Herbal Medicine Introduced Into the Basic Science Curriculum for 2nd Year Medical Students

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Herbal Medicine Introduced Into the Basic Science
Curriculum for 2nd Year Medical Students

• DJ Smith, Ph.D.
• WVU-HSC
• Coordinator Medical Pharmacology

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Does instruction in herbal medicine have a place
in a US medical school?
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The Need for Instruction in Herbal Medicine

• Herbal Remedies and Dietary Supplements are used
  extensively
• Herbal products have medicinal value toxicities
  interactions with other herbs and drugs
• Physicians need to be prepared to interact with
  patients using or requesting herbals

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Introduction of Herbal Instructionat WVU-HSC

• Early in the Medical Pharmacology lecture series
• Final 8 weeks of the Basic Science curriculum
• Began in 2000
• Students first formal exposure to herbal
  products

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Objectives of the Learning Experience

• Learn indications, side effects and
  contraindications for herbal remedies
• Appreciate herb-herb and herb-drug interactions
• Understand the regulatory climate for dietary
  supplements and herbal remedies
• Begin to understand unique barriers to effective
  physician-patient interaction

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Instructional Method

• 75 minutes of lecture
• delivered non-judgmentally, but factually
• Small group discussion (2hrs)
• faculty facilitator 8 students
• Students prepared in advance of group discussions
  
• reviewing clinical cases
• using on-line and hard copy resources
• visiting herbal retail store

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Evaluation of the Impact of the Instruction

• Questionnaire given before and repeated after the
  instruction
• Instrument was designed to evaluate students
  awareness, attitudes and content knowledge of
  herbal remedies
• Also asked the extent to which they recommend
  future students be exposed to the material

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The Case For Herbal Medicine

• Tradition used throughout history
• Natural perceived as gentler and safer
• Cost often less expensive than prescription
  medicine
• Access patient maintains control no
  prescription necessary
• Synergism a view that multiple ingredients
  working together yield better results

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The Case Against Herbal Medicine

• Lack of FDA Regulation and Oversight
• Lack of Dosage Standardization
• Potential for adulteration
• Potential for toxicity and drug interactions
  natural is not always safer
• More effective therapy may be delayed
• Many herbs are not superior to prescription
  medicines

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Regulatory Issues

• Dietary Supplement Health Education Act (DSHEA)
  of 1994
• Herbal products are legally food supplements
• Manufacturer may state usage and safety, but not
  make curative claims
• Manufacturer alone is responsible for product
  safety
• FDA must prove product unsafe to remove it from
  the market
• Europe Herbs regulated as pharmaceuticals

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Saw Palmetto (Serenoa repens)

• Used for prostatic obstructive symptoms
• Dose lipidosterolic extract 100mg (bid) or 1 g
  dried berries (tid) with food
• Side effects include nausea, diarrhea, headache
  impotence
• Cautions include false negative PSA
• Effectiveness equal to finasteride, but alpha-1
  antagonists appear better

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Introduction to Case Discussion(edited for
brevity)

• Athlete presents with SVT. Reluctantly admits
  drinking flavored beverage containing Ma Huang
  (Ephedra sinica) to enhance weight-lifting
  performance. Used two scoops for good measure.
  Observed till tachycardia resolved.
• Initial Questions
• What may account for his reluctance to admit
  using the product?
• How do health care providers perpetuate the
  propensity to withhold this information? How do
  we change?

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Facts and Assignment(discussion continues)

• Active ingredients of Ma Haung is ephedra Used
  extensively in Chinese herbal medicine.
  Alkaloids are used in FDA approved meds Life
  threatening CVS complications occur
• At a local herb store see what products contain
  ephedra, and evaluate the label information
• Questions
• Is the label information adequate?
• What medical conditions preclude ephedra use?
• What herb-herb-drug interactions concern you?

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Additional Questions

• Many herbalists and patients believe that medical
  establishment has a prejudiced view of herbals.
  This creates a rift between patient and physician
  that is a barrier to effective communication.
• Questions
• Are US physicians prejudiced, and if so why?
• Are US physicians competent to make judgments
  about herbals and to guide their patients, and if
  not how do we improve?

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Further Consideration

• The regulatory climate in the US is described.
  In Europe herbs are regulated as
  phytopharmaceuticals, and they are widely
  prescribed in Europe and Asia About 1/3 of the
  US population regularly take herbals
• Questions
• Advantages and disadvantages of US approach?
• Would you change the regulatory environment, how?
• How can patients be encouraged to share their use
  of herbals with physicians?

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Awareness of Herbal Remedies

• 60 did not have personal exposure
• Gained knowledge of the extent of herb use in the
  US
• Q. What of the US population uses herbal
  remedies

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Awareness of Herbal Remedies

• Students significantly improved their recognition
  of herbal medicine
• Q. The contemporary definition of herbal medicine
  is?

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Awareness of Herbal Remedies

• Students discovered that there are credible
  sources for information on herbal medicine which
  are available in print form and on-line.
• Professionals Handbook of Complementary and
  Alternative Medicine, Fetro and Avila,
  Springhouse, 1999.
• Herbal Research Foundation www.herbs.org
• Herb Med www.herbmed.org
• Medline Plus http//www.nlm.nih.gov/medlineplus/he
  rbalmedicine.html
• ConsumerLab.com http//www.ConsumerLab.com

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Attitudes Toward Herbal Remedies

• Students had strong opinions that changed very
  little with the learning experience
• 70 were skeptical of the reliance on herbals to
  the exclusion of Rx meds
• Overwhelmingly, herbals are to be used with
  caution
• Nearly all students accepted that their
  responsibility is to counsel patients regarding
  herbals

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Attitudes Toward Herbal Remedies

• Physicians should take a non-judgmental approach
  when counseling patients
• Q. I believe that it is _____ to take the
  position that herbal remedies are bad medicine

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Attitudes Toward Herbal Remedies

• Physicians should take a non-judgmental approach
  when counseling patients
• Q. If a patient mentions the decision to take St
  Johns Wort for depression, the physician should

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Knowledge of Herbal Remedies

• 8 Content questions dealing with the regulatory
  climate, and therapeutic effects of specific
  herbals were asked.
• Examined knowledge in a low impact manner, since
  performance on the questionnaire did not
  influence grade, nor were the students asked to
  study
• Students gained appreciably

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Knowledge of Herbal Remedies

• Q. FDA regulates the manufacture, sale and
  therapeutic claims of herbal medicine as they do
  for prescription and non-prescription drugs

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Knowledge of Herbal Remedies

• Q. The herbal product used most frequently to
  treat migraine headache is

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General Observations and Conclusions

• Our students have a high tolerance of the use of
  herbals, and are willing to counsel patients in a
  non-judgmental manner
• They express a cautious view, but accept that
  there may be medical value when patients use some
  products appropriately
• They report that exposure to this material is
  important and should be in the Medical Curriculum