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"It's very possible that a large fraction of that could be caused by drugs used with herbs. We don't have the data but recent papers show that it can react," says Woosley, Georgetown's pharmacology department chairman. "People say they're natural, but so is snake venom."

While the dietary supplement industry will hardly say that everything under the umbrella of "dietary supplements" or "natural medicine" is safe, they do contend that these substances are less potent, overall, than Western medicines. In many cases, they are also less expensive. "I'm not going to deny that there's a perception that natural is, as a rule, less dangerous than a pharmaceutical substance," says Michael McGuffin, president of the Herbal Products Association, a trade association representing manufacturers and marketers of dietary supplements. "I'm also not going to deny that in fact, natural botanicals are as a rule less dangerous than pharmaceutical substances. (Although) you need to find the references to know which botanicals to use during different stages of life, like pregnancy."

Whether they turn to these reference sources or not, people are turning to alternative medicine. Their reasons include everything from a distrust of the medical establishment to almost a spiritual belief in these products to a feeling of individual responsibility for their health. What they haven't always included in the regimen is communication about their self-medication. It's not that people are locking themselves in dark rooms, popping their pills and not telling anyone about it. More often, as with Annette Brown, they believe their herbs are harmless and, therefore, not worth mentioning to a doctor. A recent study looking at breast-cancer patients, presented last month at UCSF's International Congress on Women's Health Issues, found that 72 percent used some form of alternative treatment in conjunction with their usual treatment. And only one-third told their doctors about it.

"Sometimes when patients aren't talking about something, people may read into it that they are being secretive," says Shelley Adler, professor of medical anthropology at UCSF. "But it's more complicated than that; there's a logical and rational strategy that patients use." And those reasons, she found, varied. Many thought that their doctors just weren't interested; others thought that their alternative medicine was not relevant to their other treatment. And some thought it was almost a moot point because even if they told their physician, he/she wouldn't be able to give them any useful information.

"When I said to my oncologist, 'I've used shark cartilage,' he almost laughed me out of the office," said one patient.

"I did tell the doctor and he didn't say, 'Good,' or 'Not good,' or 'OK' or anything," said another.

That is what happened to Katie Allen, a sickle cell research nurse living in Oakland, Calif., when she told her physician about all the Chinese herbs, vitamins and antioxidants she was taking to fight her breast cancer. He just shrugged. So just before starting chemotherapy, she went to see a consultant, brought up the different treatments she was on and asked for his opinion. "He said if the antioxidants protect all these healthy tissues (from the chemotherapy), it might also protect the cancerous cells from the Adriamycin (doxorubicin)," she says. "I had to make a choice, and something had struck me about what he said."

Indeed, the dietary supplement industry's McGuffin believes that physicians have to create an environment that is more respectful of patients' treatment choices. "The message to health-care providers is to respectfully receive the information. Stop telling them that they are dumb for believing that vitamin C and echinacea is good for them."

According to Adler's study, patients were more likely to tell their doctors about their alternative medicine use when their physicians expected them to be on supplemental treatment. If a doctor broaches the topic with sensitivity, the patient will be more likely to respond. A sample question for a doctor, she says, might be: "People use a variety of different methods to maintain or improve their health. What kind of things are you doing to take care of (your health/this problem)."

Susan Winckler, group director of policy and advocacy at the American Pharmaceutical Association, says that a blending of the pharmaceutical and herbal worlds will require improved communication between patients and their doctors and pharmacists. "You can't disconnect the health care from the self care," she says. "There needs to be some type of bridge connecting the two."

And that bridge, many critics say, has to happen in doctors' offices, and at the pharmacy counters. While Winckler says it's happening on a smaller level at pharmacies across the country, the most public step by the health-care industry came last month when CVS, the second-largest pharmacy chain in the United States, announced that it is tackling this problem. When customers come in, a form will be given to them, asking them not only what other medicines they're on, but also what dietary supplements they're taking. This information will then be entered into the computer -- as prescription drugs already are -- and the substances will be cross-checked for possible interactions. "Our pharmacists were getting more and more questions from our customers about the safety of these products," says Mike De Angelis, spokesman for CVS. "The service we're offering now is an extension of technology we've always had in the pharmacy to cross-check for harmful interactions."

People on all sides of the issue applaud CVS' initiative and believe it will be commonplace in the years to come. A spokeswoman for Walgreens says the company is looking into implementing a similar system. But pharmacists also acknowledge what CVS and other companies are up against, since so little is known about the interactions. For example, how plausible will it be to check prescription medicine against a natural product when the components of that product aren't known, or may be prepared differently or mixed with some other type of natural herb?

"As a pharmacologist, I would never argue that those plants don't have value, but the product that we put in these pills is more pure and a better characterized product than the plants," says Woosley. "There are too many variables -- how long they're harvested, how well they were ground up, whatever is mixed in with it. People have died from teas that they have drunk that have wiped out their liver. That's why more research needs to be done."

That's one point all sides agree on.
salon.com | Feb. 17, 2000

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