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Herbal Center at Cleveland Clinic

The infiltration of pseudoscience and simply bad medicine into mainstream medicine continues. Hospitals are an easy breech point because they are run by administrators who may have more talent and interest in marketing than in science. Many hospitals in my area, for example, proudly display their “integrative” centers, offering nutrition advice and massage alongside more dubious offerings, such as reflexology and reiki.

So-called “alternative” treatments are tempting because they are often not covered by insurance, and so patients will have to pay cash for them, and they are often inexpensive to run – so they are a nice cash cow for hospitals.

The Wall Street Journal reports another, more serious, chapter in this infiltration – the opening of Chinese herbal clinics, specifically in the Cleveland Clinic. The article itself is reasonably balanced, and lacks the gushing anecdotes that most such pieces have, but could certainly have been more hard-hitting in terms of the serious problems with herbal medicine.

Herbal treatments are interesting from a scientific point of view because they are perhaps at the most plausible end of the CAM spectrum. The WSJ article would have benefited from stating explicitly that herbs are drugs. Their actions in the body are entirely pharmacological. This fact is often missed by proponents and in discussions of herbal remedies. They are drugs.

Herbs, however, are drugs that have not been adequately studied, whose active ingredients may not be known, that contain many chemicals, with unknown pharmacokinetics, dynamics, and drug-drug interactions. Dosing is nearly impossible to standardize. Bioavailability is anyone’s guess. And quality control is highly dubious. Other than that, they’re great.

I’m not sure why anyone would choose to take a poorly studied, dirty, variable, and poorly regulated combination of drugs with unknown efficacy. The answer, of course, must be marketing. People think herbs are “natural,” an irrelevant feature that does nothing to mitigate the many downsides of these dirty drugs. They are also reassured by the fact that they are part of an ancient and exotic medical system, the argument from antiquity. Of course, bloodletting also survived for thousands of years.

Plants are a perfectly reasonable source of potential pharmacological compounds. Much of the low-hanging fruit, of course, has already been picked. There is also huge incentive on the part of pharmaceutical companies to find other useful compounds in plants, and herbal remedies might provide a clue to potential targets. What’s left over are the dregs, what is now marketed as “herbal medicine.”

Many of the most popular herbal products, those that have been studies in rigorous clinical trials, have been found not to work. Gingko biloba does not work for memory or dementia. Echinacea does not work for the cold or flu. Black cohosh does not work for menopausal symptoms. Saw palmetto does not work for benign prostatic hypertrophy.

Perhaps the best candidate for an effective herbal remedy is St. John’s wort for depression. Apparently there is some anti-depressant effect from this herb, but only if you speak German (German studies are much more favorable than studies from other countries). Otherwise the benefits are mild and inconsistent. This is not surprising because St. John’s wort contains MAO inhibitors, which have a known antidepressant effect. They also have serious drug-drug interactions.

There are other herbs with promising preliminary results – but as readers of SBM know well, preliminary results are very unreliable and not predictive of the outcome of large rigorous trials.

The notion that herbs are somehow magically safe is very insidious. They are drugs with all the potential toxicity and drug-drug interactions of drugs. Perhaps they have the virtue, because their active ingredients are not purified, of generally having low doses of the chemicals they contain, but that cuts both ways, reducing useful effects and side effects alike.

Assuming lack of toxicity is largely based on the relative paucity of studies looking for toxicity. Toxicity from herbs, however, is not uncommon. Nephropathy (kidney damage) from Aristolochia, liver damage from kava-containing products, and black cohosh has also been linked to liver damage (here is a more extensive list of popular herbal products with known toxicities).

Toxicity can occur even when an herbal product is unadulterated and taken as intended. However, perhaps the biggest problem with the herbal industry is its poor regulation. There are problems with fungal contamination, mislabeling or mistranslating of herbs, and heavy metal contamination.

When buying herbal remedies off the shelf they are likely not even to contain what the label indicates. A recent study found that:

Most (59%) of the products tested contained DNA barcodes from plant species not listed on the labels. Although we were able to authenticate almost half (48%) of the products, one-third of these also contained contaminants and or fillers not listed on the label. Product substitution occurred in 30/44 of the products tested and only 2/12 companies had products without any substitution, contamination or fillers. Some of the contaminants we found pose serious health risks to consumers.

Therefore, even when a clinical trial, using carefully prepared and verified herbal preparations, finds some potential benefit, you cannot assume that a commercial product based on that herb will have the same effect. You may not even be getting the herb you think you are getting.

In his latest book, Paul Offit tells the story of attempting to regulate herbal product use in his hospital. Eventually he settled for one criterion, that the manufacturers provide documentation of what is actually in the products. They refused to do this. One has to wonder why.

How does an herbal clinic work in practice? The WSJ reports about the Cleveland Clinic, when asked for something for inflammation:

“Absolutely,” responded Ms. Roofener. “This is for pain, for digestion, for inflammation, all of the above,” she said, handing Ms. Lunka a bottle with capsules of an herbal combination called Xiao Yao San, which translates as free and easy wanderer. The capsules include about eight different herbs, including licorice, mint leaf and white peony root.

Not only does the preparation contain all the unrefined chemicals of a single herb, but a combination of many herbs. They also report:

At the Cleveland Clinic’s herbal center, new patients are given a one-hour consultation that may include a battery of questions (How’s your sleep? Body temperature? Ringing in your ears? Headaches?), a physical examination of the tongue, and the traditional Chinese method for pulse-taking (three fingers on each wrist to check different pulses corresponding to various organ systems). They are asked to sign a waiver acknowledging that “herbal supplements are not a substitute for a medical diagnosis.”

So – herbal remedies are not real medicines that treat actual diseases. They are just claimed to alleviate symptoms – without, of course, any evidence of efficacy except for the anecdotal experience of the practitioner. Pulse analysis, by the way, is nothing but a medical cold reading, not unlike iridology or any other bogus diagnostic method.

Conclusion

We advocate for high standards of science within medicine because that is the only way to offer patients the best chance of safe and effective treatments. It is also the only way to give proper informed consent, which requires transparency and reliable information.

It is a scandal that a hospital would offer a medical service to their patients that is not based on the best science has to offer, is based on numerous deceptions and misrepresentations, logical fallacies, and poor methods. In fact, they make patients sign wavers that essentially say that what they are providing is not real medicine.

Only the insanity of brilliant marketing can pull off such a deception.

Posted in: Herbs & Supplements

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72 thoughts on “Herbal Center at Cleveland Clinic

  1. Windriven says:

    “Herbs, however, are drugs that have not been adequately studied, whose active ingredients may not be known, that contain many chemicals, with unknown pharmacokinetics, dynamics, and drug-drug interactions. Dosing is nearly impossible to standardize. Bioavailability is anyone’s guess. And quality control is highly dubious. Other than that, they’re great.”

    To my mind, this is the crux of the story. Would Cleveland Clinic dispense IV saline that might be .3% NaCl or might be 16% or might be 0.9%? Then why would it countenance dispensing drugs with often unknown constituents, potencies, and toxicities?

    This is nothing less than institutional malpractice. One hopes that the first patient that suffers a bad reaction to this sues the Clinic down to the paint stripes in the parking lot.

    1. Jann Bellamy says:

      You don’t even need a bad reaction. An action for fraud is also an option. Many dietary supplement and homeopathic remedy manufacturers are currently being sued for consumer fraud for making claims that are not supported by the evidence. And here is one for claiming a supplement contained ingredients that were not, in fact, in the supplement. (Also, it didn’t work, according to the complaint.) http://www.topclassactions.com/lawsuit-settlements/lawsuit-news/24369-adrenalean-class-action-lawsuit-alleges-false-advertising/

      1. Windriven says:

        Interesting article. If the suit is successful I wonder if the corporation will have enough assets to pay damages. The smart play for companies like this is to keep the corporate veil intact and operate the marketing company as a shell with the fixed assets held in other corporate entities and the cash pushed to the shareholders.

        1. Jann Bellamy says:

          The majority of these class actions are settled. I don’t know of any of the homeopathic remedy class actions that have actually gone to trial in the last 5 years. Absent actual harm, damages are limited to the price of the supplement (sometimes with multipliers under various consumer protection statutes), so the companies settle them for a few million, which is a few dollars for consumers who bother to make a claim, plus costs and attorneys fees.

  2. justsayno says:

    The worst problem with herbal medicine is the big drug companies can’t make money from it.

    1. Cervantes says:

      Well, somebody makes money from it. That’s why they market it. Drug companies are regulated by the FDA — they need to have evidence that their products are safe and effective. The crap sold in the GNC does not, but you might have noticed that they don’t give it away.

    2. Frederick says:

      So how to do you explain that herbal drug market are a worth billions, that they lobby so hard to have NO regulation. And that a lot of Herbal manufacturers are owned by huge corporation, chemical and drug company also posses some of them. And since there is bascally no regulation : ( they can sale you echinacea pills, that actually contains only the grass taken from the lawn of the factory) production cost are low, they can manufacture them in china in a dirty factory with no product quality control. As long as the bottle and the label are nice looking, and make good marketing. they are in the clear! you buy them just because it is written NATURAL instead of BIG PHARMA on the label.
      On the contrary there is a lot of money to do with that, because they can sale those product premium and keep the production cost super low. Who cares about patents.

    3. LucyDean says:

      Actually, drug companies HAVE made money, and lots of it, from “herbal” medicine. Perhaps you’ve heard of the cardiac medicine digoxin? Digoxin is marketed under 30+ trade names. And its extracted from the foxglove plant.

      Aspirin? It’s an artificial reproduction of salicin, which is found in willow bark. Why don’t you ask Bayer how little money they’ve made from it.

      These are just the two examples I know off the top of my head, and I’m no scientist, so I’m sure there are many, many more.

      Perhaps the more accurate statement is that the drug companies can only make money from the ones that work. And if any of the other ones worked as touted, they would long have been exploited by these drug companies for just those uses. Since they’re not….

      1. mouse says:

        LucyDeen “Perhaps the more accurate statement is that the drug companies can only make money from the ones that work.”

        ohhhh – Good one! I’ve never thought of it in such a succinct way.

    4. Dave says:

      Another classic statement from JSN. Taxol is herbal and so are the vinca alkaloids as are multiple other meds. If a drug company can derive a medication from plants and get it approved you bet they’ll market and make money on it. “How do you hide money from a drug company? answer – You can’t.”

      How is marketing some UNTESTED plant product and selling it because it “promotes eye health” or “enhance the immune system” any better?

      Do you actually think about what you post before you submit it?

    5. WilliamLawrenceUtridge says:

      Actually, if herbal medicines were proven to work, then big drug companies would probably be very intersted, and could have a huge role. They would have the expertise and reputation to protect such that they might actually be willing to ensure what’s supposed to be in the pill is actually in the pill, in standardized doses.

      After all, drug companies currently manufacture, and make a considerable profit from, a variety of off-patent items, including ibuprofen, acetaminophen, vitamins and minerals.

      The worst problem is quacks promoting potentially dangerous, potentially worthless plants as medicine. At best, patients waste their money. At worst, they have to deal with organ failure or deaths.

      1. WilliamLawrenceUtridge says:

        Heh, ironically, if the DSHEA were ever overturned, consumers might actually get in the bottle what is on the label, because there might actually be some quality control standards.

  3. goodnightirene says:

    I can’t add much to Windriven’s spot on comment. I can only wonder why no one in the CC administrative tangle was able to put a stop to this nonsense? Perhaps someone tried. What justification do these institutions offer for such moves? The Mayo Clinic offers “alternative medicine” advice at the end of each entry now, and has a whole department with an MD to head it up, which includes cupping and moxibustion.

    These practices wouldn’t be much different than providing a chapel (in my atheist view anyway) if they didn’t charge for them or include them in their medical summaries/treatment website entries.

    My answer to “ancient Chinese medicine” is always to ask why not bring back foot binding? I know it wasn’t a medical practice, per se, but it makes as much sense as pulse testing.

  4. Eugenie Mielczarek says:

    Readers of this informative article can also check clinicaltrials.gov and study the 182 trials for Herbs and 65 for Botanicals. Some of these trials were hopeful tests on patients with liver cancer.
    Eugenie Mielczarek

  5. NotADoc says:

    I see in the WSJ article that one does need a doctor’s referral to be seen in the herbal clinic. I’m curious if the referrals are doctor-driven or at the patient’s request. I personally would be (more than) a bit mistrustful of an MD who sent me to the herb clinic. I’m also astounded that the Cleveland Clinic refers patients to a subsidiary where insurance does not cover the fees and the herbs they prescribe are sold on-site.

  6. Steven Jensen says:

    As a pharmacist I spend a lot of time counseling on OTC products and the amount of misinformation out there is incredible. Many people do not know the difference between homeopathy and herbals supplements. Many patients are shocked when I tell them that the label on the bottle may not be accurate for its contents. The amount of money spent is mind bottling . Yesterday I had one patient that reported taken a couple dozen capsules of various natural products per day spending hundreds of dollars a month yet she balked at the relative cheapness of a prescription med. Very unfortunate to see legitamacy given to many of these products and practices by reputable oraganizations. I believe University of MIchigan Hospital system in recent years has an integrative medicine arm now. Trying to cash in on the hype

  7. Martin says:

    An important note about St Johns Wort is that several of its component chemicals are potent inducers of several CYP enzymes in the liver (CYP3A4 and CYP2C9 possibly others, see #1) it also can acutely inhibit . This can have substantial effects on the pharmacokinetics of many drug classes (CYP3A4 is one of the most promiscuous of the CYPs) and can cause organ rejection (interacts with Cyclosporin, see #2) as well as “Miracle Babies” (Interacts with Hormonal Birth Control, see #3) and probably a bunch of others (#3 also mentions Midazolam).

    It does seem to have some efficacy, but it’s a pharmacist’s nightmare.

    1) http://www.ncbi.nlm.nih.gov/pubmed/11888457
    2) http://www.ncbi.nlm.nih.gov/pubmed/15100173
    3) http://www.nature.com/clpt/journal/v74/n6/abs/clpt2003519a.html

  8. Harriet Hall says:

    I read about this in this week’s TIME magazine, where it was similarly reported. It mentions that patients must be referred and the referring doctor must monitor their treatment for a year. And it says that the patients are primarily those with conditions that “Western medicine has, for whatever reason, failed to remedy.”

    I’m guessing that two factors are driving this innovation: customer demand, and a semi-legitimate way for doctors to provide placebos and hand-holding for demanding patients with non-life-threatening conditions, including the so-called “worried well.” It would be better for a real doctor (or a member of a doctor’s team) to spend more time with patients and provide the kind of hope, reassurance, and TLC the herbalists offer. But in the present system, that approach is not practically or economically feasible.

    No, I’m not saying this herbal clinic is a good idea. It’s a terrible idea for all the reasons Dr. Novella explained. But it points out that CAM offers something that conventional medicine is currently not doing very well. There is a lesson to be learned. There is a way to practice science-based medicine along with “comfort medicine” that is devoid of pseudoscience, and we need to find it.

    1. agitato says:

      “There is a way to practice science-based medicine along with “comfort medicine” that is devoid of pseudoscience, and we need to find it.”

      I couldn’t agree more! But how do we do this? When institutions like the Cleveland Clinic have Wellness Centres that offer the whole gamut of CAM thus giving it (CAM) legitimacy by association, how is it even possible?

    2. Kov says:

      “There is a lesson to be learned. There is a way to practice science-based medicine along with “comfort medicine” that is devoid of pseudoscience, and we need to find it.”

      That’s an awesome idea, Dr. Hall!

      It seems that the effective “comfort medicine” aspects of alt-med are well understood and noncontroversial (which you enumerate in the paragraph from which I quoted). I think the solution is to create a practitioner category/niche that harnesses the best scientific understanding of the most efficacious bits of alt-med style patient interactions, without all of the herbal/TCM/quackupuncture crap (but maybe useful stress relievers like massage). I don’t recall there always being physician assistants, or if there were, they weren’t that common, but it seems to be a rapidly growing niche (in fact, my primary care provider is a PA, as was the last person I saw at an ortho clinic), due in no small part to a need for such providers, in concert with less intensive requirements to become a PA than an MD.

      By defining the role and methods of the position, these valuable interaction-based benefits could be codified, legitimized, and disconnected from the alt-med hooey. It would be like extracting, refining, synthesizing, and standardizing the active ingredient from a plant and making it into effective medicine, except with practical interventions. With a presumably lower educational hurdle to clear to become one of these complementary care assistants (trademark that), it would be easier to fill the niche, and would presumably draw off those who might otherwise be seduced by an alt-med career. It would also knock down perhaps the only legitimate barrier that people often cite for going the alt-med route for “treatment,” i.e. that of more positive interactions with the provider. I imagine a lot of what could be offered would dovetail nicely with nursing or a medical assistant type of position.

      1. Eldric IV says:

        A lot of it comes down to time. Throughout my time as a pharmacy technician, intern, and resident, the number one thing I was able to offer patients that the regular pharmacist could not was more time. While my preceptor had patients scheduled every 30 minutes, I could schedule patients every hour. And time and again, patients told me that they most valued the amount of time/attention I was able to give them. (It also helped that I am the type of person who will let people talk without interrupting … again, because I had the time to do so.)

        Payment models are not good for “more time.” Provider availability is not good for “more time.” Even those positions which were created, in part, to free up time (PAs, nursing aides, pharmacy technicians) have instead just increased capacity.

        SCAMers have more time. SCAMers can pay more attention. SCAMers can claim personalized, individualized treatment specially made just for you. It allows patients to feel more like people and less like they are just getting chewed through the medical machine.

        You need someone with medical knowledge, social aptitude, friendly charisma, tons of patience, and lots of time to really offer a decent service.

    3. Dave says:

      There are ways to do it. One way is for a doctor to have a concierge practice. Numerous doctors have gone this route, and I bet their outcomes are great. For one thing, they only see the upper part of the socioeconomic ladder, people who do better health-wise anyway.

      A way which would be more applicable to society as a whole would be to ditch the current coding and billing system and pay doctors according to time spent. This has as much chance of happening as pigs flying. The billing and coding systems are going to get more convoluted, not less. It also might have unintended consequences. Access to physicians is a double-edged sword. If you schedule fewer patients that gives you more time to see each patient, but the patients you are seeing might have to wait weeks for their appointments. Seeing more patients leaves less time per patient but more timely access for those patients. Also, I suspect a lot of patients want pure efficiency with no extraneous facets to their visit. They have a problem and want it solved as expeditiously as possible. Others want more time even if it isn’t necessary.

      1. Windriven says:

        “A way which would be more applicable to society as a whole would be to ditch the current coding and billing system and pay doctors according to time spent.”

        I don’t know how long you’ve been practicing Dave, but once upon a time doctors were paid that way. That model had its flaws as well. For one thing it was easy enough to game the system. It is always the few weasels who screw things up for everyone else.

        1. Dave says:

          I entered practice in 1979. Even then we did not get paid by the minute. I agree, the system could be gamed. However, I think the present system can also be gamed. You can go to conferences teaching you how to maximize your coding. A few years ago I saw an article in a throw-away newsletter entitled “Twelve things I wish I knew as a resident.” I turned to the article expecting to find a lot of good clinical pearls. Instead, it was all about how if you do and document x,y,and z you can code for 99214 rather than 99213 and increase your income by o many dollars a year. I found the article disgusting. A single payor system with salaried doctors would be hard to game, though you’d probably have some slackers. No system is perfect since we’re dealing with humans.

      2. mouse says:

        Dave “Seeing more patients leaves less time per patient but more timely access for those patients. Also, I suspect a lot of patients want pure efficiency with no extraneous facets to their visit. They have a problem and want it solved as expeditiously as possible. Others want more time even if it isn’t necessary.”

        I had this long ramble or vent that used your comment as a jumping off point (not disagreeing, just adding my viewpoint) but my ipad powered down and I lost it, probably for the best.

        I do want to say, though, that as a patient it’s very hard to know what’s extraneous or what’s efficiency vs cutting corners. IME doctors seem to respond to basically the same lab tests and symptoms with very diverse strategies. I suppose it’s what they call the art of medicine. That sounds very lovely…like all the doctors are doing the right thing in their own way. I’m not even knowledgable enough to say that isn’t true. I think I can say, though, if medicine is an art, sometimes it sucks to be the canvas.

    4. Absolutely. When expediency and output become the sole driving forces of a practice it should come as no surprise that patients are going to seek the “human touch” somewhere else; enter the quacks. If they do nothing (and they don’t) but spend more time listening to your woes than the average MD… they have won the battle.
      In this respect, the Cleveland Clinic is basically outsourcing its TLC department.

    5. WilliamLawrenceUtridge says:

      But it points out that CAM offers something that conventional medicine is currently not doing very well. There is a lesson to be learned. There is a way to practice science-based medicine along with “comfort medicine” that is devoid of pseudoscience, and we need to find it.

      Unfortunately, not a medical issue. Doctors are well-aware of the need for good bedside manner and reassurance, but economic incentives preclude this boutique level of service. The US needs a real public health care system, not the current shameful non-substitute.

      I will never understand why the politicians and apparently the public are so averse to such a system. Nearly every other country on the planet has one, all the first-world nations do, so why the objections?

      1. mouse says:

        Harriet Hall “But it points out that CAM offers something that conventional medicine is currently not doing very well. There is a lesson to be learned. There is a way to practice science-based medicine along with “comfort medicine” that is devoid of pseudoscience, and we need to find it.”

        WLU “Unfortunately, not a medical issue. Doctors are well-aware of the need for good bedside manner and reassurance, but economic incentives preclude this boutique level of service. ”

        On what grounds you can disagree with Dr. Hall that the “comfort” of the patient is a medical issue or say that “economic incentives preclude the services”?

        I’ve never seen any evidence that the excess money spent in the U.S. health system is due to hand holding, comfort or the emotional demands of patients or any other sort of “boutique services”. In fact U.S. patients don’t appear to access health services any more than people in other countries. The information I have seen indicates that increased costs are due to higher prices on drugs, medical equipment and per procedure charges from doctors and hospitals as well as much higher administrative costs. About 25% of healthcare costs in the country goes to administrative costs, the next highest comparable countries administrative costs are 10/15% of their healthcare budget.

        Do you have any actual data or evidence that suggests that practicing medicine without regards to the emotional comfort of the patient will have any noticeable positive impact on healthcare costs, health outcomes or move us toward a national healthcare program?

        1. WilliamLawrenceUtridge says:

          I don’t see Dr. Hall and I disagreeing. She says “US medicine needs to improve comfort medicine”. I point out that the incentives for much of US medicine (i.e. Medicare, Medicade and insurance company-paid services) dissuade lengthy visits with doctors, which in turn reduces “comfort medicine”. I think all patients, those with objective, serious complaints, the “worried well”, and everyone in between, would benefit from a medical system that allows for more than five minutes and one complaint per patient within managed care.

          The incentives I’m talking about are ones placed on or directed towards doctors – how their time is tracked, how they are reimbursed, how they are punished for long appointments and rewarded for short ones. I’m not talking about the costs of medications, defensive medicine and the like, purely regarding the incentives that doctors have to keep appointments short and turnover high.

          Patients and doctors in “boutique” clinics, those paid for out of pocket with fee structures, reimbursement structures, and no obligation or desire to take Medicare, Medicade or insurance plans (i.e. those serving almost purely the wealthy whose pockets render medical costs essentially meaningless) would not have to deal with these incentives.

          1. mouse says:

            Ahhh, I misunderstood WLU – I thought you were saying that “comfort medicine” was a luxury that should be a lower priority than accomplishing national health insurance. Whoops. Thanks for clarifying.

            1. WilliamLawrenceUtridge says:

              If you didn’t understand, I wasn’t clear :)

  9. Harriet Hall says:

    The TIME article said they addressed the safety issue by finding “a Kaiser Pharmaceutical subsidiary out of Taiwan as well as a Chinese herb-specific compounding pharmacy that specializes in custom blends.” It would be interesting to find out if Dr. Offit’s criterion was applied. I wonder if the Cleveland Clinic will be sending any of these herbal products to an independent lab for verification of content.

  10. stanmrak says:

    If western medicine was working so well, people wouldn’t resort to alternatives like herbs. If you want to eliminate what you consider inferior medicine, make yours better. It looks bad when all you do is denigrate the competition. There must be something wrong with your product, plain and simple. You even have the insurance and pharmaceutical industry on your side and you can’t beat these folks into submission.

    1. Yea, all we have to do is cure all disease and illness, then we won’t have to worry about con artists and charlatans exploiting patients who have ailments that can’t be cured. It’s brilliant.

      Your assumptions, as usual, are all self-serving and wrong:

      Studies show that satisfaction with mainstream medicine is not an important factor in deciding to use CAM(http://www.ncbi.nlm.nih.gov/pubmed/20180690), that CAM users are generally satisfied with their mainstream care (http://www.tandfonline.com/doi/abs/10.1080/14768320500444216#.U1gKZPldV8E), and they use CAM because it aligns with their philosophy, and they simply want to expand their options. (http://www.ncbi.nlm.nih.gov/pubmed/20367764) It is mostly used to supplement not replace mainstream medicine, and mostly because people just wanted to give it a try. (http://www.medicalwellnessassociation.com/articles/cam_survey.htm)

      Further – it’s not that popular. Most CAM method use is in the single digits, except for manipulation for back back and massage. Use seems to be driven by marketing, not need or demand.

      But don’t let the evidence get in the way of your preferred narrative.

      1. stanmrak says:

        As usual, these survey results are manipulated by carefully-phrased questions and cannot be taken at face value. If SBM was really that superior, people wouldn’t look elsewhere, period. The primary issue with many is the dangerous side of using pharmaceutical drugs to treat a problem. For them, the risk isn’t worth the ‘cure.’ Maybe if they invented drugs without side effects. Then there’s the problem of 100,000 deaths every year from properly-prescribed-and-administered drugs, as well as the fear that you’ll end up taking a handful of medications every day just to make it thru. It starts with just one prescription for one problem, pretty soon it’s a handful. Statistics back this up. We all know these folks.

        1. WilliamLawrenceUtridge says:

          If SBM was really that superior, people wouldn’t look elsewhere, period.

          Really? What a fascinating statement. Economics was once based on the idea of a rational consumer, which works great in models, but the reality is consumers are often irrational. Does HD really merit throwing out your tube TV? Isn’t a Smart Car simply a better vehicle than a Hummer? Why would you pay $500 for jeans when you can get the equivalent warmth and modesty from something costing 1% that amount?

          And, as always, the fact that drugs have side effects doesn’t magically make CAM effective. If CAM is so great, why does it consistently have no benefits in scientific tests, and why do CAM practitioners ignore these results?

        2. Jopari says:

          Honestly, Pharmaceutical companies don’t sell you drugs where risks outweigh the benefits because
          1) You’re unlikely to buy things again if they cause more harm than good, they are always researching for better ways, if only to make money (cynical approach)
          2) Selling you things that are gonna make you sterile or go blind sure as hell ain’t a good thing. The actually have consciences and intellect. (Some alts lack in one or both areas) (faith in humanity approach)

      2. DuWayne says:

        It is easy to criticize what you don’t know. There seems to be a significant amount of studies showing the efficacy of Chinese Herbs on PubMed. I have seen Chinese herbal formulas achieve amazing results where mainstream medicine’s solution was ineffective or unacceptable. I look forward to hearing if the Cleveland Clinic Herbal Dispensary can successfully treat these cases that have previously been unsuccessfully treated.

        In my opinion, there are areas where mainstream medicine is extremely effective and areas where it falls far short. In these areas where it fails, it seems Chinese medicine excels. The military is effectively using acupuncture as shown in the documentary “Escape Fire.” I think we will see the Cleveland Clinic successful in their endeavor despite the critics.

        1. Chris says:

          “There seems to be a significant amount of studies showing the efficacy of Chinese Herbs on PubMed. I have seen Chinese herbal formulas achieve amazing results where mainstream medicine’s solution was ineffective or unacceptable.”

          Citation needed.

    2. WilliamLawrenceUtridge says:

      If you want to eliminate what you consider inferior medicine

      What if, instead, inferior medicine had the ethics to be honest that their treatments are unproven, and was willing to abandon those practices found to be ineffective?

      Why does real medicine need to be perfect before CAM can be arsed to improve?

      It looks bad when all you do is denigrate the competition.

      Oh, my poor irony meter. Considering how much of CAM is justified by “real medicine causes iatorgenic harms/drugs have side effects/doctors don’t care” rather than “my treatments work”, perhaps you might want to do something about that beam in your eye.

  11. Ekko says:

    I don’t disagree with the major points here, but I would consider updating your view of Kava. Your citation for safety is from 2002. I would put it alongside herbs like St. John’s Wort and Hawthorn as likely being effective and worthy of more research and standardization.
    Efficacy:
    http://www.ncbi.nlm.nih.gov/pubmed/12535473
    http://www.ncbi.nlm.nih.gov/pubmed/23635869
    http://www.ncbi.nlm.nih.gov/pubmed/21073405

    Safety:
    http://www.ncbi.nlm.nih.gov/pubmed/21801196
    http://www.ncbi.nlm.nih.gov/pubmed/18841189
    http://www.ncbi.nlm.nih.gov/pubmed/20720265

    1. Calli Arcale says:

      How would possible efficacy discount safety concerns? Those are two different things, so it doesn’t really follow. Tylenol is famously hepatotoxic; nobody denies that. So why deny that kava has dangers even as it is studied for beneficial effects?

      And funny you should mention St John’s Wort. As discussed upthread a bit, it’s notorious for drug interactions. Possibly effective, but since the label doesn’t have to mention the interactions since it “isn’t a drug”, it of course does not. Yet it can decrease the effectiveness of antibiotics, anti-rejection drugs, birth control pills and more. It may be effective, but those would seem to be safety concerns worth mentioning. Hell, Big Pharma has voluntarily withdrawn drugs with less severe interactions (see also Seldane).

      1. Ekko says:

        Where did I say efficacy discounts safety concerns?
        The links are reviews of the safety concerns – did you read them? The reviews show that the safety concerns have much less to do with actual quality kava than originally thought.
        Re: SJW – what label are you talking about? Labelling regulations vary from country to country – some countries do in fact list possible drug interactions on the label, as they should.

  12. Ekko says:

    Actually, I would also disagree that “much of the low-hanging fruit has already been picked” with respect to herbal medicines. For example, the common weed dandelion, has only recently begun making its way through the research hoops at the University of Windsor in Ontario, Canada.
    http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0030604
    It may of course not pan out at all once it reaches the animal or human level, but it seems a much more worthwhile use of money and time than most CAM.

  13. Kiiri says:

    For exactly the reasons enumerated I have discouraged many family and friends from taking ‘supplements’. Thankfully most of my family have the sense not jump on the bandwagon of taking a load of supplements. I always find it unsettling the level of cognitive dissidence which dismisses taking even one or two drugs to treat medical conditions but who will happily down handfuls of supplements and herbal remedies at enormous out of pocket costs without batting an eye.

  14. CrankyEpi says:

    I subscribe to a FDA service called “Health Fraud Scams” which e-mails notifications of product recalls and warning letters. I get about 3-5 per month; many involve natural and/or herbal products that are adulterated with undeclared pharmaceutical drugs (some of which have been taken off the market). For example, weight loss products that have sibutramine (Meridia), phenolphthalein (an OTC laxative taken off the market), DMAA (an unapproved dietary ingredient also known as geranium extract), “natural” pain relievers that include diclofenac and methocarbamol. So: 1) it could be quite dangerous for patients to take pills with unknown substances that have known adverse effects; and 2) perhaps your herbal remedy is so great because it’s actually a pharmaceutical drug that’s the active ingredient.

    1. WilliamLawrenceUtridge says:

      Ironically, despite DMAA’s claimed “natural geranium extract” roots, it’s actually a synthetically-prepared amphetamine mimicker whose resemblance to anything found in a plant is questionable:

      http://www.sciencebasedmedicine.org/dmaa-efficacious-but-is-it-safe/

  15. Rose Lovell says:

    While I largely agree with you, I don’t think marketing is the only reason for someone to take an herbal supplement. Perhaps I misunderstood you, but it felt like you were implying that it MUST be because of marketing.

    I’ve seen a lot of transgender women taking Black Cohosh and Saw Palmetto because they couldn’t get prescribed proper estrogen/anti-androgens from physicians because of discrimination. They literally had no other choice, and it was a desperate grab. I also know some cases of people going to herbs and supplements to manage mental health symptoms after trying many many pharmaceuticals and therapy for years with little success. Most of these people did research on known physiological effects of the herb and were careful about their choice of supplier. I think there are also people out there who are trying to deal with issues without consulting their physicians for other reasons. Others that I know of use herbs explicitly for their psychoactive effects (e.g., kava, kanna, kratom…)

    These are just anecdotes, and admittedly probably not reflective of the majority of herb-users (at least not here in Santa Cruz county). And it’s also likely true that marketing informed them that herbs existed.

    But despite these weaknesses in my own points, I think it is true that not all herb-users were primarily interested in herbs because of marketing. I think those other motivators are worth looking in to, to reduce the overall number of herb-users.

    Also – totally agree with Ekko, and thanks to them for pulling up those kava studies!

  16. AriadneCrete says:

    Not a note on herbs, but on bloodletting. You probably know this, but I just learned that it’s an actual medical treatment for some conditions. Still! My advisor is undergoing it for hemochromatosis.

    1. Harriet Hall says:

      “Bloodletting” was a medieval treatment intended to balance the 4 imaginary humors. Today we do therapeutic phlebotomies for certain conditions like hemochromatosis, but we don’t usually refer to that as bloodletting.

      1. Calli Arcale says:

        I know a guy who gets blood drawn regularly for hemachromatosis. He calls it bloodletting, but that’s because he’s a goofball with a penchant for Monty Python movies and medieval stuff. ;-)

    2. Sean Duggan says:

      {nods} I have a minor tendency to hemachromatosis and my doctor prescribed for me regular blood donation, which seems to keep it in check.

  17. ALEX says:

    I am a physician at the Cleveland Clinic that has vocalized my concern with the promotion of integrative medicine and woo. I was told by some administrators that the Wellness institute was under heavy review. Apparently I am not alone. With all the changes in healthcare nowadays, they are questioning the use of spending money on ineffective therapies. Hopefully they will come to the right conclusion and get rid of the woo.

  18. Patrick McDonald says:

    Come, come.Let us strive to be civil in our critques.

  19. Joel Wang says:

    They should get a more qualified practitioner[trollface]. Xiao Yao San does not translate to “free and easy wanderer” — 逍遥(Xiao Yao) can be translated to “free and easy”, but 散(San) means a powered form of Chinese medicine. The “wanderer” part comes from nowhere.

  20. Andy williams says:

    Ones opinion that these herbs or supplements are dangerous and that there is no scientific data that proves they work or don’t work or can interact with other meds but that same person will take prescribed meds from a dr who is compensated for prescribing meds that have a warning of side effects that is 2 pages long just because the dr writes his name on script. Try reading the indications and warnings on prescriptions you get.

    I think offering other treatments is great. I myself know that people from all over the world go to Cleveland clinic and they all have different beliefs about medicine.

    So what are your thoughts on mitococktails and the benefits of taking supplements like coQ10, L- carnitine, alpha lipoic acid and vitamins.
    I’ll tell you my thoughts. – they saved my life and got me off the prescribed meds that my drs kept throwing on my list of meds to treat the symptoms without finding the cause. The Cleveland clinic saved my life and if it were not for my geneticist in the genomics department who took a shot from his hip in prescribing my ingredients of supplements ( that insurance won’t cover because of lack of evidence and research)
    I would still be in wheelchair unable to breathe , walk , cognitive impairment , stutter, neuropathies, muscle crAmps and fasciculations.
    Every other dr I saw ( even head of neuromuscular ) told me to go home and learn to live with it.
    Why?
    Because it was too easy to write a script for over active bladder, then another for under active bladder, a seizure med for twitches and stutter , pain meds , anti imflammatory , arthritis meds , all without looking at or researching what other prescribed meds I wAs on or trying to find out what was causing the numerous erratic symptoms involving every organ system in the body.

    As of Today I happen to have found out that I have a few extremely rare and some never seen before metabolic issues and never seen variant of one of rarest diseases in world. So you can say what you want but if were not for the Cleveland clinic and my geneticist who prescribed the supplemental ( some herbal ingredients included in supplements ) I would not be walking , talking, I would still have loss of control of bowel and bladder ( have stimulator and bag)
    I might not even know who I am with the way my memory was declining.

  21. Joel Fyvolent M.D. says:

    Sad to see us as society of going backwards in understanding basic concepts of critical thinking and science. Worse is to see the current medical profession not understanding
    logical fallacies and bias and the effect on the resultant effect on people’s thinking or rather lack of it. Don’t bother me with evidence or lack of it is the resulting attitudes formed. Many medical schools are grossly deficient in teaching principles of logic and critical thinking.
    Yes there are patients that we cannot offer “cures” and they are often frustrating to try to help and are time consuming but that does not justify discarding them to unscientific venues that have no evidence to support their use. Of course there will be anecdotal cures but unfavorable results will likely go unreported.
    Remember James Lind and the history of the first clinical trail.

  22. Baxter Foskuhl says:

    Rigorous scientific evidence and methods are the foundations of medicine. Obviously. Any “alternative” medical treatments or associated terms thereof should be given the same scrutiny as modern pharmaceutical drugs, as plants and herbs used to treat ailments are drugs themselves. However, the rhetoric that herbal medicine is “ancient” or “witchcraft” demeaning and immature. Chinese and oriental medicine must have been doing something right after employing these methods. This is not to say that Western Medicine cannot be effective, but it is easy to lash out against ideas that are against the desires of major pharmacy companies and the traditions of Western medicine. Why not give it a try? If it’s carefully supervised by Docs, then allow freedom of choice of the patients to take place.

    1. weing says:

      “Why not give it a try? If it’s carefully supervised by Docs, then allow freedom of choice of the patients to take place.”

      You mean as part of a study? To see if it works for your problem? Not charging you for it? Yeah. Sure. But to have you try it and charge you for it as if it was already of known benefit? No.

    2. Andrey Pavlov says:

      Chinese and oriental medicine must have been doing something right after employing these methods

      Why? They did not stem from a sound epistemological framework. That would be like arguing that alchemy and astrology must have been doing something right in their methods as well. The reality is that while they may have stumbled across a few random bits that were of actual benefit, the methodology and thought processes used to derive and develop the actual treatments were based in, at best, misapprehensions about how the human body and the universe at large works. In many cases outright magical thinking. Why would it possibly stand to reason that a Chinese herbalist from 2,000 years ago who didn’t even know that the heart pumped blood or that blood carried oxygen from the lungs or that intestines digested food (that was demonstrated in Europe, in the middle ages, by a man who carefully recorded the weight of all his intakes and outputs for 30 years to prove that something was extracted from the food by the gut) could come up with something that “must have been doing something right?” There was no means at the time by which to come up with something that was right.

      Why do you not argue that the principles of physics before Newton also “must have been doing something right?”

      Why not give it a try?

      Well, because it was tried. For a long, long time. And it wasn’t until around 100 years ago, when actual scientific practice was applied to the study and implementation of medicine that things actually became “right.” For thousands of years these Chinese medicine men practiced their nostrums and what of it? Disease was rampant, simple infections and wounds were lethal, and life expectancy was low and relatively stagnant. I believe it was Hahneman himself who said that the entire materia medica could be destroyed and humanity would be the better for it. He was right. At the time, that was true.

      Why don’t you argue that we should also look at the Europeans of the middle ages? Why not continue bloodletting? Balancing humors? Drinking mercury? Why does it make more sense to unblock the flow of qi or balance yin and yang? Because that is the basis of these Chinese nostrums, and they are just as ridiculous.

      And yes, that is ancient witchcraft. It is not demeaning nor immature. It is a statement of fact. The whole of humanity was struggling to find out what was true and what worked. In the interim, witchcraft and magical thinking, ideas like bile and phlegm and qi and yin and yang prevailed. The same way we no longer do astrology and alchemy, so should we no longer do traditional Chinese medicine.

      So when you say:

      Rigorous scientific evidence and methods are the foundations of medicine. Obviously.

      You are either disingenuous and using that as a rhetorical tack to try and slide in the woo all buddy-buddy, or you really don’t know what you are saying. Because at it’s very base TCM and CAM is precisely not based in rigorous scientific evidence or methods. The foundation is incompatible with science. Which is precisely why we don’t just “give it a try.” If there is good reason to suspect that this ancient witchcraft actually did stumble blindly onto something worthwhile then we test it, scientifically, not “just give it a try.”

  23. Our spinach contains iron so dont we get iron from spinach when we eat it?

    After taking known weight iron tablets how sure are we that the exact amount get to the right target considering some bind to other substance and others do not even get absorbed?

    Eg the presence of vitamin c affects the amount of iron that will be absorbed. May be we should measure the amount of vitamin c present each day each hour in each patient before giving our iron tablets else it is the same as giving an unknown weight in spinach.

    1. WilliamLawrenceUtridge says:

      There’s a difference between giving someone food to correct a nutritional deficiency, and giving someone herbs to cause a drug-like effect.

      Also, are you aware the belief that spinach is excessive amounts of iron in it is actually a myth caused by a misplaced decimal? It’s got about as much iron in it as any other leafy green. Want dietary iron? Eat meat regularly.

      As for knowing how much iron is absorbed or not – there’s a massive clinical and preclinical body of literature surrounding how iron moves from pill to blood, if you really want to read up on it. Hope you’ve got a good background in biochemistry.

      1. Andrey Pavlov says:

        I did not know that! I knew that spinach was not somehow exceptionally high in iron as the myth goes, but I did actually assume it was on the higher end and had no idea about the origin of the myth.

        Thanks for sharing!

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