alternative vs. turer of the herbal/dietary product. In practice, no one is actually conventional) where an article was published and whether it demon taking responsibility for the safety of products, unless the FDA strated positive or negative results. chooses to try to prove that a product is unsafe. The manufacturers Of the best quality trials in homeopathy, 15 had positive results, can suggest doses on the label and these products are not standard and 7 did not. The authors of the BMJ overview indicated that there ized. is some evidence that homeopathic treatment can be efficacious in Other countries have better rules. For example, Germany gathered the following illnesses: respiratory infections, hay fever, , GI together a group of experts, called the German “Commission F,” complaints (especially gastritis and irritable colon), arthritis pain, which was in effectfrom 1978until 1994. This commission included migraines, and recovery from sprains. Most trials were with poly toxicologists, pharmacologists, physicians, and other scientists and (multiple combined remedies), and/or did not have indi they produced 400 monographs on herbal medicines. They re vidualized treatment, which has been a source of criticism by the viewed the available evidence, using a standard of “reasonable many homeopathic practitioners. certainty of efficacy” and then produced guidelines for their use, Herbal remedies dosing, and administration. The Commission E’s monographs are This will be a brief review of some of the current oversight (or lack available in English in the U.S., though more scientific evidence has of it) on herbal medicines, some of the most commonly used herbs, been accumulating since they were published. and a review of a few herbs with documented toxicities. In contrast, in the U.S., in order to obtain FDA approval for a drug, The U.S. law currently does not provide good oversight of herbal a company would need to provide evidence and meet a standard of remedies and dietary supplements and there is some work being “absolute certainty of efficacy,” and the average cost to achieve that done to improve the regulation of these products. Other countries standard is now about $350 million per drug. Since none of these

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a the symptoms of BPH. Larger placebo-controlled trials are sorely activity. It does contain several courmarins, which are vasodilators needed. and antispasmodic, though the utility of these effects has not been well-defined. Clinically, it is being used for menopause, menstrual (Ailium sativurn) seems to lower cholesterol, and inhibits irregularity. PMS symptoms, and as a women’s general “tonic” (a clotting. It has evidence offibrinolytic activity and it lowers platelet word used frequently to describe herbal medicines, meaning that it aggregation in vitro. It may help lower blood pressure; there have helps people adapt to their environment, keeping them healthy, and been studies with divergent results on garlic’s effect on treating high making them feel more energetic). It appears to be safe in the usual blood pressure. There is indirect evidence that it may have an doses but studies are lacking. It is popular right now, especially for antibiotic effect, and it has been touted as helping to treat colds and treating menopause symptoms. yeast infections. It has ingredients that are antibacterial but whether it works as such when ingested is not that clear. Some herbalists say (Panax ginseng). There many different plants that are it ought to be eaten raw instead of cooked, because cooking seems sold under the name “ginseng,” but the genus Panax ginseng is the to inactivate its main pharmacological ingredient. allicin. The best source for true ginseng root. Adulteration and the use of other plants effect was seen with very high doses, which will be equivalent to 5- called Ginseng (e.g. Siberian Ginseng, American ginseng, etc.) are 20 raw cloves a day for a 175 lb. person; this might be socially a problem in identifying its characteristics. True ginseng root is very problematic! There were 2 ineta-analysis by different researchers expensive; it takes six years to grow a crop and it is easily and out of Oxford, England in j993)9 Each reviewed studies with commonly adulterated, and easily inactivated by processing. Gin standardized powdered garlic (with a standardized allicin content). seng is supposed to be an adaptogen, or “tonic” and is thought to be They had conflicting results, and they came up with opposite antifatigue and antistress. It was thought to have some estrogenic conclusions. More recent trials have also had conflicting results, activity, but recent studies have not found any evidence of direct some showing significant decreases in serum LDL cholesterol, and estrogenic effect. It might induce hypertension in some individuals. others showing no effect. The discrepancies may depend on the Ginseng is a classic example of the “doctrine of similars,” which is garlic preparation used. The upshot is that garlic might lower found in all cultures. The “doctrine of similars,” states that there is cholesterol, and it might lower blood pressure. It is unlikely to have some physical clue about the plant which tells you what malady it adverse effects beyond halitosis, though some experts recommend will be useful for. For example, ifa plant has yellow sap, it would be that patients not take garlic supplements if they are anticoagulated, useful to take it forjaundice. Ginseng root grows in various shapes, for fear of additive effects. but it often looks like a little person: it may look like it has arms and legs, and herbalists have taken this as a sign that it is supposed to be Feverfew is used for migraine headaches. Two or three fresh for the well-being of the whole body. It also often looks phallic, and leaves are supposed to be ingested every day, however, it is usually at times even a bit like female genital labia, so it has been purported not sold as fresh leaves. It may have a spasmolytic effect, similar to to be useful for male potency, and as an aphrodisiac for males and methysergide or parthenolide. It has indirect anti-seratonin proper females. Ginseng has apparently been studied to see if has any ties on animal tissue in 0vitro.’ Its clinical efficacy has not been aphrodisiac effect, with good evidence that it does not have any demonstrated with well-designed large clinical trials. Many com effect as an aphrodisiac. However, it is still marketed as such, and mercial preparations available in the U.S. seem to have a minute herbalist literature states that it is useful to improve the sex life. amount of the herb, which is unlikely to have any effect. It appears (There are a countless other interesting examples of the “doctrine of safe thus far but good studies are needed. similars.” For example, there is a leaf that the South Americans use which is quite stiff and if it is crumpled up, it will pop back into is probably the most commonly prescribed sleep medi shape, and that leaf is also used as a male aphrodisiac.) cine in Europe. It is from the root of the plant Valeriana . There are many varieties of ginseng, and it is often not labeled It has been used medicinally to induce sleep for thousands of years. correctly. There is adulteration and often processing inactivates it. It has an ingredient that binds to the benzodiazepine and other All of this variability has made it hard to investigate reported receptors in the brain, and it has sedative properties. It is available toxicities. There have been reports published of ginseng toxicities, as a tincture, or freeze-dried extract capsules. Its safety seems well and the product when investigated has been found to not have any established, especially considering its widespread and long-term ginseng. There are no good studies that demonstrate ginseng’s use. A published case report of an intentional overdose showed that effectiveness. It is probably safe, based on the thousands of years it its toxic effects were very mild. In some small studies, it doesn’t has been used, but adulteration makes it very hard to be certain. seem to cause any addiction or rebound insomnia when it is discon tinued, but larger well-designed studies are needed. Ciiikgo biloba. leaves come from an ancient tree species; it has been around since the ages of the dinosaurs. It is hardy and Dong Quai or Tang kuei. Angelica sinensis is the Latin name ftw grows in cities all over the world. A standard extract is produced this medicinal plant, which has been called “the female ginseng,” from the leaves which contains 24% flavinoids and 6% terpenes; and it is often used for various gynecological ailments. It is pur tablets always have 40mg of the extract. It is easy to standardize and ported to have weak estrogen-like activity and so some literature has relatively inexpensive and commonly available, so it is easier to advised avoiding use of the herb for patients who have breast . study this herb than one like ginseng. Its use is primarily to prevent However, it does not have phytoestrogens, and research to date has or improve memory loss, especially in the elderly, and a recent not been able to clearly identify whether it does have any estrogen article in JAMA demonstrated a small but significant effect on

HAWAII MEDICALJOURNAL, VOL 58, FEBRUARY 1999 14 decreasing progressive memory loss in patients with mild demen placebo group. Commercially, it is often combined with chondroitin tia.” It is supposed to improve cerebral blood flow, and some studies sulfate. There are no good studies that I have found on the efficacy have indicated a possible positive effect for other neurological of chondroitin but there was a popular book called The Arthritis ailments including headaches, tinnitus (especially if it has a CNS that was a bestseller last year. The author claimed that source) and depression. There is one study published in the Aviation, should be combined with condroitin for maximal Space, and Environmental Medicine Journal in 1996.12 The authors efficacy, and now they sell preparations with the two combined in did a randomized controlled trial of an extract of 761 the ratio he proscribed. There was a recent review in The Medical used for altitude sickness during a Himalayan expedition. There Letter (a conservative and respected publication), in September of were 44 men in the study. They randomized them and gave half of this 6year.’ Their view was that glucosamine is safe and possibly them 80mg orally BID of standardized ginkgo extract and compared effective, but there is a need for longer trials. As they have with all them to a double-blinded placebo group. The results were striking: “dietary supplements” that they review, they caution with the fact none of the ginkgo group developed signs of cerebral mountain that this is a dietary supplement, so you never know if what you are sickness vs. 40.9% developing such symptoms in the placebo group buying is what is on the label. The NIH’s Office of Alternative (p= 1.4 xl 0-3). The difference was also striking for respiratory Medicine is currently funding a large trial on both glucosamine and symptoms and high altitude pulmonary edema (HAPE): three in the chondroitin in the treatment of osteoarthritis. ginkgo group developed respiratory mountain sickness symptoms (13.6%) vs. eighteen (81.8%) in the placebo group (p=1.2x 10-5). Toxicities from Herbs Since prior studies had indicated that ginkgo had apositive effect on There are some important herbal toxicities that practicing physi improving circulation to the extremities during cold exposure, the cians should be aware of. researchers took a plethysmography device along on the climb up the mountain. Then they checked the study participants for both Germander. This is an old time drug used to treat diarrhea and objective evidence of compromised blood flow of their extremities used topically for oral lesions. It was found to cause hepatitis and its with plethysmography, and a questionnaire about symptoms of use has been banned in France, but is still readily available in the vasomotor constriction (stiffness, numbness, aching). These were U.S.A. It’s especially worrisome when patients combine it with also highly significant and demonstrated a marked improvement of other potential hepatotoxins. peripheral circulation among the studyparticipants who took ginkgo. This study has attracted virtually no notice in the medical commu Chaparral. This is an old American Indian remedy. This is used nity, and perhaps it needs to be repeated to see if it can be replicated for everything (always a good warning sign that an herb is probably in a larger population before ginkgo can gain acceptance as a not good for anything!), including arthritis, cancer, VD, tuberculo possible safe and efficacious preventative for acute mountain sick sis, URI symptoms, as a hair tonic, and to remove LSD from your ness and frostbite. It increases arterial and capillary vasodilatation, system. It has been conclusively proven not to remove LSD from and it slightly lowers clotting time, so it should be used with caution your system, by the way. There is an ingredient in chaparral that has in people on and blood thinners. A reported overdose of verypotent antioxidant qualities called NDGA, which has no proven Ginkgo caused restlessness, nausea, vomiting and diarrhea. This is medical value, but it has been shown to increase the life span of a an herb which is ripe for well-controlled sizable trials. mosquito from 29 to over 45 days. Nevertheless, chaparral was removed from the Generally Recognized As Safe (GRAS) List in Glucosamine is a constituent of cartilage glycosaminoglycans. 1990 because it causes subacute hepatic necrosis.’ You can still This is sold as a dietary supplement. Glucosamine stimulates carti buy it in health food stores in the U.S. ”7 lage cells to produce glycosaminoglycans and proteoglycans, which may allow restoration of cartilage in intra-articular destructive Conifrey is an old-time remedy and its name sounds like it should diseases. There have been trials, all short term, that have shown that make the ill well again. Itcomes from the plantSymphytum officinale, it’s effective in relieving pain and increasing range in motion in and it is used for many different illnesses, something of an herbal osteoarthritis. A four week double-blind trial in 252 osteoarthritis “wonder drug” It used to be called “knit-bone,” and was applied patients demonstrated that glucosamine was significantly superior externally as a poultice for broken bones and internal injuries. The to placebo.’ In another four-week trial on 200 patients, it was as tea has been used to treat peptic ulcers, it is purported to “purify the effective3 as ibuprofen 400 mg tid from the second week 4on.’ blood,” in addition to being recommended for almost any ailment Glucosamine seemed slightly slower to relieve symptoms, but you can think of. All comfrey products tested have contained subsequently it works as well (or better than) ibuprofen. A double- hepatotoxins called pyrrolizidine alkyloids. There are several herbal blind eight-week trial with 40 osteoarthritis patients randomized to remedies in various countries with these same toxic ingredients, two groups: one group took 500 mg glucosamine tid and another including “bush tea,” and “gordolobo tea” in Central America and took ibuprofen 400 5tid.’ This study demonstrated that ibuprofen and Mexico; these also contain pyrrolizidine .”' They can cause glucosamine were as about equally effective during the first two liver cell necrosis and veno-occlusive disease in lungs and liver. weeks of the trial, and by week eight, the glucosamine group was Veno-occlusive disease can cause pulmonary hypertension, and doing better. Another study demonstrated that the positive effect of there have been several documented cases of comfrey-induced glucosamine on arthritis symptoms seems to last for a week or two pulmonary hypertension. The toxicities seem to be related to the after stopping the drug, unlike NSAIDs. In all trials, glucosamine is total dose, host susceptibility and route of exposure, with the root well tolerated. Any side effects were equally as common in the being considerably more likely to have significant levels of toxic

HAWAIIMEDICALJOURNAL, VOL58, FEBRUARY1999 15 alkyloids than the leaves. It’s been banned in Great Britain and in schools. Canada, but you can still buy it here in the U.S. Upon review of Naturopathy started in Germany, again as a result of physicians’ several of the herbal books at a local bookstore, several had sections horror at the toxicity of the commonly used medical treatments. extolling the virtues of Comfrey, with nothing about potential health Early naturopaths were interested in “water cures” where they gave problems or any indication that the herb has been banned in other patients pure spring water to make them better, and they used countries. treatment intended to build up the healing power of nature, with emphasis on gentle, nontoxic remedies. A naturopath interviewed Sculicap () is commonly used for “female here on Oahu indicated that about two-thirds of his practice was pain weakness,” as a tonic, and it is purported to have tranquilizing and treatment, adjunctive cancer care, chronic allergies, chronic arthri antispasmodic activities. The studies done on it to date have failed tis, chronic GI problems (especially irritable bowel, chronic nausea) to find any effect at all, so it seems doubtful that it has any medicinal and menopause and PMS. Some naturopaths interested in women’s value. It was reported to be hepatotoxic in four women who were using it to treat stress. Subse quently, the investigators had reason to wonder FREEPICKUP • DELIVERY• DOCUMENTSTORRGE• DESTRUCTION• SHREDDING if this was actually caused by a Germander substitution. It is not really clear that the scuilcap is toxic but there have been published warnings about possible °2toxicity. Sassafras (Sassafras albidum) is what old- time root beer used as a flavoring and it was used as “spring tonic”. It has safroles and allylbenzenes which have been proven to cause cancer in mice. It is not clear ifit is carcinogenic in humans because we don’t have the enzymes that change the sassafras ingredients into the carcinogenic substances, so we probably don’t have the risk of carcinogenesis that mice have. It is not clear if it should be banned, but right now it is prohibited by the FDA as a flavoring or a food additive based on the murine studies. However, you can still get it as an herbal rem edy, primarily in sassafras tea. There is no evidence that it does anything medically at all, so it may be prudent to advise avoidance of this herb as long as there exists doubts about it’s safety. Naturopathy In order to be licensed as a naturopath in Hawaii, a practitioner must have a N.D. degree, obtained from a four-year naturopathy school. There are two such institutions in the Pacific Northwest, one in Arizona, and there are others — . .ThJ..** —‘ opening in the East Coast. Their training is like medical school, their first two years are basic science, pathology and other basic sciences, and the latter two years are devoted to study about herbalmedicine, homeopathy, nutritionandlife style changes, which are the basics of modern the naturopathy. Most schools teach something at - dO 00 00 about spinal manipulation, and spend consider tile _ — able time teaching counseling techniques, and z -eC ..h 0’ve usually 0 • P ileO some teach some acupuncture, although . 0!— 00 lie 0 that would be taught at a separate institution. a on_a ha hO 3 - -e The training in the last two years is in the . outpatient clinics that are affiliated with the

HAWAIiMEDCAL JOURNAL, VOL58, FEBRUARY1999 16 ______‘s

health may have most of their practice treating menopause and PMS. for arthritis. There is a published report of thirteen American Basically, naturopaths often treat illnesses that conventional physi patients taking this for rheumatoid arthritis and they all improved cians don’t havereliably safeor effective treatments for. Naturopaths markedly when they were taking it.2122 However, then they devel can order diagnostic tests and they can give homeopathic treatments oped side effects, including ecchymoses, Cushingoid appearance, but they don’t have a license to prescribe drugs. , hypertension, arrhythmia, weight gain, and one had com pression fracture and one had bone marrow suppression. When the Chinese Medicine medicine was analyzed, it was found to contain indomethacin, Like many complementary medical systems, Chinese medicine is prednisone, small amounts of lead, and aminopyrine (a very toxic based on the idea that illness arises Outof a life or body force that has substance known to cause bone marrow failure). Also, when the been disrupted or placed out of balance. Chinese medicine is based patients stopped taking the first batch and started the next batch, all on the idea of Ch’i, the life force. In Chinese medicine, all of life is had a flair of their arthritis symptoms, indicating that they probably Yin or Yang, and sickness is due to the imbalance of these two received quite different ingredients in the second batch. So it would opposites. All medical care is directed to adjusting the balance. The be wise to caution patients not to take unlabeled, proprietary concepts of Yin and Yang are complex. Yin is cold and female and medicines. Yang is hot and male, but it is much more complicated than that. The Chinese system of medical diagnosis is very different from Acupuncture anything that is taught in western medical schools. There is exten Acupuncture is based on twelve meridians, or lines of , in sive emphasis on using the pulse for diagnosis. There are six the body. Acupuncture points lie on the meridians. Meridians don’t different pulse points with three depth levels for each pulse point. necessarily follow the nerve pathways. It is clear that acupuncture Chinese practitioners take the pulse very carefully and they make the releases endorphins, and it changes the electrical conductivity of the diagnosis from the character of the pulses. In addition, the tongue is skin. Whether that has anything to do with whether or how acupunc also used for diagnosis, and Chinese texts may have many pictures ture works, nobody knows. In the West, acupuncture is primarily of tongues that tell you what the diagnosis is. In addition to the pulse used for pain, but inChina they use it forjust about every illness. The and tongue diagnoses, practitioners depend on general observation research on it is demonstrating that it may be very useful for a variety of the patient. The diagnoses are not like anything that western of symptoms in addition to pain. The studies are small, and it’s been physicians are familiar with. The nomenclature is entirely different, very hard to have adequately blinded trials. It is possible to blind the with symptom complexes that are grouped together in ways entirely patient to some degree, but it’s been difficult so far to blind the different from any western symptom complexes. Since the language persons delivering the acupuncture treatment. for illnesses is foreign from Western medicine, it is very difficult to In the studies so far, the most promising evidence is for translate back and forth. “Stagnant blood” is one of the most acupuncture’s role in treating nausea. There is enough evidence that common diagnoses, and “extravasation” is frequently referred to as many who have reviewed the studies would say that acupuncture is a common illness. It is very confusing to try to make sense of useful for nausea, especially postoperative nausea. The Oslo Review Chinese medical books after learning about illness from a European on Research in published an endorsement for perspective. acupuncture’s effectiveness in nausea, chronic pain and post-stroke Chinese herbs are given in formulae or combination, and it would recovery but found no good evidence for its effectiveness in treating be unusual to have a single herb given. Herbal formulae are usually asthma or addiction treatment. The NIH Advisory Counsel on steeped as a tea, often unpleasant-tasting. There are over 7,000 Alternative Medicine, in October 1997, recommends acupuncture different herbs that are used in Chinese medicine. Patients will be treatment as effective for nausea andpost-operative dental pain. The prescribed a bag with a mixture of herbs, and it is not uncommon for American Journal of Chinese 23Medicine had a very good review this the herbalist to use substitutions by accident or on purpose, which year that indicated that well-designed studies really need to be done makes it very difficult to track ingredients or the source of any because so many of the studies published have been poorly done. But toxicity. In general, toxicity from Chinese herbs is quite uncommon. there is clearly some positive evidence from some of the better trials Of the 150 commonest herbs given, about 10of these have clearly that demonstrate that it is probably useful in tinnitus, angina, dry had instances of reported toxicities. But most of the herbal formulae mouth, post-operative pain, migraine, dental pain, dysmenorrhea, have been used for many thousands of years. Cases of severe or fatal tendinitis and lowback pain and clear evidence of efficacy in nausea. poisoning do occur with both Chinese herbal medicines and Chinese Research into the mechanism of action of acupuncture is ongoing. proprietary medicines (packaged pills with combinations of drugs Recently, a study using functional MRI imaging evaluated the eye for a specific ailment, e.g. “Dr. arthritis formula”). Both acupuncture points, which are found in the foot. They showed brain herbal and proprietary medicines have been contaminated with activity in the visual cortex when the points in the foot that are used serious toxins and prescription drugs, including heavy metals, for eye illness are stimulated. steroids, potent NSAIDS and substituted cheaper herbs. The main Acupuncture is generally very safe as long as practitioners use toxic effects from Chinese medicines are from a few things that are disposable needles. (When reusable needles were used, there was used: podophyllin, aconites and anticholinergic effects from things hepatitis and AIDS passed to patients.) Today, in developed coun that are often used in asthma medicines. tries complications are very rare. There is an example of a Chinese proprietary medicine, Chuifong Toukuwan, called by most of the westerners who used it “black balls from .” The pills look like little gumballs and they were used

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if considered risky: spinal manipulation of the cervical spine, some 12. Roncin,JP et at: Egb761inControlofAcuteMountainSicknessand VascularReactivityto Cold herbs, “patent” remedies from uncontrolled places, restrictive diets, Exposure.AviatSpaceEnvironMed1996;67:445-52 13. Moack,W.et at.Osteoarthritiscartilage2:61,1994 megadose , IM or IV substances and reusable needles. He 14. Muller-Pursbederet at.Osteoarthntiscartilage2:61,1994 considered very low risk: homeopathy, most , prayer, 15, VazA,L.,CurrMadResOpin,8:145,1982 16. GlucosamineforOsteoarthntis;TheMedicalLetter;Vol39)1010)September26, 1997 guided imagery, hypnosis, some herbs, and acupuncture with dis 17. D’ArcyPF . Adversereactionsand interactionswithherbalmedicines.Part 1.Adversereactions. posable needles. He advised to watch for indirect toxicity inthe form AdverseDrugReactToxicotRev.1991;10:189-208 18. GordonDWet at. Chaparralingestion.The broadeningspectrumof liverinjurycaused by herbal of delay. There is also concern that some of these therapies, particu .JAMA.1995;273:489-90 larly prayer and guided imagery, can engender guilt and severe 19. RidkerPMet at.Comtreyherbtea andhepaticveno-occlusivedisease.Lancet1989;1:657-8 Sassafrasandherbtea. Potentialhealthhazards.JAMA1976:236:477 emotional duress because if the therapy fails, the patients can 20. DeSmefPA,Healthrisksofherbalremedies.DrugSat. 1995;13;81-93 succumb to the idea that they were not “good enough” to get a 21. Myarson,GE,at al,ChineseTherbalmedtcinemailordersyndrome;ACauseof Hypercortisotism ArthritisRheum25 )Supp.14)587,1982 benefit. Also, practitioners need to alert patients that drug-herb or 22. GoldmanJA at at., Chineseherbalmedicine:camouflagedprescriptionantinttammatorydrugs, drug-diet interaction can occur, for example, people on grapefruit corlicosteroids.andlead.ArthritisRheum.1991;34:1207 23. Ernst,E.andWhite,A.:AReviewofProblemsinClinicalAcupunctureResearch,AmJ Ch.Med1997 diets can induce potentiation of channel blockers, and in 25)1(:3-11 particular chemotherapy regimens may be rendered more toxic, or 24. Buter,K.,“Consumer’sGuidetoAttamativeMedicine”1992;PrometheusBooks,Buffalo,NY. 25. Koas,Bat at:TheEfficacyofChiropracticManipulationforBackPain:BlindedReviewofRelevant ineffective, due to concurrent use of alternative medicines. It is RandomizedClinicalTrials.J ManipPhysTher1992Oct;15(8):487-94 much preferable if patients are willing to try one thing at a time, so 26. MylarL:ARiskAssessmentofCervicalManipulationvs NSAIDsfortheTreatmentofNeckPain.J ManipulativePhysiolTher1996June; 19(5):357 that efficacy can be assessed and to avoid increasing toxicity. 27. PowellFC,at at.Arisk/benefitanalysisofspinalmaniputationtherapytar reliefoflumbarorcervical pain.Neurosurgery.1993;33:73-9 Eisenberg also outlines a step-by-step approach to helping pa 28. Eisenberg,D:AdvisingPatientsWhoSeekAlternativeMedicalTherapies.AnnInternMed1997;127: tients try out alternative therapies with their physician’s assistance 61-69 to determine if the treatment has been effective and safe, and he Other References recommend that physicians involve themselves in supporting pa • Astin,J:WhyPatientsUseAltemativeMedicine.ResultsofaNationalStudy.JAMA1998;279(19):1548- tients’ trials of treatments from acompassionate and evidence-based 53 • MurrayJ and Shepherd5: Alternativeor AdditionalMedicine?An EaploratoryStudyin General perspective. He recommends against referral based solely on patient Practice.Soc.Sci.Med.1993;37)8):983-88. demand, but only when it is part of a rational therapeutic plan. He • Weiner,M.andGoss,K:‘TheCompleteBookofHomeopathy”1989AvaryPub.Group,Inc.;NewYork • LockieAandGeddes,N: ‘The CompleteGuidetoHomeopathy”1995DKPublishingNewYork advises that there are times when we must “agree to disagree,” and • Uttman,D.:“TheConsumer’sGuidetoHomeopathy”1996TarcherlPutnam he ends with the following statement: “No patient should feel that • ReillyD.at al:IstheevidenceforhomoeopathyreproducibleLancet1994;343:1601-6 • JacobsJ. at at:Treatmentofacutechildhooddiarrheawithhorneopathicmedicine:a randomized their medical journey is to be taken alone or according to some clinicaltrialinNicaragua.Pediatrics1994;93:710 stealth trajectory, invisible to their conventional providers. The • Linde,K.at at:Aretheclinicaleffectsofhomoeopathyplaceboeffects?Amata-analysisofplacebo- controlledtrials.Lancet1997:350:834-43 delivery of medical care, like the experience of illness is best viewed • Tyler,V.“TheHonestHerbal:a SensibleGuidetothe UseofHerbsand RelatedRemedies.’3rdad. as a journey shared”. Binghamton,NY;HaworthPr; 1993 25 • LucernoMA,at at.Alternativestoestrogenforthetreatmentofhotflashes.AnnPharrnocother1997; CAM is a fascinating area of investigation and the practicing 31:915-17 physician will need to keep abreast of the literature as studies are • D’ArcyPF, Adversereactionsand interactionswithherbalmedicines.Part 2—DrugInteractions. AdverseDrugReactToxicotRev.1993;12:147-62 published. There is increasing funding support for research in this • McCartyMF,Theneglectofglucosamineas a treatmentforosteoarthntis—apersonalperspective. area, and conventional medical journals are likely to be publishing MedHypotheses1994May;42)5):323-7 • HungOLet at: Herbalpreparationuse amongurbanemergencydepartmentpatientsAcadEmerg research about “alternative” practices in the coming years. As our Med1997Mar;4)3):20913 knowledge base grows, it is likely to further blur the line between • Berges,RRet at. Randomized,placabo-controtted,double-blindclinicaltrialof Beta-sitosterotin patientswithbenignprostatichyperplasia allopathic and complementary/alternative medicine; making the • SegetmanABetat.WorldHealthOrganization.HerbalMedicinescontainingGermanderwithdrawn. moniker “Integrative Medicine” a reality. PHAinformationExchangeservice.Geneva:WorldHealthOrganization;1992 • LarrayD,et at.Hepatitisaftergermander(Teucriumchamaedrys)administration;anotherinstanceof herbalmedicinehepatotoxicity.AnnInternMed.1992;117:129-32 Acknowledgement • Manaka,Y.andUrquhart,I:“TheLayman’sGuidetoAcupuncture’1972Weatherhilt;NewYork • Vickars,U. Canacupuncturehavespecificeffectson health?Asystematicreviewofacupuncture Appreciation is expressed to Linell Goya for secretarial and emesistrials.JR SocMed1996;89:303-11 editorial services. • Hasketh,Tet at.HealthinChina.TraditionalChinesemedicine:onecountry,twosystems.BrMedJ 315;July12;115-18 • ChanTyatat.,Chineseherbalmedicinesrevisited:a HongKongperspective.Lanet1 993;342:1532- References 4 1. Eisenberg,D.,et al:UnconventionalMedicineintheUnitedStales,Prevalence,costsandpatternsot • Langone,J., “Chiropractors:AConsumer’sGuide”1982;Addisen-WesleyPublishingCo,Reading, use. NEngJ Med1993Jan. 28:328(4)246-52 MA 2. Kleijnen,J. et al:ClinicalTrialsofHomoeopathy.BrMedJ 1991;302:316-23 • Gross,ARetat:Conservativemanagementofmechanicalneckdisorders.Asystematicoverviewand 3. LindeK,et at.StJohn’sWortbr Depression—anoverviewandmets-analysisofrandomizedclinical meta.analysis.OnilneJ CurrC/inTrials1996Jul30;Doe.No200-201 trials,BrMedJl996; 313:253-258 • MeadeTW,etat:Randomizedcomparisonofchiropracticandhospitaloutpatientmanagementtortow 4. Homig,M.,Hypericum(St.John’sWort)br TreatmentofDepression,AltMedAlert1998Jan:1(1);4- backpain:resultsfromextendedfollow-up.BrMedJ 1995Aug5;311(7001):349-51 7 • Comments:BrMedJl995 Nov11(7015):1301-2and 1302;andNov18(7016):1371 5. ChaterjeeSSetat.Hypertorinass possibleantidepressantcomponentofhypericumextracts.LifeSci • HurwitzE, at at: Manipulationand Mobilizationofthe CervicalSpine.A systematicreviewofthe 1998;63(6):499-510 literature.Spine1996,21(15):1746-59,comment1759-60. 6. Gerber,GS,etat. Sawpalmetto(Seranoarepass)inmenwithlowerurinarytractsymptoms:effects • Koes,Bat at:SpinalManipulationforLowBackPain.Anupdatedsystematicreviewofrandomized onurodynamicparametersandvoidingsymptoms.Urology1998;51:1003-7 trialsSpine1996;21(24):2860-73 7. PloskerGL,et at. Seranoarepens(Permixon).Areviewofitspharmacologyandtheraputicefficacy • ShekellePG,at at.Spinalmanipulationfortow.backpain.AnntntMed.1992;117:590-9849. inbenignprostatichyperplasia.DrugsAging1996Nov;9)5):379-95 • WilkinsonJA The Internetas a researchand informatontoot for herbalmedicine,BritishJ of 8. Mail,HA,etat,GarlicPowderinthetreatmentofmoderatehyperlipidaernia:a controlledoralandmats- Phytotherapy.1995;4:34-45. analysis;JR CoilPhysiciansLord-1996;30(4):329-34 9. Silagy,etat.Garlicasa lipid-loweringagent--amara-anatysis;JRCoilPhysiciansLord1994;28(1):39- 45 10. Tyler,V. “HerbsofChoice’.NY,PharmaceuticalsProductsPress 1994 11. 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