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Herb, Nutrient and Drug Interactions: Multi-Disciplinary Team Plots Course Out of Paranoia PDF Print E-mail
Written by John Weeks   
Sunday, 25 May 2008

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.”
hjerb drug interactions, nutrient drug interactions book
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.

Mitchell Stargrove, ND, DC, interaction of drugs, herbs, nutrients, clinical strategies
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.

oncology, drug herb interactions, clinical
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?”


herbalist, drug herb interactions, clinical
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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Last Updated ( Saturday, 31 May 2008 )
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