Herbs and the Perioperative Patient

AORN Journal, Nov, 2000 by Cindy Brumley

In the United States, sales of dietary supplements exceeded $13 billion last year. Seventy million Americans take herbal supplements, approximately 80% of people in developing countries rely on traditional herbal medicines, and an estimated 500,000 plant species grow in temperate climates.(1) Herbs, also known as botanicals or phytomedicines, are medicinal plants. Herbs may elicit one or more pharmacologic actions. Approximately 25% of traditional medicines are derived from plants. In Germany, herbs cannot be obtained without a prescription; however, in the United States, herbs are classified as dietary supplements. This classification means that the Federal Trade Commission, rather than the US Food and Drug Administration (FDA), has primary responsibility for dietary supplements. In 1994, the Dietary Supplement Health and Education Act was created to define what these products, with the exception of tobacco, must contain. A dietary supplement contains at least one of the following: (1) a vitamin, (2) a mineral, (3) an herb or botanical, (4) an amino acid, (5) a dietary substance `for use to supplement the diet by increasing total dietary intake,' (6) or any concentrate, metabolite, constituent, extract, or combination of any of the aforementioned ingredients.(2)

The act was passed because of intense lobbying from the supplement industry and its allies. It was passed in response to the FDA's intent to prevent companies from making false claims and to remove unsubstantiated ingredients from the market.(3) What this means to consumers is that we are at the mercy of any company that wants to place a supplement on the shelf and make unsubstantiated claims about its use or effects.

DEFINITIONS

The ambiguous use of terminology adds to the confusion surrounding herb usage. One researcher defines a nutraceutical as "any substance that is a food, or part of a food, and provides medical or health benefits, including the prevention and treatment of disease."(4) Examples of nutraceuticals include soybeans, cranberry juice, green tea, onions, garlic, tomatoes, and wine. A "functional" food refers to processed foods containing ingredients that aid specific bodily functions, in addition to being nutritious.(5) Examples of functional foods include orange juice with added calcium, margarine with plant stanol esters (eg, Benecol), kava kava com chips, gingko candy bars, and herb-laced beverages. "Designer" foods are fruits and vegetables that are purported to have extraordinary health-giving compounds.(6) This may involve genetic engineering. What is confusing is that the terms nutraceutical, functional, and designer, are not only used interchangeably, but also often are alluded to as natural when they may not be.

Most herbs have multiple uses, which can make diagnosing problems exceptionally difficult if the patient has not disclosed herb usage. Ginseng, categorized as an adaptogen, is one such multi-use herb. A broad definition of an adaptogenic herb is one that increases the body's ability to withstand assault from a variety of toxins, establishes normalization of body functions, and is intrinsically harmless.(7) One last term is homeopathy. Homeopathic products are made from minerals, botanical substances, and distilled water combined with alcohol or powdered lactose. These remedies contain herb amounts so minuscule that it is almost impossible to measure their existence.(8) Most health care professionals view homeopathy as relying on the placebo effect to produce results. The placebo effect occurs 30% to 50% of the time.(9)

CONSUMER ISSUES

Health care providers, as well as consumers, must be diligent in seeking facts and reliable resources concerning products. The fact that the FDA does not oversee the medicinal properties of herbs makes it very difficult to cull fact from fiction. Many consumers rely on sales clerks in nutrition and herbal stores, health care providers, acupuncturists, friends, and the Internet.

According to one researcher, the most logical person to educate the consumer is a pharmacist. As the scope of phytomedicines is so large, data show that less than 2% of pharmacists believe they are equipped to disseminate this information.(10) This makes obtaining accurate information regarding herbs difficult. In addition, patients who consume herbs seldom disclose this information to their physicians or other health care providers. Whether they believe they are stigmatized or just believe herbs are equivalent to vitamins and thus relatively harmless, many fail to realize an herb's potential for medication or disease process interactions. People may be willing to experiment with herbs because they can be relatively inexpensive and purchased without a prescription.

Many consumers fail to assess all of their bodily systems when deciding to add herbs to their health regimens. This can have serious implications. For example, many herbs have more than one name so proper identification is important. Consumers should purchase herbs according to their botanical name. For example, milk thistle (Sylybum marianum) also is called lady's thistle or St Mary's thistle. If the consumer does not know the botanical name, he or she may mistakenly purchase holy or blessed thistle (Cricus benedictus). Herbs may require different doses or plant parts to be effective, and mistakes can be lethal. Labels show there are certain ingredients in one brand and not others, and they offer no explanation for why these ingredients are or are not present. It is important to remember that "natural" does not necessarily equate to safe or harmless.