Vermont doctors respond to pharma gifts report

David Johnson, MD, President of the Vermont Medical Society, comments on the recent report from the Vermont Attorney General's office on gifts to doctors by pharmaceutical companies (Times Argus):

"As the JAMA article [referencing the report] noted, pharmaceutical companies can designate spending on physicians as a "trade secret," which prevents the public from finding out about it. Many companies are doing this. The Vermont Medical Society supports eliminating the trade secret exception, so that all pharmaceutical marketing spending becomes public record.

Why do physicians accept payments worth more than $25 in the first place? The vast majority of this spending is in the form of food served during educational sessions on new medications. Physician offices are very busy, so the best time to hold these sessions with pharmaceutical representatives is over lunch. Nurses and other office staff members also participate, but for reporting purposes Vermont's law requires that the cost of their meals be attributed to practitioners in the office who can legally prescribe medications. For example, the cost of a lunch for an eight-person office staff is split between the two physicians in a practice. Because of that, the meal amounts reported for doctors are inflated and trigger the reporting threshold.

There are other steps being considered by the Legislature that will greatly reduce pharmaceutical manufacturers' influence over physicians. The most important is a bill supported by the Vermont Medical Society that would stop chain pharmacies from selling data on your physician's prescribing habits to the drug manufacturers, who in turn use this information to push their expensive products – and drive up health care costs. Halting the sale of this information will take away the most powerful weapon that pharmaceutical marketers have".

David Johnson, M.D., is the president of the Vermont Medical Society.


Cranberry for urinary tract infections

Phytomedicine reports on a pilot study that seems to corroborate the idea that regular consumption of cranberries (or cranberry extract / juice) can help prevent recurrent urinary tract infections (UTIs). Though the study followed only 12 women, it selected those women based on frequency of UTIs (6 over the last year) and followed them for 12 weeks of cranberry therapy.
The results: none experienced UTIs during the 12 weeks of the primary trial. The women were followed for 2 years total, and 8 continued with the cranberry extract during those years. None of those taking the cranberry had a UTI during the follow-up time either!
Previous research seems to point to cranberry's ability to limit bacterial adhesion and the formation of bacterial biofilms in the urinary tract (and oral cavity, by the way). Adding this new, in-vivo information to the mix might help not only to relieve the often painful and distressing symptoms of recurring UTIs, but also to reduce the administration of potent antibiotics like Cipro.

Gifts to doctors from big pharma

A article came out last week in JAMA providing some details from the Vermont and Minnesota reports that track "donations" made to doctors by the pharmaceutical companies. These monies, gifts, dinners, and trips have been disclosed to these two states as part of new laws supposedly enforcing regulations on gifts to doctors - but whether this regulation has any "teeth" is very debatable. For example, the Vermont law allows non-disclosure if the company can claim the gift is related to a "trade secret": not surprisingly, this loophole was abused.
Nevertheless, some interesting data emerges from the Vermont report:
  • In Vermont, 58 pharmaceutical companies said they made payments totaling $5.58 million in payments over the two years studied -- but they disclosed details for only 12,227 payments totaling $2.18 million. Another $3.41 million in payments were not disclosed based on the trade secret claim.
  • Of the companies reporting payments in Vermont, 13 companies during the first year studied and 10 more during the second year designated their payments as trade secrets.
  • The median payment in Vermont was $51 (range 0.22 to $63,458). Twenty-three percent of the 12,227 payments to Vermont doctors were for $100 or more.
  • About two-thirds of the $100 or greater payments in Vermont were in the form of food and 24.4% were cash, check, honoraria, or donation.
  • In Vermont, 28.4% of the $100 or more payments were designated for education, 25.5% to cover detailing, and 14.1% for speakers.
You wonder why the prescription drug machine keeps rolling on, despite Vioxx, women's HRT, antibiotic overuse, and so much more. Sometimes I really feel bad for the dedicated medical staff that really has only one option - drugs - to help improve the lives of patients. Then I think about the free trips to Hawaii...


Antibiotics overprescribed for sinusitis

We've been following a trend in medical research that has been casting antibiotic use in a new light (see previous: 1, 2). As drug-resistant bacteria continue to evolve and spread, the healthcare establishment is responding by trying to avoid antibiotic use in cases that are self-limiting, or where viral causes are often to be suspected. A few years ago, ear infections. Next, bronchitis. Now, sinusitis: a new study underlines that antibiotics are grossly overprescribed in this condition, and casts some doubts on the use of inhaled corticosteroids as well.
Acute sinus infections (most often viral) tend to clear up fairly well on their own. The problems can come when the infection becomes chronic, often seeing folks take multiple trips to a doctor for a prescription of Amoxicillin. Not the best strategy, it seems - for your personal health, or for the health of the environment (which, truly, isn't really separate from you, but we won't get into philosophical expounding...). So consider some tried-and-true herbal therapies:
  • a nice, hot tea of red clover blossoms. Consider mixing in some goldenrod flowers - and, if you or someone you love is feeling a little 'fussy', some catnip leaves as well.
  • tincture of lobelia and myrrh, rubbed around the sinus area (around the eyes, nose, even the back of the neck - be careful not to get any in your eyes!!!).
  • if you're prone to allergies (often an aggravating / complicating factor), try red Reishi or a fresh stinging nettle extract.
  • nasal irrigation (neti).
Echinacea and/or eyebright may not be bad ideas either. Consult with your local herbalist to see what blend might be best matched to your whole self!


Herb use roundup

Here is a quick review of some information that can shed light on who is using herbal and complementary medicines today. My comments at the end.
  • Alternative Therapies (vol 13, number 2, March/April 2007) produced two interesting studies on herb use. In the first, a survey was conducted amongst over 30,000 adults asking about the use of a limited number of herbs and supplements (29 of 35 were herbal). During the last year, about 20% of respondents reported using one of the products. Factors associated with use were: age 45 to 64; being uninsured; being female; living in the West; using prescription and OTC medicines; having education beyond high school; and being of non-Hispanic ethnicity. The most common herbs: Echinacea, ginseng, ginkgo, garlic - most often used for head and chest colds, followed by muscoloskeletal complaints, and GI tract issues. Crucially, over half of respondents did not inform their primary care doctors about the use of herbs. Cost of conventional treatment was often cited as a factor leading to herb use.
  • The second study in Alternative Therapies followed over 800 people coming through outpatient clinics in San Jose, California. The population here was about 45% Hispanic, but of those who used herbs, 52% were Hispanic - suggesting a contradiction to the above study. Herb use was assessed for potential interaction with conventional treatment, and where the potential existed, case history was reviewed to see if any adverse events had actually occurred. The conclusions: about 15% of those surveyed used herbal medicines. Adverse interactions were deemed possible in 40% of those users. These theoretical interactions included potentiation of hypoglycemic medicines; potentiation of anticoagulant medications; interaction with the metabolism of statin and other drugs through effects on liver metabolism; effects on blood pressure; and effects on clotting time. Actual adverse events were only observed in 7% of total herb users, and the severity of these events was generally rated as mild.
  • The Australian and New Zealand Journal of Obstetrics and Gynaecology released a report showing that women who pursue fertility treatments are much more likely than average to be using complementary and herbal therapies (as recommended by naturopathic doctors and/or herbalists). In this case, the authors of the prospective study also found that such use of non-traditional therapies is rarely reported to the "conventional" doctor.
Not all of this is new information for herbalists. What comes out loud and clear to me are two main things: first, many people aren't talking to their doctors about herbs and supplements they are taking. While the first study listed above does go into why this may be, the main reason in my opinion is the attitude that conventional medicine has put forth over the last 60+ years, especially in the United States. Pushing "unscientific" medicine away has led not only to the greatest health care crisis our country has ever seen, it has also kept care providers in the dark about what the public is doing to address the holes in the modern healthcare machine.
The second striking fact is that, generally speaking, herbs have very few adverse events associated with them, and that these are most likely linked to the concomitant use of prescription medicines. This, at first, is reassuring - but when we factor in the knowledge that doctors aren't really getting the full picture before they prescribe powerful drugs, I feel a bit less calm.
My recommendations: doctors need to ask more questions. Herbalists need to speak up more, and try to help doctors understand everything their patients are doing. We are living in a world where "modern medicine" is not the only treatment modality! I'm not sure everyone involved in health care, let alone clients and patients, has a clear grasp of this fact. The future lies in an integrative approach, and while this holds great promise, it requires clear communication.


Grian Herbs

A little redesign and reorganization, and the new website is complete. Yes, we do sell products there - but there's also a lot of other useful information.

Drug Warnings

The FDA has put out two press releases in recent days, one that focuses on prescription sleep aids, the other on drugs that stimulate erythropoiesis (the formation of new red and white blood cells in the bone marrow).
As far as drugs like Ambien, Lunesta, Halcyon and others go, we're informed that consumers need to be advised of certain risks associated with these sleep aids:
  • Anaphylaxis (severe allergic reaction) and angioedema (severe facial swelling), which can occur as early as the first time the product is taken.
  • Complex sleep-related behaviors which may include sleep-driving, making phone calls, and preparing and eating food (while asleep).
Seems pretty common-sense to try herbal and other alternatives first, especially considering the cost difference.

What is even more concerning to me (and don't even get me started on cost in this case: Procrit often runs into the $2000 / month range) are the new black-box warnings for the anti-anemia drugs given to so many folks who are receiving chemotherapy. These have been touted as ways to keep red blood cell counts elevated in these patients. Some highlights:
  • Aranesp, Epogen, and Procrit and other erythropoiesis-stimulating agents increased the risk for death and for serious cardiovascular events when dosed to achieve a target a hemoglobin of greater than 12 g/dL.
  • ...shortened overall survival and increased deaths attributed to disease progression in patients with metastatic breast cancer receiving chemotherapy.
  • Patients treated before surgery with epoetin alfa to reduce allogenic red blood cell transfusions had a higher incidence of deep vein thrombosis.
  • for example: "The FDA was notified in February 2007 of the final results of a double-blind, placebo controlled study to evaluate whether use of epoetin alpha in anemic non-small cell lung cancer patients not on chemotherapy improved their quality of life. The epoetin alfa dose was titrated to maintain a hemoglobin level of 12 to 14 g/dL; epoetin alfa was dosed at 40,000 IU every week. The study was terminated early when the data safety monitoring committee determined that the median time to death was 68 days in the epoetin alfa arm versus 131 days in the placebo arm (P=0.040 and the majority of deaths were due to disease progression. Also treatment with epoetin alfa did not significantly reduce the need for transfusion or improve the quality of life".
How about two excellent rooty preparations, made from cheap, abundantly growing plants, and which are certainly safer and probably more effective?

Astragalus root

Rehmannia root

An easy way to prepare these herbs is as a decoction. Using 4 heaping tablespoons of Astragalus root and 2 of prepared Rehmannia root (both available at a good herb store) per gallon of water, create a broth by simmering in a covered pot for at least an hour, better still for 3 or 4, adding water as necessary. Strain, and keep in the fridge. 12-16 ounces three times a day can be taken with meals.


Endangered plants and Mountaintop Removal

The herbwife already brought to our attention the insane mining practice of mountaintop removal. Now Herbalgram has published an excellent article which will hopefully ignite a bit more of a furor in the herbal community around stopping this craziness. Sure, endangered plants are being wiped out by the truckful - actually, by the moutainful. But what of the mountains themselves? They hold powerful spirits that are essential for the health of our souls, ecosystems, weather patterns, and more. I think of all the talk of new "clean coal" plants, a supposed "alternative" energy source. At what cost?


American Ginseng and Colds

The American Botanical Council is very excited about a proprietary Panax quinquefolius preparation (Cold-FX) and has released a comprehensive monograph on this herbal product. The bottom line: Cold-FX seems to be quite good at preventing colds and flus, when taken at moderate doses, and even effective in managing symptoms once the cold has started, when taken at much higher doses. The best research that isn't partially funded by the manufacturers comes out of Canada and is a trial involving over 300 people - and the results are indeed interesting.
I reviewed the pharmacology of this product, and it seems to isolate the polysaccharide fraction from ginseng roots. There has been a good amount of research around these compounds (Clinical Microbiology Review, e.g.), and some have proposed that complex sugars such as rhamnose, galactose and arabinose present in genera such as Larix, Echinacea, Andrographis, Eleutherococcus, and Panax are at least partially responsible for their immune-enhancing power. Human studies seem to point at increased proliferation of CD4 T-cells and NK cells of the immune system, although why this happens still remains a mystery. Perhaps the polysaccharides have some similarities to the sugar-like antigens on the surface of bacterial cell walls - but that is simply speculation.
In sum, I think this is further evidence that dietary polysaccharides have a positive effect on human immunity. But don't rely on expensive proprietary products to get these chemicals into your diet: consider an excellent soup stock made of bones and/or seaweeds, astragalus, reishi, and ginseng (American and/or Siberian). You can freeze this preparation in ice cube trays after simmering it for 4-6 hours in a crock pot, and take 2-3 ice cubes in warm water during the cold and flu season. This is a tried-and-true, ancient (minus the ice cubes) way of using these excellent herbs.


Lunar eclipse

Not exactly an herbal topic, but for those of us who enjoy gazing at the full moon, tonight may hold a special treat. On the East coast, moonrise (around 5:45pm, in the dusk hours) will bring an already-completely-eclipsed disk of the moon. It will be visible in the east, reddish-orange, and slowly return to its fully illuminated form over the course of the next hour. If the weather cooperates where you are, this eclipse promises to be quite spectacular: the twilight colors of sunset on one side of the sky, a fiery red moon on the other. Enjoy it! Next chance comes in August.


Garlic gets a bad review

Well, a trial conducted at Stanford University that followed almost 200 patinents has found no evidence that garlic lowers levels of LDL ("bad") cholesterol and general blood lipidity. HerbalGram's review of the study is a good summary, if you don't want to read the whole thing.
Aside from the inevitable media frenzy over this (best headline award: "Garlic stinks for lowering cholesterol"), the study does seem to be a fairly well-crafted, in vivo trial. My only quibble comes with the dose on the fresh garlic, which is very low at 4 grams (about 1 clove) daily. I usually suggest more like 4-5 cloves a day, and generally prefer the whole-plant preparations to health food store pills like Kyolic or Garlicin. In my practice, I have seen these levels of consumption have an impact on total cholesterol and LDL levels when used as part of a balanced, plant-rich, fiber-rich diet.
I think we can draw two lessons from this new information: first off, as the HerbalGram review points out, it may be that garlic has a more potent anticholesterol effect in folks who have seriously elevated levels, not just mildly elevated ones. Secondly, garlic has powerful effects on other markers of cardiovascular disease such as hypertension and vascular inflammation. It may be that, again, we are taking serum cholesterol too seriously as a causative factor in CV disease - and that garlic will reduce blood lipids only in cases where there is actual vascular damage, progressive atherosclerosis, and hypertension.
This study says nothing, of course, about garlic's power to combat infection, address colds and flus, or deal with intestinal parasites and infections - although it does detail effects on breath and body odor, thankfully.