Herb, Nutrient and Drug Interactions: Multi-Disciplinary Team Plots Course Out of Paranoia
Written by John Weeks
Herb, Nutrient
and Drug Interactions: Multi-Disciplinary Team Plots Course Out of Paranoia
Summary: Dialogue over
the integration of herbs and nutrients into clinical practice has
focused on potentially negative impacts on the value of prescribed
pharmaceuticals. Missing has been a view which respects these concerns,
but which puts the patient, rather than the pharmaceutical regime, in
the center of clinical concern. The recently published 930 page Herb,
Nutrient, and Drug Interactions: Clinical Implications and Therapeutic
Strategies
(Stargrove, McKee, Treasure) offers a measured walk for clinicians
which Tieraona Lowdog, MD, chair of the US Pharmacopoeia Dietary
Supplements Information Committee calls, in a forward, "appropriate
balance between recommendation and risk based on the overall strength of the
scientific evidence and their own clinical experience."
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“With
the primary emphasis on adverse interactions, the topic of beneficial
interactions has received little attention … An integrative approach would
utilize therapies that reduce or mitigate the adverse effects of medications
deemed necessary for the patient whenever possible.”
Continuous, practical clinical focus
This statement is from Tieraona
Lowdog, MD, chair of the United States Pharmacopeia Dietary Supplements
Information Expert Committee. Lowdog makes it in the forward to Herb,
Nutrient, and Drug Interactions: Clinical Implications and Therapeutic
Strategies (MosbyElsevier, 2008) The authoritative 930 page text, the
collaborative product of a multidisciplinary team, takes a giant step toward
balancing the jaundiced, adverse-event oriented view of botanicals and
nutrients in the first era of the integrative medicine dialogue.
This volume, co-authored by
clinician-editor Mitchell Bebel Stargrove, ND, LAc, medical oncologist and
hematologist Dwight McKee, MD, and registered herbalist Jonathan Treasure, MA,
MNIMH, RH (AHG) asks for a paradigm shift. In the words of the authors in their
forward:
“The
questions raised here and throughout this text challenge the attentive reader
to reconsider drug activity within the full context of therapeutic strategy and
patient outcomes. Simply put, is it a higher priority to manage therapies for
the sake of the patients or the stability of their drug levels? Ultimately the
question arises: when do we counsel patients to avoid healthy behavior on the
basis of the possible risk of disrupting predictable drug levels.”
Let
me de-construct this a moment. Those who come to the “integrative medicine”
dialogue from a conventional, pharmaceutically-based academic orientation will
know not how right Lowdog is in stating that the primary emphasis has been
on – in the editors words – “the stability of drug levels.”
Interestingly,
such drug-herb interactions can also be a kind of Trojan horse in conventional academic medicine to get the
attention of one’s Dean. Arguing for support of an integrative medicine
program, a typical opener by an intrepid new integrative physician is fear: Look, consumers are using these herbs and
our doctors don’t even know how they may be harming the effectiveness of drugs
or increasing the chance of adverse responses. Education in integrative
medicine thus enters conventional academic medicine as good defensive medicine
and from an ethical high-ground position. Let’s make sure patients get the full
value of our drug therapies.
Stargrove: Culmination of 20 years of multi-disciplinary work
Yet
for those who come to the integration dialogue from the perspective of
community-based integrative practices, defensive medicine may instead be
framed as using natural therapeutics to help patients protect themselves from the adverse effects of
prescribed pharmaceuticals. Patient non-compliance with a prescribed
pharmaceutical regime – perhaps because of unwanted adverse effects – is an
opportunity to make changes so that the prescribed drug may not be necessary.
Many holistic medical doctors, naturopathic physicians, acupuncture and
Oriental medicine professionals and broad-scope chiropractors routinely work
with patients to back them off of prescribed drugs. They seek to address health issues
with natural approaches so they can avoid needing prescriptions for agents with more significant adverse effects.
What
Stargrove, et al do with this volume
is respectful to the wishes of both parties to render integrative care more
effective and to defend against adverse responses in the patient. They explore
adverse interactions with a cautionary tilt. But they also give due
considerations to the potentially beneficial therapeutic interactions which
can come from titrating levels of nutrients in the ways that functional
medicine practitioners and naturopathic physicians practice. Here is Lowdog,
again:
“The authors demonstrate an appropriate
balance between recommendation and risk based on the overall strength of the
scientific evidence and their own clinical experience. The text is
well-referenced, balanced, and objective, and the use of icons and summary
tables allows the clinician to quickly identify areas of potential risk, as
well as potential benefit.”
Stargrove
and his team are research-oriented but clinically-based. The text - which
includes in-depth looks at 31 herbs, 12 vitamins, 9 minerals, 6 amino acids,
and 13 other “Nutraceuticals and Physiologics,” acknowledges the ongoing
experimentations by clinicians of all kinds. Clinicians practice in an era of
polypharmacy and simultaneous care from multiple practitioners who are typically not collaborating with each other.
The authors know that oncologists mix and match their chemical cocktails and
integrative practitioners their natural agents and pharmaceuticals as evidence,
experience, instinct, and patient feedback guide them. The text affirms that practitioners live, and will always live, in an evidence-instructed, not an evidence-based world.
Co-author Dwight McKee, MD
Readers
of Herb, Nutrient, and Drug Interactions will find their way into this
complex terrain mapped by an “Interactions Evaluation Guide.” Sets of icons
are used to facilitate efficient use of the information. Scored components include:
interaction probabilities based on a six-category range from “certain” to
“improbable” and “unknown;” interaction types and clinical significance;” and
the strength and character of the evidence.
Some
of the categories of interaction may surprise a conventional clinician who is
disposed to protect the value of the pharmaceutical intervention. For instance,
readers are alerted to cases such as:
Adverse
Drug Effect on Herbal Therapeutics, Strategic Concern
Drug-Induced
Adverse Effect on Nutrient Function, Co-administration Therapeutic, with Professional
Management
Bi-modal
or Variable Interaction
Drug-induced
Nutrient Depletion, Supplementation Contraindicated, Professional Management
Appropriate
“To me,” said Stargrove in an Integrator interview, “the whole issue
is (clinical) tactics and strategies.” He clarifies: “You can combine nearly
any reasonable therapeutics as long as you have a strategy.” He disputes the
typical use of the word “supplements” to denote natural agents when applied in
the context of professional care. “This is an inappropriate, second class
citizen term. What is a ‘supplement’ depends on the therapeutic agenda.”
To make his point, Stargrove
references some clinic notes he received from a medical doctor with whom he was
sharing a patient. The notes said: “Patient taking herbs.” Reflects Stargrove: "What do you suppose he would have thought of me as a clinician had I sent him
some clinic notes that said: ‘Patient taking pharmaceuticals.’ That would be
totally irresponsible.”
“In a flat world,” Stargrove
continues, “you have a contra-indication between a drug and a nutrient. In a
dynamic model, we say, what is your
clinical strategy? Ultimately, what is your loyalty? To the drug? To the
patient and their choices? To education and lifestyle change? What is your
strategy?”
Co-author Jonathan Treasure, MA, MNIMH, RH (AHG)
This volume, conservative,
revolutionary, and full of clinical common sense was developed out of 20 years of
collaborative research and publishing of multi-disciplinary teams. The first venture, predating
the online natural products compendiums, was the visionary Integrative Mind-Body Information System (IBIS) database. The next product came in 2000, an Interactions software database, which
Stargrove says grew out of feedback from clinicians. This current volume, a
labor of a lifetime, and also largely a labor of love, clearly represents the star toward which the
rest of the work was pointed.
The back cover includes
superlative endorsements from Wayne Jonas, MD, Joseph Pizzorno, ND, Lowdog and
David Riley, MD. Riley underscores the value of how the authors “integrate
scientific evidence with practical clinical experience.”
Comment: My mantra of
late has been that it is time that we end
the era of segregation in the integration dialogue. My focus has been on
how, to keep from alienating some medical bigot or another who has a position
of power in a health system, well-trained but distinctly licensed complementary
healthcare practitioners (read: practitioners of color) are excluded from
participation and dialogue. We need to stop being shaped by apartheid-era
thinking.
"Herbs and nutrients are
not
second class citizens.”
- Stargrove
In
this same way, the conventional system’s fealty to its fundamental building
block of prescribed pharmaceuticals has spawned a dialogue about herbs which
focuses on the potential harm to the drug rather than the potential value to
the patient. Drugs are often criticized by conventionally-practicing
physicians, meeting among themselves. But these same individuals become defenders and circle the wagons when
any outsider questions the safety and efficacy of a given drug therapy.
Natural
therapeutic agents (read: agents of color) are typically viewed with more
suspicion than are the often harmful pharmaceuticals. “Herbs and nutrients are
not,” as Stargrove asserts, “second class citizens.” They are, of course,
citizens which have received second-class treatment. Either they are not examined or
they are viewed in culturally inappropriate methods which remove the agent
from a broader integrative strategy and from the focus on the patient.
Those
worried about health and productivity issues due to failure of patient
compliance to drug protocols would be served to explore this text for
alternatives which may well be more palatable (and effective) for the outcomes
which one wants with patients. In the view of Stargrove-as-clinician, “patients
will be proud and excited to have a respectful, open-minded, responsive and
pragmatic doctor providing them with care, whatever their professional degree.”
Ultimately,
this book asks us - to extend Stargrove’s earlier question - where is our loyalty in this
integration dialogue?
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