Introduction

The 1990's has seen a blurring of the distinction between traditional and alternative medicines. In the decade of personal empowerment more people have chosen to take direct responsibility for their own health. An estimated 60 million Americans use herbal medicines every year, spending more than $3 billion annually on the botanical products. At least a third of these people never tell their physicians they are taking alternative medicines, despite the fact that herbals can cause side effects, interact with prescription drugs and mimic other illnesses.

Many traditional medical doctors have begun to incorporate the use of alternative therapies into their own practice or at least be receptive to their patients seeking alternative health care providers in addition to mainstream therapy. The alternative medicine industry, fueled largely by the unregulated growth of dietary supplements and herbal remedies, has blossomed into a multibillion dollar per year giant.

Some healthcare advocates view this as a positive change, believing that the medical community is now recognizing traditional medicine can not treat all ailments and that listening to the patient promotes a better overall healthcare experience.

Others view this new openness to alternative therapies more skeptically, believing that medical doctors are catering to the wishes of their patients in order to keep them happy (blowing with the changing winds of popular public opinion) while ignoring weak or no scientific evidence to support the claims of many herbal products.

Types of alternative treatments/ providers

The term "Alternative Medicine" or "Alternative Therapies" cover a wide range of treatments and practitioners.

(Click to see comprehensive listing of alternative care providers and therapies)

Alternative care providers:

Acupuncturists, hypnotists, massage therapists, and meditation instructors are among the providers of alternative therapy. Chiropractic therapy is still considered to be alternative therapy by many mainstream medical doctors as well. However, there is increasing acknowledgment by many in the medical community that chiropractic therapy has a useful role in the treatment of certain conditions such as recurring or chronic musculoskeletal problems.

Herbal medicines and supplements:

Dietary supplements include not only herbal agents but other substances such as blue-green algae; vitamins and minerals; hormones such as melatonin or DHEA; proteins and amino acids; and traditional cultural remedies with unknown combination of products.

Vitamins

Vitamins and minerals are substances that are required in very small amounts for normal health and metabolism. Science has identified various vitamins and health problems caused by specific vitamin deficiencies. Although a well balanced diet contains more than enough of the essential vitamins to keep a person healthy a phenomena of taking massive doses of vtiamins has become increasing popular since the early 1980's. Claims have been made that very high doses of vitamins such as beta carotene and vitamin C can greatly improve health and prevent various disease conditions. Megavitamins have not been shown to have the benefits supporters have claimed and in some cases have been harmful.

Likewise, fantastic claims have been made touting the miraculous health benefits of various trace minerals including zinc, selenium, and chromium picolinate. Although certain areas of health are improved when supplements are taken for mineral deficient states no benefits have been shown to occur when taken in doses greater than required to prevent deficiencies.

This article will focus on herbal medications as they represent the largest part of the alternative therapy industry in terms of dollars spent.

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"Nutritional Supplements" to learn more about creatine, DHEA, and protein powders.

"Vitamins and Minerals" - separate fact from fiction

Reasons for seeking alternative therapy

Reasons for seeking alternative treatments include dissatisfaction with traditional healthcare, belief that alternative therapies are some how more natural, and costs of traditional medicines.

Many believe that because herbs are natural, they are safe. Or they think that conventional medicine is too technical, impersonal and expensive, and may have certain fears about prescription drugs due to highly publicized recalls, such as the withdrawal of fen-phen from the market.

The down side of alternative therapies

Don't think that herbal health products are safe just because they come from plants- some plants are poisonous. Although herbal products are advertised as "natural," they aren't natural to the human body. 4

Unlike prescription medicines, herbal products don't have be tested to prove that they work well and are safe before they're sold. In addition, herbal products may not be pure--they might have other things in them, like plant pollen or contaminants, that could make you sick. At the present time testing and standardized manufacturing of herbal and other supplements is needed.

Doesn't the government require medicines to be safe and effective?

Medicines yes! The widespread abuses of snake-oil salesmen and other quacks in the 19th century patent medicine era led to the establishment of the Food and Drug Administration and strict regulation of drugs in America.

However, herbal products are technically considered food products- not medicine. How can this be? After intense lobbying by herbal supplement industry and some public pressure, Congress essentially deregulated the industry with passage of the Dietary Supplements Health and Education Act (DSHEA) of 1994. Alternative medications are treated as food, not medicines, because they are considered "natural". They can be sold as dietary supplements without a prescription. Supplement claims are not subject to the same scientific scrutiny as prescription medications.

It is interesting that the DSHEA passed after the FDA (Food and Drug Administration) banned sale of the dietary supplement L-tryptophan in 1989. L-tryptophan was a popular amino acid supplement that was claimed to increase muscle mass, aid weight loss and improve sleep. The ban was placed after a bad batch that contained contaminated by-products was linked to 38 deaths and over 1500 cases of eosinophilia myalgia syndrome, a very painful immunologic disorder. 3

Dietary supplements are often sold next to nonprescription (over-the-counter or "OTC") products such as aspirin, tylenol, allergy and other medicines. However, unlike OTC products, dietary supplements do not require a multistep approval process requiring them to prove that they are both safe and effective when used properly.

Cultural herbal remedies have been found to frequently contain prescription medications as adulterants. Several studies have found that from 25% to 75 % of Chinese herbal remedies tested contained prescription medications as adulterants. 2 , 3 The most common ingredients were benzodiazapines (nerve pills such as Valium), corticosteroids, and nonsteroidal anti-inflammatory agents (medicines such as Motrin). More dangerous compounds such as phenylbutazone and aminopyrine, banned in the U.S. because of life-threatening side effects, have been found in cultural remedies found in the U.S.

An analysis of calls made to a Taiwanese poison control center showed almost 7% of cultural remedy poisonings were fatal. 3

Have bad side effects been reported from herbal medicines?

Adverse effects and interactions with other prescription medications have been reported with ginko ebola, ephedrine containing (ma huang) "natural supplements", St. Johns Wort.

There are disturbing report that many Chinese herbal skin care products contain high doses of potent corticosteroids such as dexamethasone. 2 Such medications have an appropriate place when used for some skin conditions but must be done under the supervision of a physician to prevent complications.

In Germany certain herbal medicines are standardized and sold as prescription drugs. They are required to meet strict manufacturing requirements and demonstrate that they are both safe and effective. Both benefits and side effects must be listed. No such requirements are present in the United States for herbal medications.

Recent studies have found wide variation in the concentration of herbal medications between different brands and even different bottles of the same brand for products sold in the United States. 1 , 3 , 5

Questions to ask before seeking alternative therapy

Are alternative therapies safe?

Are they really useful?

Can claims made be scientifically substantiated?

Should I let my medical doctor know I am using "herbal medicines"?

One the whole we believe the answer to be: usually, sometimes, not usually, and always. Each treatment or medication must be examined individually.

Traditional Medicine

Alternative treatments

A recent survey by Consumer Reports surveyed its readers about a wide range of traditional and alternative therapies. 1 Of the more than 46,000 readers responding over 16,000 had used alternative therapies including herbal medicines / megavitamin supplements; deep tissue massage; chiropractic therapy and acupressure; and meditation, biofeedback, and relaxation therapies. Almost half of those using alternative treatments tried remedies on their own- most often herbal remedies.

This survey was not intended to clinically test the benefit of any supplement. It could not control for the quality of supplemental ingredients, the amount taken, or for the placebo effect (the psychological benefit people get from believing a treatment will work). Various studies have shown that up to 20% of persons have a dramatic positive placebo response when treated with a "dummy pill" for a given condition.

Nevertheless, this survey did allow readers to rate the traditional and alternative therapies they used most often for the two most serious or bothersome medical conditions they had experienced in the past two years. 1

It is clear that people seek both traditional and alternative therapy for many of the same or similar conditions.

Traditional vs Alternative - How well does each therapy work?

The above survey listed the most common forms of treatment reported for each condition. Certain conditions such as high blood pressure, high cholesterol, prostate problems, depression and insomnia had relatively few listed treatment options ( 4 to 5) when compared to arthritis and back pain (14 each).

Respondents rated treatment as either very effective, somewhat effective, or not effective at all. Several conclusions can be made about the survey respondents:

1. Traditional therapy (prescription medication and /or surgery) where reported to be significantly more useful than herbal medications in all categories.
   
   
2. Herbal remedies were much more likely to be reported as having little or no benefit in all categories tested compared to prescription medications.
   
   
3. Hands on treatment (chiropractic treatment, deep tissue massage, and exercise) were more effective than prescription medicines in back pain. The Consumer Reports survey did not distinguish between acute back pain that gets better on its own within 4 weeks and chronic or recurring back pain. According to other studies there is no difference between hands on treatment and traditional treatments for acute back pain (lasting less than 4 weeks). Chronic back pain can have different causes.
   
   
4. Conditions in which no one therapy was reported to be extremely effective (arthritis and  back pain) had the most treatment options listed.
   
   
5. Regular exercise was reported to be fairly effective for all conditions except insomnia. No treatment was reported to be extremely effective for insomnia.

Specific Herbal and Alternative Medications

Herbal medicines have been used for thousands of years by native cultures around the world. In many poor countries today, herbals are the only affordable medicines. Native Americans have a long tradition of using herbs for medicinal purposes, and Europeans brought herbal remedies from their homelands to the United States. Herbs and plant preparations have been used to treat medical ailments for thousands of years. Indeed, approximately 25% of medicines used today have plant origins including aspirin, digitalis preparations, many laxatives, antibiotics, and more. Penicillin, the first modern antibiotic that changed the course of hisory, was initially derived from a mold. Modern methods of producing synthetic medicines has only been in use for a little over 50 years. Other substances such as Melatonin, Glucosamine nad Chondroitin are not herbs, but rather derived from naturually occuring substances produced by the body.

It is extremely important to realize that most synthetically produced medications are usually safer and more effective than their "natural predecessors". They have been extensively tested and refined. Yet the idea that natural herbs are somehow superior to and healthier than synthetically produced medicines has gained in popularity.

"Natural medications" listed above are among the most popular and widely used today. Medications that have been shown to be somewhat effective generally have active ingredients similar to those found in their prescription counterparts. These medications have also been reported to have side effects similar to their prescription counterparts. Because they are considered dietary supplements, not medications, and assumed to be safe they are not under the same strict requirements as their prescription counterparts.

Can taking herbal health products be dangerous for some medical problems? 4

Yes. It may not be safe to take herbal medicines if you have certain health problems. Talk to your doctor if you have any of these problems:

Can herbal products change the way prescription medicines work? 4

Yes. Some medicines shouldn't be taken with herbal products.

• Don't take Ginkgo biloba if you're taking aspirin, ticlopidine (brand name: Ticlid), clopidogrel (brand name: Plavix) or dipyridamole (brand name: Persantine).
  
  
• Don't take St. John's wort if you're taking an antidepressant.
  
  
• Don't take ephedra if you're taking a decongestant or a stimulant drug, or if you drink caffeinated beverages.
  
  
• Don't take kava products if you're taking a benzodiazepine, a barbiturate, an antipsychotic medicine or any medicine used to treat Parkinson's disease.
  
  

Also, don't drink alcohol if you take kava products.

What are possible side effects of herbal health products?

Herbal health products aren't tested to be sure they're safe, so they may cause problems. Be sure to tell your doctor if you get a health problem while you're taking an herbal product.

• If you're taking Ginkgo biloba, you may have bleeding as a side effect.
  
  
• St. John's wort can cause an upset stomach, a tired feeling, dizziness, confusion or dry mouth. You may also get a sunburn more easily.
  
  
• If you're taking an ephedra product (also called ma huang), you could have many problems. You might get high blood pressure or an uneven heartbeat. You may feel nervous, have headaches or have trouble falling asleep. You could even have a heart attack or a stroke.
  
  
• If you take kava products, you may feel sleepy, get a rash or have strange movements of your mouth and tongue, or other parts of your body.

Conclusion

DoctorsCorner.Com staff does not recommend or support the use of any herbal products, "natural hormones and supplements", or mineral treatments at the present time. Prior to researching this topic our reviewers believed there would be stronger support for the effectiveness of herbal and nonherbal "natural" remedies than is currently present. In other words, we were quite suprised by the scarcity of well controlled large studies for just about all herbal and nonherbal supplements.

The most promising products thus far are probably:

• Saw Palmeto for urinary retention due to benign prostatic enlargement in men
  
  
• St. John's Wort for depression.

Even if St. John's Wort is shown to be effective in treating depression, as preliminary studies indicate, we believe it should be a prescription medication. Depression is a serious health disorder that is complicated and easily mistreated- we believe all persons with significant depression should be under the treatment of a physician skilled in treating depression in addition to any other health providers.

Products to save your money on and run the other way if anyone tries to sell them to you include ephedrine containing preparations including:

• Ma Huang
• Weight loss supplements containing ephedrine (Metabolife wt loss, etc..)
• Herbal ecstacy or products claiming to give a "natural high"

The prices charged on these dirt cheap products are usually outrageous!

Stay away from any "Asian or Chinese" combination remedy that claims to cure skin problems- these preparations likely contain high doses of potent corticosteroid preparations. Although such preparations are effedtive in many skin problems they can cause damgerous side effects when used improperly. A qualified physician can treat the same problems under proper supervision.

The lack of standardized quality control for "dietary supplements" and unproven effectiveness is simply unacceptable and , in our opinion, the result of special interest money influencing Congressional votes.

We are not opposed to new and inexpensive medications. Indeed, we have many problems with the way mainstream pharmecutical companies operate and believe too many medications are overpriced.

We are also opposed to the relatively new "fast track" approval of prescription medications that the FDA has been ordered to provide that has resulted in several prescription medications, including Propulsid™ and Rezulin™ being removed from the market because of unacceptable complications and patient deaths. It must be noted that at least these medications were required to show they worked as claimed prior to being made commercially available. This is not required of supplements. It sometimes takes years for relatively rare, but serious, side effects to show up.

We are opposed to any company making unproven claims for a product that at best is a waste of your hard earned money and at worst a threat to your health or even life. We simply say, " Any company selling a product that claims to treat or help a certain condition then they need to prove beyond a shadow of a doubt that a product:

1. Really works
2. Is really safe or at least the risk to benefit profile is clearly stated.

In the now famous words of "Spock" (aka Leonard Nimoy)- "Live long and prosper"

In our wours, "When you need to- see your doctor!"

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Resources

1. "Alternative Medicine Survey: What's Good For What Ails You" Consumer Reports, May 2000:17-25.

2. "Analysis of Chinese herbal creams prescribed for dermatologic conditions." Keane, F.M., et al. in BJM February 27, 1999;318:563-4

3. "Dietary Supplements: 'Natural' Is Not Always Safe". Mary E. Palmer, M.D. in Emergency Medicine,September 1998: 52-74.

4. "Herbal Health Products- What You Should Know" in American Family Physician, March 1999 vol 59, no. 5: 1245. Viewable online @ http://www.aafp.org/afp/990301ap/990301e.html

5. "Herbal Remedies: Adverse Effects and Drug Interactions" Melanie Johns Cupp, PHARM.D. in American Family Physician, March 1999 vol 59, no. 5: 1239-1244.
Viewable online @ http://www.aafp.org/afp/990301ap/1239.html

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