3/11/2021 Objectives • Identify the most common herbal therapies with psychotropic effects Highs, Lows, and Health Hazards of Herbology used by clients • Assess the pharmacokinetics and unwanted effects of psychotropic A Review of Herbal Medications with drug interactions with herbal therapies Psychotropic Effects • Discuss the importance of empowering clients to use herbal Shannon L. Smith-Stephens medications as a compliment rather than replacement DNP, APRN-BC, SANE 1 2 Who-What-When- • “A group of diverse Where-Why? medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine” What is CAM? https://nccih.nih.gov/health/integrative-health 3 4 Which is it? Complementary- Integrative-Alternative? • Complementary: non-mainstream practice used with conventional medicine • Alternative: a non-mainstream practice is used in place of Integrative Health Care conventional medicine Bringing conventional and complementary approaches together in a coordinated way https://nccih.nih.gov/health/integrative-health https://nccih.nih.gov/health/integrative-health 5 6 1 3/11/2021 Overview of Conventional Medications with History of Herbal Natural Origins Medicine Medication Botanical or Fungal Origin Atropine Belladona (Atropa belladonna) • 15th century BCE-Egyptians used saw palmetto for urinary symptoms in men Codeine Poppy (Papaver somniferum) Colchicine Autumn crocus (Colchicum autumnale) th • 5 century BCE-Hippocrates Digoxin Foxglove (Ephedra sinica) documented use of St. John’s wort for Ephedrine Ephedra (Ephedra sinica) mood ailments Lovastatin Ang-khak rice mold (Monascus purpureus) • Two-thirds of the 1820 first edition of Penicillin Penicillin mold (Penicillium chrysogenum) the US Pharmacopoeia were botanical Reserpine Rauwolfia (Rauvolfia serpentine) substances Salicylic acid Willow bark (Datura stramonium) • > 120 conventionally used Taxol Pacific yew (Taxus brevifolia) pharmaceuticals are derived from plan Vincristine Madagascar periwinkle (Catharanthus roseus) species Saper, 2019 Wilt, 1998 Blumenthal, 2003 Adapted from Saper, 2019, UptoDate 7 8 Mental Health Disorders DSM V-Depression • Leading cause s of hospitalization and disability for young and middle-aged adults • A common and serious mood disorder characterized by persistent feelings of • Depression sadness, hopelessness, and loss of interest in activities once enjoyed, lasting for • Anxiety at least two weeks. • Insomnia • Diagnostic criteria include experiencing five or more symptoms during the same two-week period and at least one of the symptoms should be either depressed • WHO ranks depression as the single largest contributor to global disability. mood or loss of interest or pleasure. • Anxiety disorders ranked 6th • Symptoms must cause the individual clinically significant distress or impairment • Approximately half of all Americans will be diagnosed with a mental illness in social, occupational, or other important areas of functioning. Center for Disease Control and Prevention. (2018). Mental health data publications. Retrieved from https://www.cdc.gov/mentalhealth/datapublications/index.htm WHO, 2017 APA, 2013 9 10 DSM V CAM and Mental Health • Generalized anxiety disorder: excessive anxiety and worry, occurring more days • 2012 national survey-more than 30% of adults use health care than not for at least 6 months, about a number of events or activities (such as work or school performance). approaches that are not part of conventional medical care or have origins outside of Western medicine. • Anxiety: an emotion characterized by feelings of tension, worried thoughts, and • Nationally representative survey in the U. S. found that ~ 50% of physical changes such as increased blood pressure. individuals with self-reported depression had used CAM and alternative therapy within the past year. • Insomnia: disorder found in individuals who experience recurrent poor sleep • Of those being treated by a conventional medical clinician, two-thirds quality or quantity that causes distress or impairment in important areas of functioning. reported using both prescription and a type of complementary therapy.3 • 30-43% of patients treated in primary care for anxiety use CAM remedies for at least part of their treatment. APA, 2013 Gitlin, 2020 Bystritsky, 2019 NCCIH, 2018 11 12 2 3/11/2021 Why herbal medicine? Why herbal medicine? • Chronic conditions for which conventional medicine does not offer • CAM is seen as more compatible with the patients’ values, worldview, or straightforward answers or cures beliefs regarding the nature and meaning of health and illness. • Herbs are appealing to those who perceive nature as benevolent and healing • Finding alternatives to be more congruent with their own values, beliefs, and • Herbal- “safe”, “good”, “weak”, “healthy” philosophical orientations toward health and life. • Enhancing health • Psychosocial factors associated with CAM • Aiding with common chronic symptoms • Individual cultural upbringing • Memory loss • Ethnicity • Mood • Arthritis • Fatigue Kaufman, 2002 Austin, 1998 Kaptchuk, 1998 Cauffield, 2000 13 14 Common Herbal Therapies Used with Mental Who is using herbal medicine? Health Disorders • Education is the single socioeconomic value • St John’s Wort • Chronic illness-Individuals with declining health status • Chamomile • Income level-higher • Kava-kava • More educated • Lavender • Reporting poorer health status • Ginseng • Ginko biloba Astin, 1998 Cauffield, 2000 Thompson, et al., 2014 15 16 St. John’s Wort • Antidepressant St. John’s • Anti-inflammatory Wort • (Hypericum Wound healing perforatum) • Anxiety 17 18 3 3/11/2021 St. John’s Wort-Mechanism of Action St. John’s Wort Evidence • Unknown • Hypericum extracts were significantly superior to placebo (95% • Numerous compounds possessing pharmacologic activity confidence interval 1.7 to 4.01) and similarly, effective as standard antidepressants for the treatment of mild to moderately severe depressive disorders. • Hyperforin-modulate neurotransmitter levels • Serotonin • Norepinephrine • Dopamine Muller, et al., 1998 Linde, et al., 1996 19 20 St. John’s Wort-Adverse Effects Pharmacokinetic Interactions and SJW • Photosensitivity • Nausea • Fatigue • Sedation • Dizziness • Anxiety • Dry mouth • Possible decreased fertility • Serotonin syndrome Roby, et al., 2000 David, et al., 2004 21 22 Known CNS Drug Interactions of SJW Drug Interactions Prescription Drug Interaction/Effect Mechanism of Action Amitriptyline* Blood level 22%. Active Induction of CYP3A4 • Other antidepressants • Topical beta blockers metabolite nortriptyline level 41% • SSRI • Immunosuppressive agents Midazolam Reduced plasma levels Induction of CYP3A4 • TCA • Narcotics Nefazodone Causes serotonin syndrome: Additive effects of inhibition of • MAOI • Digoxin shivering, myoclonus, altered serotonin reuptake in neuronal • Alcohol consciousness, CNS irritability cells • Hormonal contraceptives Nortriptyline Plasma concentration 53% Induction of CYP3A4 • Anticoagulants Paroxetine* Sedative-hypnotic effects Combined effects of drugs • Antiretrovirals (weakness, fatigue, slow inhibiting reuptake of movements, incoherent) neurotransmitters • Antifungals Quazepam* Plasma concentrations 25% but no Induction of CYP3A4 clinical effect change Sertraline Serotonin syndrome As per paroxetine Sapier, 2019 Adapted from Bressler (2005) 23 24 4 3/11/2021 St. John’s Wort-Patient Education • Avoid high-tyramine foods • Avoid increased caffeine intake with PO SJW • Therapeutic effects may take 4-6 weeks for depression (similar to SSRI) Chamomile • Avoid ETOH or products containing ETOH (Matricaria • Use sunscreen or protective clothing to prevent photosensitivity recutita) David, et al., 2004 25 26 Chamomile Anxiety GI Upset Chamomile Insomnia ANXIETY ANTI-INFLAMMATORY ANTIHYPERGLYCEMIC ANTICANCER PROPERTIES Topical skin and oropharyngeal conditions NCCIH, 2016 27 28 Chamomile-Mechanism of Action Chamomile Evidence • Flavonoids-apigenin • 8-week RCT using standardized chamomile extract vs. placebo • Affinity for benzodiazepine receptors • Found chamomile significantly reduced participant’s anxiety scores on HAM-A compared to placebo • Generalized anxiety disorder (GAD) • Mixed results from reducing anxiety to no statistical difference from placebo Viola et al, 1995 Medina et al, 1998 Sarris, et al., 2011 29 30 5 3/11/2021 Adverse Reactions Drug Interactions Chamomile Patient Education • Burning of face, eyes, mucous • Increased anticoagulant • Avoid nobile during pregnancy membranes (topical) properties of the herb • Avoid concomitant use with CNS depressants and ETOH • Hypersensitivity • Cyclosporine • Alcohol • CNS depressants 31 32 Kava-kava (Piper methysticum) Mechanism of Action • Remedy comes from the root • Principal active ingredients: kavalactones • Involvement of GABA activity and inhibition of norepinephrine and dopamine reuptake Kava-kava (Piper methysticum) Sarris, et al., 2011, 2013; Teschke, et al., 2008 33 34 Kava-kava (Piper methysticum) Kava-kava Evidence • Medicinal • A Cochrane review of 11 RCT Statistically significant anxiolytic activity • Religious purposes of kava compared with placebo in all but one trial. • Social purposes • RCT, kava was demonstrated to be equally as efficacious as buspirone and opipramol when treated GAD in the outpatient setting. • *Anxiety reduction • Meta-analysis of seven randomized trials of 380 participants with • Antidepressant elevated anxiety symptoms found that kava extract reduced anxiety • Antipsychotic