Herbal Medicine Introduced Into the Basic Science Curriculum for 2nd

Year Medical Students

DJ Smith, Ph.D.

WVU-HSC

Coordinator Medical Pharmacology

Does instruction in herbal medicine have a place in a US medical school?

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

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

Objectives of the Learning Experience

Learn indications, side effects and contraindications for herbal remediesAppreciate herb-herb and herb-drug interactionsUnderstand the regulatory climate for dietary supplements and herbal remediesBegin to understand unique barriers to effective physician-patient interaction

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

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

The Case For Herbal Medicine

Tradition: used throughout historyNatural: perceived as gentler and saferCost: often less expensive than prescription medicineAccess: patient maintains control & no prescription necessarySynergism: a view that multiple ingredients working together yield better results

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 saferMore effective therapy may be delayedMany herbs are not superior to prescription medicines

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

Saw Palmetto (Serenoa repens)

Used for prostatic obstructive symptoms

Dose: lipidosterolic extract 100mg (bid) or 1 g dried berries (tid) with foodSide effects: include nausea, diarrhea, headache impotenceCautions: include false negative PSAEffectiveness: equal to finasteride, but alpha-1 antagonists appear better

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?

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 informationQuestions: Is the label information adequate? What medical conditions preclude ephedra use? What herb-herb-drug interactions concern you?

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?

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 herbalsQuestions 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?

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

Awareness of Herbal Remedies

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

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. Professional’s 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/herbalmedicine.html ConsumerLab.com: http://www.ConsumerLab.com

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 medsOverwhelmingly, herbals are to be used with cautionNearly all students accepted that their responsibility is to counsel patients regarding herbals

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”

Attitudes Toward Herbal Remedies

Physicians should take a non-judgmental approach when counseling patients Q. If a patient mentions the decision to take St

John’s Wort for depression, the physician should

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

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

Knowledge of Herbal Remedies

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

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