Risk-Benefit Profile of Commonly Used
Herbs - Legal & Otherwise
Dr. Rick Bayer
Pubdate: Summer/June 2002: Issue 22
Source: Alternatives Magazine (Quarterly): Salem, Oregon
Author: Dr. Rick Bayer
Physicians and consumers need reliable information on medical herbs. The
popularity of such therapy in the US is growing rapidly but the science is
not progressing as rapidly as sales. In the January 1st, 2002 Annals of
Internal Medicine, Dr. Edzard Ernst (from the UK) wrote The Risk-Benefit
Profile of Commonly Used Herbal Therapies: Ginkgo, St. John’s Wort, Ginseng,
Echinacea, Saw Palmetto, and Kava. The Annals has a history of conservative
politics (for example, they oppose the Oregon Death With Dignity Act and
have written scathing half-truths about the medical use of marijuana). With
those conservative politics in mind, I have provided the following review of
Dr. Ernst’s article.
The seven top selling legal herbal medicines are ginkgo biloba, St. John’s
wort, ginseng, garlic, echinacea, saw palmetto, and kava. Dr. Ernst looked
for the best scientific articles he could find and graded them as to how
well they answered questions such as, “Are objectives of the study clearly
stated”, “Are the data sources stated”, and “Are inclusion and exclusion
criteria stated?”. Readers are welcome to review the scientific abstract at
Ginkgo is mostly used for memory impairment, dementia, tinnitus (ringing
ears), and intermittent claudication (legs hurt when walking because of
clogged arteries). In persons with memory impairment and dementia, ginkgo is
superior to placebo but in normal persons, ginkgo does not enhance normal
function. Ginkgo may help with ringing ears but there is insufficient data
to make any consistent claims. Ginkgo is just as effective as the allopathic
drug company competitor, pentoxifylline, for intermittent claudication but
the best treatment is to stop smoking and to start walking exercise. Ginkgo
is generally safe but inhibits clotting (like aspirin does) so may interact
with other medicines such as warfarin blood thinners.
St. John’s wort is used almost exclusively as an herbal antidepressant. Its
mechanisms of actions appear similar to drug company products like
imipramine. St. John’s wort is more effective than placebo in the treatment
of mild to moderate depression and is similar in effect to moderate doses of
drug company products. My experience is that no antidepressant drug works
all the time and that persons with severe and/or recurring depression
usually benefit more from talk therapy plus chemical treatment rather than
either treatment alone. St. John’s wort can cause sensitivity to sunlight
and can interact with other drugs such as blood thinners and oral
contraceptives. Because of drug interactions, all of your doctors should
know if you are taking this herb.
Ginseng is a confusing herb looking for a home in allopathic circles. The
studies are poor and conclusions are not reliable. Sold as an ergogenic
(energy giving) booster or an aphrodisiac or “other”, the reviews do not
show ginseng to enhance performance. It does interact with warfarin blood
Echinacea preparations contain many potentially active ingredients but no
single active constituent has been found. The best-researched indications
are prevention and treatment of uncomplicated upper respiratory infections.
In prevention trials, the results were not conclusive but suggested that
groups receiving echinacea received benefit compared to control groups. In
treatment trials, most groups showed benefit with echinacea compared to
placebo. Dr. Ernst states, “Echinacea (particularly E. purpurea) may be
efficacious, but the trial data are weak and inconclusive”. Side effects
from echinacea are rare. I use echinacea during high-risk settings (like air
travel) to prevent a cold. It seems to help and there is no alternative
because antibiotics are ineffective and dangerous in this setting.
Saw palmetto is almost exclusively used to treat benign prostatic
hyperplasia, a condition of aging men when the prostate grows and interferes
with normal urinary flow. The results show superiority of saw palmetto over
placebo in terms of urination frequency and peak flow and suggest similar
effectiveness to finasteride (the drug company competitor). In some European
countries, saw palmetto is considered first-line therapy over finasteride.
Side effects are rare but long-term studies are lacking.
Kava is mainly used for its anti-anxiety effects and short-term
administration of kava appears to be effective. Unfortunately, several cases
of toxic liver damage requiring liver transplants have been reported. Kava
also interacts with other drugs, including alcohol, that impair the central
nervous system. A skin condition can occur with long-term use of kava at
Garlic was reported on by Dr. Ernst in a prior Annals article (19 Sept
2000). Garlic was reported to be superior to placebo in decreasing
cholesterol levels. However, the impact was small (around 5% compared to the
drug company “statins” impact of about 20% or more). About 20% of garlic
users complained of indigestion and odor.
It is encouraging that we know this much about the best-selling legal herbal
remedies. Some herbs demonstrate attractive risk-benefit profiles,
particularly ginkgo (for dementia and intermittent claudication), St. John’s
wort (for mild to moderate depression), and saw palmetto (for benign
prostatic hyperplasia). Echinacea appears to have modest benefits. Claims
for ginseng appear to be more myth than fact. Kava and garlic are superior
to placebo but inferior to other pharmaceutical options when treating severe
anxiety or elevated cholesterol levels.
Dr. Ernst concludes, “trials of herbal medicine products have been too few,
too small, and too short”. This limits our abilities to predict drug
interactions and yields inadequate information to consumers or doctors.
In my opinion, though he didn’t say it, Dr. Ernst’s caution may be applied
equally to allopathic drug company products. Pharmaceutical drugs are often
recalled after severe events (liver failure, kidney failure,
gastrointestinal bleeding, and death). Consumers and doctors can never know
too much about any drug. Finally, choices should be made on scientific merit
rather than dogmatic viewpoints shaped by profit motives, our country’s War
on Drugs, or bigotry against certain types of medical practitioners.
The 8th Herb: Medicinal Marijuana
What would happen if we took an enlightened pro-patient approach and applied
the same risk-benefit profile to medical cannabis/marijuana as was applied
to the previous seven herbs?
Towards that end, addictions specialist nurse, Mary Lynn Mathre, from the
University of Virginia, and her nonprofit group, Patients Out of Time
(www.MedicalCannabis.com/) presented The Second National Clinical Conference
on Cannabis Therapeutics on May 3 & 4, in Portland. The conference theme was
Analgesia and Other Indications and was co-sponsored by the Oregon
Department of Human Services, Oregon Nurses Association, Mothers Against
Misuse and Abuse, and the Portland Community College (PCC) Institute of
Health Professionals.* Patients Out of Time presented their first conference
at the University of Iowa in 2000.
Cannabinoids are the scientific name for the natural agents found uniquely
in the cannabis plant but includes the synthetic compounds made in the lab
(synthetic cannabinoids) and naturally occurring hormones in our body that
are similar to cannabis (endogenous cannabinoids). The main psychoactive
ingredient in cannabis is THC (tetrahydrocannabinol) although there are many
other cannabinoids in cannabis such as cannabidiol. The only cannabinoid
that doctors can prescribe is synthetic oral THC called dronabinol and sold
under the brand name Marinol; which under the Controlled Substances Act is a
schedule III drug (same group as acetaminophen with codeine).
On Friday, May 3, Dr. Esther Fride from Israel reviewed the molecular
biology of cannabinoids and how they work in the body. She explained how
cannabinoids and opioid pain medicine (like morphine) work together in a
synergistic fashion. New research shows there are at least three different
endogenous cannabinoids. One of these has been shown to be essential for
suckling in newborn rat pups. If the action of the cannabinoid is blocked
with an antagonist drug, the newborn pups do not suckle and thus die.
Therefore, not only is the internal cannabinoid system important for pain
control but it also regulates important appetite areas in the brain that are
essential for life in newborn mammals.
Later in the morning, Dr. David Bearman provided a historical review of
medical cannabis that has been used as medicine for thousands of years. Dr.
Rick Musty reviewed the studies that showed pain relief with cannabinoids in
patients with multiple sclerosis. Dr. Juan Sanchez-Ramos talked about how
cannabinoids might help some persons with movement disorders such as
Dr. Donald Abrams discussed his odyssey of having to spend years trying to
study cannabis in persons with AIDS/HIV. The federal government blocked his
study on the possible benefit of cannabis until he changed his study around
to look for the bad effects rather than the good effects of cannabis. In
spite of this federal stonewalling that lasted for years, Dr. Abrams finally
completed a study and published it last year showing that smoking cannabis
has no negative effect on the immune system of persons with AIDS and
actually helps patients improve appetite and gain weight. He is looking
forward to more clinical studies to include using cannabis for pain
management in persons with prostate cancer and breast cancer whose cancer
has spread to the bones.
Dr. Stuart Rosenblum, the director of the Legacy Emanuel Pain Clinic in
Portland, reviewed clinical case studies from Oregonians who are
participating in the Oregon Medical Marijuana Act (OMMA) and who volunteered
to fill out questionnaires and pain diaries. Dr. Rosenblum reported,
“Patient comments emphasize efficacy and functional improvement”. Dr. Wenner
from Hawaii also discussed positive clinical experience with more than 250
patients in Hawaii.
At lunch, Oregon State Health Officer, Dr. Grant Higginson, discussed The
Oregon Medical Marijuana Act—Three Years of Experience. He reported there
are currently some 3003 patients and 628 doctors participating in the OMMA.
The average age of the patients is 46 years old and most are men. The most
common reason for using cannabis in Oregon is to control pain.
In the afternoon, the editor of Journal of Cannabis Therapeutics, Dr. Ethan
Russo, and other researchers discussed a study in which they looked at the
effects of cannabis on four patients who have been using cannabis daily for
many years under the now-discontinued federal Investigational New Drug (IND)
trials. Three of the four patients attended the conference and told their
stories. One of the patients has smoked 10 joints (7 to 9 grams of cannabis)
daily for 31 years and the other two have used cannabis medically for nearly
as long. Sadly, George Bush (the elder) shut the program down to new
applicants in 1992 because there were “too many applicants”. Dr. Russo’s
conclusion is that cannabis works for pain, spasms, and reducing eye
pressure while the major risk is some inflammation of the airways. No
evidence of liver damage, kidney damage, brain damage, or malignancy has
been found. The authors strongly encouraged our federal government to
re-open the IND program for sick and dying persons.
On Saturday May 4, persons from Hawaii, California, and Colorado discussed
the state programs. The Hawaii program is the only program in the country
that was created by the legislature and governor and it was modeled after
the OMMA. Like Oregon, all the other states with medical marijuana programs
had to bypass an ignorant or uncompassionate legislature and governor who
forced the citizens to seek justice through the Initiative process.
Oregon patients under the OMMA told their stories at the conference
reporting on the benefit they receive and the improvement they seek in the
laws. Medical cannabis providers from Oregon, Washington, California, and
British Columbia also spoke on issues of access to medical cannabis for
patients. Interestingly, the Americans uniformly described our federal
government as the major obstacle for patient access to medical cannabis;
while the speaker from British Columbia praised her federal government and
said that in Canada, it is the doctors who slow down federal political
gains. Dr. Mark Ware from Quebec discussed Canadian clinical trials of
Cannabis for chronic pain. He confirmed that by the time that patients got
to pain clinics a significant percentage have already tried cannabis.
Doctors are taught that cannabis is not medicine so tend not to ask if the
patient is using cannabis to control pain. Our medical educators need to get
with the program. He also confirmed that there is no causal relationship
between cannabis smoking and the development of head and neck cancer. The
positive image of the Canadian federal government depicted by its citizens
contrasted dramatically with the endless condemnation of the US drug policy
by all American participants.
Dr. Geoffrey Guy, founder of GW Pharmaceuticals in the UK, spoke on matching
medicinal cannabis strains with symptoms. His company is testing cannabis
extracts that are higher in THC and lower in cannabidiol versus extracts
that are lower in THC and higher in cannabidiol versus extracts that have an
equal THC to cannabidiol ratio. This is some of the most exciting research
headed our way because under-the-tongue spray preparations are currently
undergoing clinical trials in the UK and may be on the market next year,
plus GW Pharmaceuticals is committed to using a whole plant extract rather
than synthetic products.
I have concerns that if the only products available to patients are
synthetics then there may be an escalation of the War on Drugs aimed at
cannabis, sick patients and their doctors (see my article in the Fall 2000
issue of Alternatives)
Using medical herbs as an alternative to medical pharmaceuticals must be a
patient’s choice. Having many preparations of therapeutic agents to tailor
therapy is good but patients should not be arrested for using the
“politically incorrect” medi-cine. Right now, in spite of polls showing that
most Americans support allowing patients medical access to cannabis, the
major health risk of using marijuana in the US is being arrested. This is
inhumane in a civilized society. Period.
Dr. Audra Stinchcomb from the University of Kentucky shared interesting
research on the transdermal (skin) patch. The good news is that the American
Cancer Society funded her study to deliver a cannabinoid through a patch but
the bad news is the research has just started on lab animals and human
trials may be years away.
Dr. Sumner Burstein, from the University of Massachusetts, discussed very
early research on a synthetic cannabinoid called ajulemic acid or CT3. He
has removed the section of the THC molecule that causes psychoactivity (the
“high”). His reports in mice indicate it is equivalent to morphine in pain
control but has no psychoactive effects and it is equally effective as the
potent anti-inflammatory medicine, indomethacin (Indocin). To have a drug
that would control pain like morphine, cool off joints without the bleeding
risk of most anti-inflammatory drugs, and still allow one to drive a car or
work crossword puzzles sounds almost too good to be true. My recommendation
is to be cautiously optimistic and stay tuned.
Finally, Professor Mathre moderated a panel for questions and answers.
Prescription: Sane Public Policy
This conference shows what can happen when health care professionals and
others apply the same risk-benefit analysis to cannabis and cannabinoids
that we apply to other medicines, whether complex herbs or space-age
designer drugs. Ideally, if everyone was in the same business to practice
safe medicine and protect consumers/patients, we could use science to break
through the bigotry and propaganda that clouds all herbal drug discussion
but especially the medical use of the ancient herb cannabis.
There will never be enough information to satisfy some people. Some persons
will always oppose medical access to cannabis for reasons unrelated to
science. This includes those who are committing senseless violations of
constitutional rights while enriching the huge drug testing industry. This
includes most law enforcement and the prison industrial complex, which has
become a major political force and needs a steady stream of “customers”
(prisoners) to satisfy its profit quota driven by shareholder expectations.
Private industry entering the prison business is especially scary.
But most of all, this includes the barbarians in the current Bush
Administration such as Attorney General Ashcroft and his cronies at the Drug
Enforcement Administration (DEA) and the Office of National Drug Control
Policy (ONDCP). Doesn’t US Justice, DEA, and ONDCP have better things to do
than raid medical cannabis clubs in California, take medicine from dying and
suffering patients, block medical research, convolute administrative rules
concerning controlled drugs and threaten doctors? Their War on Drugs is a
war on good American citizens whose crime is “illness” and it must stop.
Americans must stand up for our fellow citizens who are chronically and
terminally ill. This is an issue of personal choice for them and, after all,
we may be sick someday and want the same choices available to us. In spite
of the harsh reality of the “War on Drugs” and the “War to Make Money”,
common sense must prevail and patient advocacy must come first.
Dr. Bayer is board-certified in internal medicine, a fellow in the American
College of Physicians American Society of Internal Medicine, and practiced
in Lake Oswego for many years. He is co-author of Is Marijuana the Right
Medicine For You? A Factual Guide to Medical Uses of Marijuana. He was a
chief petitioner for the Oregon Medical Marijuana Act in 1998 and manages
the website www.omma1998.org that includes a medical bibliography with
referenced scientific books and articles on medical use of cannabis and