For the past three years, this column has been exploring the issue of the complex interactions between herbs and drugs. I must admit to holding an ulterior motive for writing about this topic: I have wanted to provide a counterpoint to the current trend of herb-bashing. Even though herbs and drugs can be used together in ways that are synergistic and mutually beneficial, the popular press has frequently focused on the negative or antagonistic aspects of their interactions. Some self-proclaimed authorities have unfairly maligned herbal medicines by repeatedly characterizing them as being toxic, ineffective, or both. By emphasizing the facts over biased opinions, I have hoped to set the record straight.
It is relatively easy to perpetuate canards about the dangers of herbal medicines. Isolated reports of negative reactions make national headlines without a reasonable attempt to verify their accuracy. Once published, these reports transform into standing waves that echo and reverberate throughout the popular and medical literature, regardless of whether they have ever been subjected to rigorous scientific scrutiny.
Remember the man who became temporarily lethargic after adding some kava (Piper methysticum) to his regular daily cocktail of three prescription drugs (which included a tranquilizer)? Despite the fact that after a few hours he fully recovered without any need for intervention, the published case report was entitled, “Coma from a Health-Food Store,” a headline that made national news. It wasn’t long before many medical doctors began displaying posters in their offices that stated, “Beware, kava causes coma.” (I’m not making this up!)
In contrast, before significant reactions to a prescription medicine get publicized, a fairly large number of them must occur. Consider phenylpropanolamine, a popular decongestant and weight-loss medication. It was sold over-the-counter for years before mounting reports of toxicity and deaths led to its removal.
The underlying implication is clear: It is acceptable for synthetic medications to have a certain level of toxicity. This explains why the medical community speaks in terms of the “risk/benefit ratio” when describing a drug’s effects. But when someone has a negative reaction to an herb, we are quickly reminded that the herbal industry is unregulated and that taking “unproven” remedies produced by such an industry constitutes inherently risky behavior. The worst-case scenario is when an herb appears to interfere with a drug. In this situation, the typical recommendation is to avoid taking the herb. While the herb is viewed as dispensable, the drug isn’t questioned.
I will depart from the process of clarifying the details of specific herb-drug interactions. Instead, I will ask a more complex question—namely, what constitutes a workable spectrum of healing that integrates both herbal and synthetic medicinal approaches? In other words, when dealing with a health problem, what are the respective roles of diet, herbs, nutritional supplements, and over-the-counter or prescription drugs? Rather than framing an intervention as an either-or situation and trying to determine whether an herb or a drug would be the best solution, I will examine the benefits of an integrated approach, where all of these agents can work together.
Pain and Inflammation
The current treatment for pain and inflammation provides an excellent springboard for exploring the spectrum of healing modalities. Inflammation is, quite simply, the normal physiologic response to injury. Whether the injury is from an infection, laceration, sprain, burn, toxic chemical, or a speck of pollen, the basic response pattern is identical. In all of these situations, the immune system is summoned forth to defend against attack and repair the damage. The signs and symptoms of inflammation—namely pain, heat, swelling and redness—all result from various chemicals released by immune cells as they go about fulfilling their routine duties.
After an acute injury, these responses are a good thing—they help fight off infection or allow cuts to heal, for example. But some inflammatory responses are difficult to appreciate, especially when they are recurrent or chronic. The pain of a migraine headache or a swollen, sprained ankle is perceived as noxious rather than beneficial. It’s easy to forget that pain is a signal telling us that we need to change our behavior. So many of us respond to this warning not by making the needed but difficult behavioral changes but rather by opening the medicine cabinet and popping a painkiller.
Analgesics (painkillers) are taken by so many people on a daily basis that they have jokingly been referred to as a new food group. In fact, the American Pharmaceutical Association estimates that every year we swallow more than 50 billion nonprescription pain pills, an average of 178 pills per person. The cost of all these drugs is staggering—approximately $800 million per year for over-the-counter pain relievers and another $2 billion for the prescription versions. But there is also a hidden cost—the cost our bodies pay from side effects and toxic reactions. The nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen are associated with kidney damage and/or bleeding stomach ulcers, the latter accounting for 76,000 hospitalizations and 7,600 deaths per year. To make matters worse, NSAIDs have also been found to have negative interactions with a large number of other drugs. Acetaminophen may not be so bad for the stomach, but high doses of it can damage the liver as well as the kidneys.
In an attempt to reduce some of these side effects, a new class of drugs called COX-2 inhibitors was introduced a few years ago. The idea behind them was to selectively block the “bad” enzymes responsible for producing inflammatory chemicals, while leaving the beneficial enzymes (COX-1) alone. However, there have been a lot of problems with these drugs. The seemingly straightforward proposition that blocking a single group of enzymes would be an effective way to control inflammatory pain turned out not to be so neat and tidy. Even though the COX-2 inhibitors are a lot more expensive than regular NSAIDs, they have not proven to be any more effective. Moreover, they still have a lot of the same side effects.
The Herbal Connection
Ironically, this current generation of analgesics was inspired by a common herb. For thousands of years, various species of willow (Salix spp.) bark and leaf have been used by indigenous healers around the world to lower fevers and relieve pain. In 1829, a group of chemical compounds called salicylates were isolated from the bark and identified as being the probable source of willow’s anti-inflammatory effects. Several years later, an even more purified form of salicylic acid was extracted from meadowsweet leaf (Filipendula ulmaria). Soon after, its chemical structure was replicated in the lab and mass-produced. Although willow and meadowsweet are generally well tolerated, synthetic salicylic acid has a very bitter taste and tends to cause upset stomach and nausea. Efforts to mitigate this problem led to a modified version called acetyl-salicylic acid, which was first sold in 1899 under the brand name aspirin.
Aspirin’s popularity skyrocketed, leaving willow to be cast aside as an effete relic. However, in the past few years it has been making a comeback. Highly concentrated (20:1) extracts of willow have been studied in several carefully conducted clinical trials and found to be just as effective as NSAIDs but with minimal side effects. An interesting finding from this new research is that salicylic acid alone may not account for willow’s therapeutic effectiveness. Willow appears to share some of the same benefits as the selective COX-2 inhibitors, but it also modulates the overall inflammatory response. In other words, preliminary data implies that it may actually have a broader spectrum of action than the drugs that were derived from it.
In a recent review article on the potential role of herbal extracts to treat arthritis and similar ailments, willow concentrate was referred to as a “phyto-anti-inflammatory drug.” Other herbs included in this category were borage seed oil (Borago officinalis), black currant (Ribes nigrum), devil’s claw root (Harpagophytum procumbens), feverfew (Tanacetum parthenium), stinging nettle (Urtica dioica), boswellia (Boswellia serrata), ginger (Zingiber officinalis) and turmeric (Curcuma longa). The authors noted that published studies had documented the effectiveness for all of these herbs in alleviating arthritic pain. It only takes a short search of the medical literature to show that this list of herbs with anti-inflammatory activity is just the tip of the iceberg.
The Bottom Line
So how can we fit all this information together into a spectrum of healing modalities? First, we need to consider the pros and cons of both drugs and herbs. As a general rule, the synthetic anti-inflammatory drugs tend to work more quickly and have a higher potency than their herbal counterparts. The downside is that these drugs can have dangerous side effects, are expensive, and—despite their potency—tend to have a very narrow mechanism of action. In contrast, anti-inflammatory herbs can take longer to work and may require fairly high doses to achieve a noticeable effect. Yet many of them have been around for thousands of years, during which they have established an excellent safety record. Rather than suppressing a single biochemical pathway, the mechanism of action of herbs tends to be a generalized dampening effect on the entire inflammatory cascade.
When pain is severe enough to require immediate relief, it’s hard to beat the efficacy of a synthetic drug. But for chronic pain that is mild to moderate in severity, a strong argument could be made for initiating therapy with an herbal anti-inflammatory. More research needs to be done on this, but current evidence suggests a potentially complementary effect between many of these herbs and NSAIDs or acetaminophen. In other words, they may work well together, allowing the dose of the NSAID to be minimized or eventually eliminated altogether. In the long run, our bodies will appreciate that option.
Robert Rountree, M.D., is a physician in private practice in Boulder, Colorado, where he practices integrative medicine. He is co-author of Smart Medicine for a Healthier Child (Avery, 1994) and Immunotics (Putnam, 2000), and is an Herb Research Foundation advisory board member.