Herbal Meds: When CE Equals Caveat Emptor
From early Imperial times until the Communist era, the teaching of herbal medicine in China took the form of a master teaching an apprentice.
About 2,000 years ago, Chinese herbalists turned away from blaming anthropomorphized agents (i.e., demons) for disease and instead began attributing sickness to yin-yang imbalance.1 Primitive, folkloric medical practices of tongue and pulse diagnosis served as mainstay diagnostic tools.
With these methods, herbalists determined which potentially effective but possibly injurious plant products to give patients based on the color of the tongue and feel of the pulse. Few asked questions about the pharmacologic actions, adverse effects or interactions of the herb mixtures. Even the exact nature of the ingredients remained a tightly held “family secret.”
This sounds quaint and exotic until one realizes that much of this is continuing in veterinary medicine today in North America. Continuing education courses in Chinese herbal prescribing are more popular than ever.
While online courses and Internet chats have modernized delivery of the message, certain pitfalls persist, such as apprentices worshipping the master, espousing blind faith in his or her secret formulae.
Mystique and metaphors, however, do not substitute for true investigation into the mechanisms of action, safety and effectiveness that are necessary elements for practicing veterinary medicine safely and judiciously.
Veterinarians seeking to add herbal or supplement prescribing to their practice often first pursue some sort of formal instruction, though the content of these courses has rarely been scrutinized.
Practitioners who hear that they should “leave their Western mind at the door” at the start of a course in Chinese medicine should consider grabbing their coat instead. Veterinarians must often employ their professional judgment to discern the level of scientific validity and credibility of the claims made.
By failing to disclose or intentionally avoiding disclosure of conflicts of interest, faculty leading courses in herbal and dietary supplement prescribing may be utilizing the educational opportunity to sell their products.
Course directors and instructors have an obligation to illuminate bias and protect the objectivity and scientific integrity of CE programs.2 Offering information on a select group of products developed or manufactured by the instructor serves as a telltale sign, as does endorsing a particular product based on one’s asserted expertise while lacking appropriate scientific backing.3
Human medicine, too, has awakened to a crisis concerning the influences of commercial interests, product promotion and medical education.4 Growing dependence on commercial support of continuing education for medical practitioners has generated widespread criticism, prompting alerts from academia, congressional hearings and medical journals.
As early as the 1950s, an outcry against allowing pharmaceutical companies to maintain ties to education resulted in a schism between those who sought to strengthen ties between organized medicine and drug companies on the one hand and those who supported furthering rational therapeutics, untainted by corporate incentives, on the other.5
But over the past 50 years, firewalls set in place between continuing education and commercial support did little to stem the promotional messages entering into medical education. Highlighted by the so-called “Neurontin Legacy,” drug companies’ disguised marketing tactics reached ever higher levels of sophistication, including education, publications and research with undisclosed promotional intent.6
Internet-based learning and peer-to-peer marketing campaigns have created novel vehicles through which to send the company’s message. The medical community’s backlash resounds with cataclysmic warnings; a perspective published in this year’s New England Journal of Medicine noted, “Although some pharmaceutical marketing may be less opaque, deceptive and manipulative, evidence indicates that drug promotion can corrupt the science, teaching and practice of medicine.”7
The problems with herbal makers teaching courses run deeper than mere a conflict of interest. What drug would veterinarians prescribe wherein information about the products’ actions and benefits are based on the company owner’s word?
Not knowing the contents of the herbal product negatively affects patient safety. Even if a supplier lists only the herbal ingredients but omits the ratio and quantity of those compounds, this could spell the difference between a possible interaction being clinically insignificant and one becoming deadly.
For example, a mixture containing large amounts of coumarins could inhibit coagulation during surgery. Plants that induce cytochrome P450 or P-glycoprotein may interact with medications, including chemotherapy or anesthetic agents; how much this interaction affects clinical outcomes may depend on how much of certain botanicals a bottle has.
Immune-stimulating Chinese herbs might counteract the immunosuppressant effects of drugs employed for control of cancer, autoimmune conditions or allergies.
Even China has called for fuller disclosure.8 In late 2008, a Chinese integrative medicine journal article called for transparent reporting of adverse effects to Chinese herbs. The authors elucidated five adverse effects that should be studied through randomized controlled trials, citing the potential for acute and chronic toxicity, allergy, overdoses, heavy metal and pesticide contamination, and more.
Shouldn’t we begin there, before pursuing such heavy commercialization? Shouldn’t we expect veterinarians to have ready access to a searchable database that lists the amount of herbs in a given formula? Why do we need to first agree to further marketing of herbs and courses to get the necessary information to guide our clients who may be using these products now?
Narda Robinson, DVM, DO, Dipl. ABMA, FAAMA, offers an evidential and scientific perspective on the latest trends in complementary and alternative veterinary medicine. She oversees complementary veterinary education at Colorado State University.
8. Cheng C-W, Bian Z-X, Li Y-P, et al. Transparently reporting adverse effects of traditional Chinese medicine interventions in randomized controlled trials. Journal of Chinese Integrative Medicine. 2008;6(9):881-886.