Herbal medicine is the traditional remedy for disease and disease prevention in many underdeveloped and developed countries around the globe. This is not the case in the U.S., where the herbal tradition lost its status as the mainstay of medicine after the development of antibiotics in the 20th century. However, in the early 1980s, Americans did latch on to a groundswell in consumption of nutritional supplements, an occurrence that also brought a landslide of advertising and health claims, some truthful and others exaggerated. When the Food and Drug Administration countered with threats to remove all nutritional supplements from store shelves, there was public outcry. Congress responded by passing the Dietary Supplement Health and Education Act (DSHEA) in 1994. The act helps ensure that nutritional supplement manufacturers do not make unsubstantiated or misleading claims about their products.

Currently, herbs are big business. Twenty years ago, if you wanted something like Ginseng, you would have had to go to a specialty store like GNC (General Nutrition Center). Now all you have to do is walk down the aisles of any grocery or drug store. You will find a wide array of vitamins and herbs with the most popular ones being patented into popular products like Ginsana® or Ginkgoba®.

Even though herbs are classed as dietary supplements, there is often little information to guide consumers and their nurses through the maze of weeds, seeds, flowers, barks, and roots used in herbal medicine. The market is wide-open, and the public can freely purchase herbal preparations over-the-counter (OTC). Because the FDA does not require testing for therapeutic or adverse effects, consumers have no guarantee of quality. Although some manufacturers do produce quality herbal products, only informed buyers can evaluate which herbs and products to use. Quality aside, just because medicinal herbs are easily available OTC or naturally to American consumers doesn’t mean that they’re safe. For example, Foxglove (Digitalis purpurea), the source of the potent cardiac drug, digoxin, grows abundantly in gardens. It would be unwise and even deadly to munch on its leaves or make tea from its flowers.

Embracing Alternate Therapies

The American public has embraced complementary and alternative medicine from A to Z, that is, from acupuncture to Zen. The popularity of CAM has sparked a rediscovery of herbal medicine. A recent survey of Midwest Americans found that almost 42% reported the use of herbs.¹ However, traditional remedies need to be integrated with mainstream medicine when patients are taking modern drugs. Patients taking herbal preparations often neglect to inform their healthcare providers. One of nurses’ most important roles is to be sensitive to this possibility and to encourage patients to communicate their use of herbs and other nutritional supplements because of the possibility of herb/drug interactions and contraindications.

Although many years of study are necessary to become proficient in the art of herbal medicine, most nurses can become knowledgeable enough to answer many of the questions patients ask and to guide them in a safe, objective way. Recently, several schools of nursing have begun to include CAM course work as elective study. Major universities and medical centers now offer conferences and symposia on current issues surrounding CAM to heighten the awareness of nurses, physicians, and other healthcare professionals. Within recent months, at least two U.S. schools have developed degree programs for phytotherapy. Bastyr University in Seattle, WA <www.bastyr.edu>, offers a bachelor of science in herbal sciences, and Tai Sophia Institute in Laurel, MD <www.tai.edu>, offers a master of arts in botanical healing degree. Both schools are accredited. Also, Dominion Herbal College in British Columbia, Canada <www.dominionherbal. com>, offers both resident and distance-learning programs, but its degrees are not recognized in the U.S. at this time.

One organization that champions the practice in the U.S. is the American Herbalists’ Guild, established in 1989. Practitioners obtain membership by meeting criteria that include at least four years of training and clinical experience with clients. A rigorous peer review process is involved, and continuing education credits are required to maintain professional membership. General membership is also available to nonprofessionals. The AHG can provide a list of professional members to consumers upon request. The AHG can be contacted at 1931 Gaddis Road, Canton, GA 30115 ([770] 751-6021) or through its website <www.americanherbalist.com>.

How Herbs Are Taken

All plants, including those we eat, contain active constituents, or phytochemicals, that have physiologic effects. For example, the common tomato contains hundreds of constituents, including vitamins, minerals, and phytochemicals. Although there are several thousands of phytochemicals, most fall into a few categories. The most potent therapeutic compounds are alkaloids, which include such substances as caffeine, nicotine, scopolamine, and morphine. One important group is pyrrolizidine alkaloids (PAs); however, plants that contain PAs, such as Comfrey (Symphytum officinale) and Coltsfoot (Tussilago farfara), can be poisonous and should only be used under the supervision of a professional herbalist. Another significant group is the glycosides, which contain substantially active properties, ranging from antiinflammatory to cardioactive effects. They are the most abundant substances found in plants. They are responsible for powerful immune-stimulating activities in such herbs as Echinacea (Echinacea spp) and in Foxglove (Digitalis spp) from which the potent drug digoxin is made.

A third group, lipids, Omega 3 and Omega 6, for example, are essential fatty acids. Phenols are compounds, which contain antiviral, antibacterial, and some anticancer properties. Finally, essential oils give plants their odor and contain antiseptic properties. Plants such as Mint (Mentha spp) or Lavender (Lavandula officinalis) are familiar examples. A special note of caution: Most essential oils should never be taken internally or applied directly to the skin unless they have been diluted. The exceptions to topical applications are Oil of Melaluca and Lavender oil.

Commercially, herbs come in many forms. With so many to choose from, it is easy to see why the average person can become confused. Some options include teas, tinctures, glycerites, tablets, freeze-dried extracts, capsules, and standardized preparations.

A tea is an infusion made from delicate plant parts, such as leaves and flowers. This preparation is used when desired constituents are easily drawn out using water as the solvent. Teas are often steeped, that is, allowed to sit undisturbed in hot water for 15 minutes to 30 minutes.¹ A decoction is made by simmering plant parts in water for 20 minutes to 30 minutes. Decoctions use hard or woody plant parts, such as bark or roots.² Tinctures are mixtures that use alcohol and water as solvents. Some plant constituents, such as resins and alkaloids, are more easily brought into solution by combining certain percentages of alcohol and water.^3,4 Because tinctures are concentrated, only small amounts (drops) are generally used. Glycerites are like tinctures, except glycerin is used in place of alcohol. They are generally less potent because glycerin is less effective in extracting the desired constituents. Tablets are often made up of compressed, dried plant material and use binders to hold them together. Freeze-dried extracts begin as tinctures. Freeze-drying eliminates the alcohol, and the resulting substance is often placed in a capsule. Standardized products, which are often produced as tinctures, but can come in other forms, are manufactured to consistently guarantee specific amounts of phytochemicals that the producer believes may be the active constituent.⁵

The New Old Remedies

In the Middle Ages, people didn’t have drugstores to run to for their common problems. They either went to the local wise woman or looked to the natural world around them. In an age where expensive pharmaceutical drugs come with many warnings and cautions, some consumers are looking for remedies that are simpler, less expensive, and less laden with adverse effects.

However, often viewed as harmless, not all herbs can be used by everyone. Dosages can be highly relative to the person and situation and must be individualized. When discovering that their patients are using herbs, nurses should exercise caution in advising them and, if in doubt, check with an herbalist or natural practitioner. Many herbs have not been adequately studied and their uses are sometimes based on anecdotal reports. From a list of hundreds of herbs, the following few are among the most commonly used.

Echinacea (E. angustifolia, E. purpurea): Echinacea has long stems that bear purple, daisy-like flowers, which gives it the common name, purple coneflower. Its flowers, leaves, stalk, and roots are available as dried extract and tinctures.⁶ This medicinal plant has been known to stimulate the immune system and the body’s defenses against disease through potent antibacterial and antiviral effects; extracts of Echinacea have shown to increase phagocytic activity.⁷ Echinacea is taken for infections, including fevers, colds, flu, urinary tract infections, tonsillitis, bronchitis, inflamed connective tissue, and allergies.

Since the herb stimulates nonspecific immunity, it may benefit people with compromised immune systems, such as those with allergies or sinusitis or those undergoing chemotherapy.⁷ Although controversy surrounds the use of Echinacea with patients who have HIV or autoimmune disease, no literature supports its contraindication. A recent study to evaluate the safety of taking Echinacea during pregnancy when used for upper respiratory tract ailments found that it was safe during the first trimester of pregnancy.⁸ Caution is advised for patients who have had transplants and are using immunosuppressant drugs.

Ginkgo (Ginkgo biloba): Commonly lining city streets in North America, ginkgo might be the oldest leaf-bearing tree on Earth. Although relatively new to the U.S., practitioners of Chinese medicine have used its leaves and seeds for many years, particularly for lung problems. Today, this herb has a wider application in treating vascular and neurological disease.⁹ For example, a metaanalysis of eight randomized trials found a significant increase in pain-free walking distance along with little adverse effects in people suffering from intermittent claudication who took Gingko biloba.¹⁰ This herb may also reduce short-term memory loss and combat mental fatigue. One study associated the administration of its standardized extract with sustained improvement in attention in healthy young volunteers.¹¹ Because gingko inhibits platelet aggregation, it should not be taken by patients who are on anticoagulants, such as warfarin, aspirin, and vitamin E. Patients should stop taking ginkgo supplements at least two weeks before surgical procedures.

St. John’s Wort (Hypericum perforatum): Historically, this plant was used for warding off evil spirits. Today, this popular herb with yellow, lemon-scented flowers and balsamic-scented leaves is used to treat mild depression and anxiety. In fact, it has been touted as an alternative to fluoxetine (Prozac) and one German trial found it to be equivalent (with fewer adverse effects) to imipramine (Tofranil) in treating depression.¹² Some herbalists also use this herb to alleviate nerve pain and injury,¹³ as well as to help sleep. Because there is controversy that St. John’s Wort may potentiate monoamine oxidase inhibitors,¹⁴ providers should monitor patients for an additive effect with these drugs. Published reports have indicated other possible interactions, including a decrease in plasma concentrations of warfarin; digoxin; indinavir (Crixivan), an HIV-protease inhibitor;¹⁵ and cyclosporine, an immunosuppressive drug used with heart and lung transplant patients, in which acute rejection occurred.^15,16

Used topically, St. John’s Wort is applied to alleviate muscle aches and pains and to promote the healing of sprains, wounds, burns, cuts, and bruises. However, it can cause dermatitis in some people.

Saw Palmetto (Sabal serrulata, Serenoa repens): The Seminole Indians used the berries of saw palmetto for food and the leaves to make baskets, toys, rope, and ceremonial items. Early American settlers who observed that local animals that had eaten the berries appeared to grow “sleek and fat,” used them as medicinal remedies for wasting conditions, loss of strength, and fatigue. Now, they are attributed with being tonic, anabolic, diuretic, and sedative, but the plant’s big publicity comes from the men who use the herb for enlarged prostates.

One of the top-selling phytomedicines in America, saw palmetto got a boost in popularity when the U.S. Pharmacopoeia published a dispensing-information monograph to deal with its therapeutic parameters.¹⁷ Many clinical trials have recently taken place to determine the efficacy of saw palmetto on benign prostatic hyperplasia (BPH). One metaanalysis compared saw palmetto with the conventional medication, finasteride (Propecia), and found similar improvement in urinary tract symptoms and urinary flow, but fewer adverse effects, such as erectile dysfunction.¹⁸ No significant adverse effects are reported from long-term use.

Ginseng (Panax ginseng [Chinese/Korean/Japanese], Panax quinquefolius [American], Eleutherococcus senticous [Siberian]):
A member of the ivy family, ginseng takes several years to mature enough to use. The three different types include a Siberian variety that is not really a true ginseng, but grouped together with the other two because all three have similar properties and, in some instances, can be used interchangeably. People use ginseng to enhance physical and mental function and resistance to infections and stress. This herb is a tonic and stimulant, and combats fatigue. Nevertheless, it is beneficial to take a rest period from this herb occasionally.

Goldenseal (Hydrastis canadensis): The Cherokee used goldenseal as a yellow dye, antibiotic, digestive, eyewash, and as a means for recovery from childbirth. They called it yellow root, using its rhizome (underground stem) and roots. Popularized as an antiseptic in the 19th century, its name became goldenseal. Besides its use to heal wounds and inflammations of mucous membranes, this herb had wide applications, including as a remedy for digestive disorders, an adjunct to cancer therapies, a stimulate for the immune system, and an agent to counter sore throats of colds, flu, and diarrhea. Some have touted its effectiveness with acne, and eye infections. Large amounts can cause gastrointestinal upset, irregular heartbeat, and hypertension. This herb should not be used by pregnant or breastfeeding women because some of its components can stimulate the uterus.

Dandelion (Taraxacum officinale): This bitter herb originally came from Asia; now it’s so common that many regard it as a weed. Dandelion is an amazing plant with a wide range of uses. The greens are placed in salads, the buds can be pickled, the flower heads are used to make wine, and a magenta dye can be made from its roots. Dandelion is considered to be beneficial to both the kidneys and the liver. The leaves are a powerful diuretic, and the roots are a blood purifier and bile stimulant. Some of its other uses are as a mild laxative and an antiinflammatory. The white sap has been used as a treatment for warts and corns.

Whether they know it or not, nurses encounter patients who are taking herbs along with modern medications. By being alert, nurses can identify these patients and ask them why they are using herbs and under whose guidance. Nurses can also refer patients and their primary providers to sources of accurate information about the efficacy of herbs and their interaction with modern remedies, including websites, books, and journals. For nurses who function as primary healthcare providers, they should review treatment options with patients and help them prepare questions for the CAM provider, if there is one. At the very least, CAM therapy needs the same monitoring and follow-up that is vital to any treatment option.¹⁹