Friday, July 28, 2006

It's ok they're herbal....

We seem to have lost our way somewhere. All the surveys done show that people trust Doctors much much more than Politicians. Except when it comes to one of the key things we do. Therapeutics.

I'm willing to admit we can often be our own worst enemy here. As in the folowing:

1995-- "Oh yes Mrs Grundy, this HRT is just the thing for you. It'll protect your bones and your ticker. You should probably be on it forever, or at least for the next ten years...."

2005-- "Oh no Mrs Grundy, we only recommend HRT for a year or two, IF you really can't manage the flushes. No it probably won't help your bones or your ticker, and it might give you cancer...."

The problem is our relentless struggle to be "evidence based". As a junior doctor with all the latest advances that medical science had to offer it used to drive me mad when "old fogey GPs" stuck to a very limited and very outdated therapeutic armamentarium. Now I'm driving the next generation of bright young things mad in their turn.

Down the past decade there have been a number of high profile "voltes faces" in therapeutics like the HRT debate so elegantly precised above (I thank you). It seems every analgesic invented since paracetamol comes in to a fanfare as the safest bestest and most wonderful. Most are a bit better that what we had before, but then dissappear in a flurry of litigation when it turns out they might also be a tiny bit poisonous. We've been promised an alternative anticoagulant to warfarin for thrombosis treatment, that would take away the need for nasty blood tests every 3-4 weeks, for years but still so far nothing....

So the sharks in the Herbal industry step in. Well if it's herbal it's natural so it must be ok mustn't it. And anyway you can buy it from the Health Food shops so that proves it. And the chemists often sell it too....

It may be true that St John's Wort is effective in relieving depression in some. It also messes with many orthodox treatments for other health problems in ways that we can't entirely predict because no-one has done the rigorous asessment it would have had if it had been brewed in a vat... but hang on how precisely do they get the herby stuff into the pill / capsule / goo? Still you know what I mean. It's natural. It didn't need chemists to "build it". ('cos God beat them to it)

In truth, herbs are some of our oldest drugs. Chemists have helped us to tidy them up a bit as aspirin or digoxin or tacrolimus (yew trees used to treat cancer and horrible skin disease). They take away all the icky organicky bits and leave use the pure therapeutic agent. Then they study it to see what it does. Not so the Herbalists.

Christine, a lady of a certain age, heard that HRT might not be that fab a long term option. She went to the health shop and got some "Phyto-oestrogen" containing Black Cohosh pills. The she started to itch a bit. Then she went a bit tanned looking. In November. Having never left dear old blighty.

We talked about her herbal treatment and looked at her liver function as a result. Sure enough she was jaundiced . This was around five years ago. Google couldn't assoiate Black Cohosh and liver disease. Neither could the Hepatologists we sent her to see. So she carries a doiagnosis of "Autoimmune Hepatitis". After a recent Uk and EU health warning I am no longer so sure this diagnosis is correct.

She stopped taking the stuff anyway, and her liver function is stable. But I can't help wondering if her "health supplement" hasn't left her far from healthy. And because it's "only" herbal, I doubt very much if there's anyone she could pursue for a legal remedy for any inury it gave her.

So next time you find yourself in the health food shop looking at the supplements, have a quick look on the label. If it claims great things but offers no warnings think long and hard before you buy, and don't assume for a moment it's going to better or safer than "orthodox" treatments. We may not know everything about the newer treatments we use, and we may change our minds about them. Often. But at least we are looking at them. There's even a formal reporting system applied to new or relatively untried drugs to make us think a bit harder before we use them. There's nothing similar for Herbal Remedies.

After all they're only natural aren't they.....


Geena said...

I hear what you are saying and I am no proponent of herbal therapy - but one has to admit that it is used today without the knowledge that the 'ancients' had....and it is often used in conjunction with other modern day treatments - which the 'ancients' didn't have...maybe it's just that a) we don't know enough about how herbal remedies work and b) they shouldn't be used with medical treatments?

There must be a safe way to use these things - problem is we, as a society, are too lazy to actually study up properly and use these treatments in a safe and effective manner. We abuse them.

I guess we don't know how many people died, in the old days, in their trial and error therapies, but somewhere, somehow, they must have figured out how to get the best from the natural things..maybe they practiced on the old fogies?

Z said...

Unfortunately, sometimes people feel that they are not being helped by their doctors and so turn in desperation or hope to alternatives. Sometimes they are asking for the impossible, sometimes they are led up the garden path. But it does seem remarkable that they believe what an alternative practitioner tells them, who might have trained for a few weeks or not at all, when they discount what their doctor tells them, who trained for years and surely some of that time wasn't spent in the pub?
My friend Sue took HRT for years, has recently stopped and is dismayed to find that, in her 60s, she is getting all the symptoms she had staved off for 10 years. Me? I'M STILL YOUNG. I may be a grandmother, but I'M STILL YOUNG. OKAY?

Anonymous said...

Geena wrote:
'maybe it's just that a) we don't know enough about how herbal remedies work and b) they shouldn't be used with medical treatments?'

(Please scuse tired rambling)
I agree with a): the dissertation / project for my degree involved many, many experiments on a tiny corner of this area - the experiments worked (antimicrobial properties a go go) but who'd take it up, when such things grow naturally - where would the profit lie? You can't copyright a plant (unless you muck it about), so only university students carrying out independant research can study such things, surely?

b) - well, I agree that they shouldn't be used with medical treatments without testing the results of such interactions!

Interestingly, some Chinese medicine contains added corticosteroids, I think it no wonder the (ahem) natural medicine has an effect on some conditions.

Doctor Jest said...

geena-- Good points. There are a number of recognised clashes between "orthodox" and "alternative" remedies and will doubtless be others we have tey to recognize. As you say "alternative" treatments are not studied with the same rigour, and that largely was my point. Im not denying ancient wisdom often proves to have a scientific validation, but sometimes does not, and a lot of these "remedies" are not even ancient.

z-- and you still look radiant ;-)

anon-- glad to hear someone is trying to bring method to the madness. You're undoubtedly right re the funding. And how true re the chinese remedies. there was a fad in the eighties for chinese herbal treatments for eczema, which turned out to be rebranded high potency steroid creams with a few added twigs and such. The fault then might have been in part over precious dermatologists trying to limit use of these powerful drugs and causing punters to seek alternatives.

Geena said...

I do love the way the standard patient is referred to as a 'punter'...

Doctor Jest said...

geena-- Well, as you've probably gathered coming to see me in a professional capacity is a bit of a gamble.... ;-)

Claire said...

You've most probably seen already but in case not, here's a reference to a 2003 report on black cohosh & liver problems:

Doctor Jest said...

Thanks claire. Sadly the article was not available when Christine first presented, and alarmigly it has taken till now for the regulators in Blighty to react...

Caveat emptor indeed.

Damian said...

I think you've slightly misadvised people about claims on herbal medicines.

The main problem is that the "claims" on natural medicines are carefully worded not to be claims at all. Note the judicious use of "may" on the labels, which you should always read as "does not" or "we think it does, but cannot, or cannot afford to, prove it".

Real claims say things like, "Reduces the intensity of cold and flu symptons" and the manufacturer has proved the claim, and the safety of the drug when used in that way, in order to be able to apply the CE mark to the label. The pseudo-claim version is "May reduce the intensiyt of cold and flu symptoms".

The problem with the claims/non-claims debate is that by the time the person buys the medicine, they are already convinced by media and word-of-mouth that they need whatever it is that they're buying.

So it doesn't matter if the bottle of deadly nightshade says, "Warning, this preparation may cause death", because the person who has bought it to treat, say, warts, will be thinking, "Death? But that lady on the train said it's for warts. I'll try it anyway."

When I was studying information seeking behaviour, back in the day, one of the things we learned was that about a third of people will almost always trust what people tell them over what they read.

In my book, the key things to remember are:

1. Read all labels as if you have Aspergers Syndrome, because their litteral meaning is that precise
2. Buy medicines with the CE mark, if you are in Europe, or FDA approval in the US, TGA approval in Australia, MHW approval in Japan, or your relevant local body - there is a reason it is hard to get your drugs approved
3. Beware of "may" - it didn't help Ceasar, and it may not help you
4. Remember that natural just means natural. Penecillin is natural and good - unless you're allergic to it; Strichnine and Atropine are natural, and bad - unless you want to die.
5. While it's fine to listen to lots of advice, weight it on the amount of knowledge behind it - the doctor probably knows more than the lady you were chatting to at the school gate, or the man in the health food shop

I am not anti-herbal - I use supplements myself occasionally, and am a big fan of the antibiotic properties of Garlic and Honey, but it's important to keep it all in perspective, and not believe everything you read.

Doctor Jest said...

damian-- hi. how right you are. I am sure the claims on "Natural Remedy" labels are passed through several layers of legal filtering before they make it on, to make sure they are vague enough to cover the glutei of their vendors.

I would also agree I'm not anti-herbal per se. after all so much of modern medicine began at the apothecaries. what I fear is this trend to view all "orthodox" approaches as tainted because they bear the sticky paw prints of Government regulators and big business. the multinationals do nothing to help their case when they bury trial data that shows their products in a less than glowing light either mind you.

Perhaps the best we can advise everybody these days is to stick to taking the regulation two aspirin and seeing if they feel better in the morning ;-)

PPLIC said...

Nice article. very interesting, thanks for sharing.