Not every condition requires a pill, nor every imperfection a corrective procedure. But when the body can’t get better on its own, it’s appropriate to give drugs a try. The question is, which drugs?
It was a dark and stormy night. The fashionable guests, gathered in the drawing room for cocktails, chatted gaily about the day’s activities. Then, a sudden crash of thunder. Blackness. Nervous gasps. A few ribald comments. But when Col. Fitzroy, ever ready for action, lit a candle, he was rewarded with a scream in earnest. Their hostess, Mrs. Pertivic, lay unconscious on the Persian carpet. The colonel stepped forward for a closer examination. "Dead," he announced grimly.
What caused her death? She was in excellent health and had spent the day in vigorous outdoor exercise. As it happened, among the company was a diminutive elderly person whose skill at solving crimes was matched only by her uncanny knack of being present at their commission. In her quiet but firm voice, she delivered the verdict: "Murder." The weapon was digitalis, extracted from the leaves of foxglove plants growing wild on the estate, and delivered in a massive dose.
How could this have occurred? After all, foxglove (digitalis purpurea) is a naturally occurring drug. But does natural always mean safe? Obviously not.
Though natural substances can be used for deliberately murderous effect—foxglove, snake venom and big rocks all have been tried—I suspect that more harm is done in the name of "natural medicine" than even Miss Marple encountered in her busy career. Innocent-sounding concoctions, ingested for minor complaints, can turn out to be debilitating or worse.
Now, before you dismiss me as a stooge for the Big Pharmaceutical Companies, let me state for the record that I’m a firm believer in the ability of a basically healthy human body to regulate and heal itself. Not every condition requires a pill, nor every imperfection a corrective procedure. I am no fan of scattershot antibiotics, fad diets or extreme makeovers, all of which take a toll on the physical and/or psychological health of the patients and the public. But when the body can’t get better on its own, it’s appropriate to give drugs a try. The question is, which drugs?
To get an idea of the commercial importance of natural remedies in the eyes of the public, just notice the space and prominence given to the "herbals and supplements" category in your local pharmacy. These largely unregulated and unproven (in scientific terms) compounds appeal to two groups of buyers: the desperately ill, whose serious medical problems haven’t responded to conventional therapy, and the "worried well," looking for a safe and somehow virtuous way to tune up their metabolism and stave off the predations of time. To the former, we can only offer understanding, perhaps with advice on better-founded experimental treatments. The latter, larger group deserves at least to be informed of the downside risk.
Risk no. 1 is inconsistent dosage. Herbals generally are not standard formulations. Even when the bottle says that each tablet contains so many grams, it refers to the raw vegetative material, not the pharmacologically active ingredient. The latter depends on species and variety, where it is grown, when it is harvested, the weather conditions in which it is grown and a host of other uncontrollable phenomena. The effective dose thus may vary widely among manufacturers, and from batch to batch from the same manufacturer. Assuming that the compound has a physiological effect in the first place, it will be diluted or exaggerated if the dose is wrong.
Contamination or adulteration is another source of problems. There are cases in which an herbal tea contained an extremely high level of lead, probably the result of lead-containing vessels at the processing plant. One customer, who was estimated to have ingested more than 2 grams of lead, eventually required a liver transplant. Some herbals have been found to be contaminated (or spiked) with regulated drugs. One product promoted to improve "women’s mood" was found to contain phenobarbital! Lydia Pinkham might have approved, but the U.S. Food and Drug Administration was less understanding.
You should ask explicitly about supplements when taking a history; many people don’t think of them as medications.
Then there’s a risk of overdosing, not by a factor of two or three, but of hundreds or thousands. On the theory that a lot of a good thing is a very good thing, and in the absence of scientific proof to the contrary, there are "experts" who advise megadoses of herbal preparations. But just as eating too many carrots can make you turn orange (really!), certain herbals are known to cause problems, from irritability to liver toxicity, when taken in high doses. And, of course, expectant and nursing mothers who take any substance in excess run the risk of inadvertently overdosing their babies.
Finally, undesirable interactions between herbal supplements and prescription or over-the-counter drugs also occur. Supplements are known to affect seizure and clotting disorders, for example, by inhibiting the action of other medicines.
Does this mean all herbals are bad? Of course not. If you think that celery or rice or dandelions are good for you, then a diet rich in your chosen "herb" is unlikely to do any harm, provided it’s done in moderation. And don’t forget that some 30 percent of our regulated medicines are based on herbs and plants, though they are manufactured in inspected facilities according to strict standards for purity and consistency. Plus, they are backed by scientific evidence of safety and efficacy.
As clinicians, we need to be aware of, and sensitive to, our patients’ attitudes toward herbal and other "natural" supplements. You should ask explicitly about supplements when taking a history; many people don’t think of them as medications. If the level seems excessive, a minute or two of gentle patient education may be appropriate. But don’t expect the trend to reverse anytime soon. The allure of natural healing is just too strong to ignore.
