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

1. Herbal Medicine Introduced Into the Basic Science Curriculum for 2nd Year Medical Students DJ Smith, Ph.D. WVU-HSC Coordinator Medical Pharmacology

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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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?

13. 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?

14. 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?

15. 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?

16. 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

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

18. 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

19. 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

20. 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”

21. 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

22. 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

23. 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

24. Knowledge of Herbal Remedies • Q. The herbal product used most frequently to treat migraine headache is:

25. 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