Wirth HerbalTher 2005

Judith A. Paice, PhD, RN‡

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Original Articles

rom the *Department ofsychology, Purdue University,est Lafayette, Indiana;

Department of Medicine, Divisionf Hematology/Oncology Feinbergchool of Medicine, Northwesternniversity and the Robert H. Lurieomprehensive Cancer Center oforthwestern University, Chicago,

llinois; ‡Department of Medicine,ivision of Hematology/Oncology,einberg School of Medicine,orthwestern University and theobert H. Lurie Comprehensiveancer Center of Northwesternniversity, Chicago, Illinois.

ddress correspondence and reprintequests to Judith A. Paice, PhD, RN,AAN, Division ofematology/Oncology, Northwesternniversity; Feinberg School ofedicine, 676 North St. Clair Street,

uite 850, Chicago, IL 60611. E-mail:[email protected].

524-9042/$30.002005 by the American Society

or Pain Management Nursing
soi:10.1016/j.pmn.2005.08.003
Use of Herbal Therapiesto Relieve Pain:A Review of Efficacy andAdverse Effects

yyy James H. Wirth, BA,* J. Craig Hudgins, BA,† and

ABSTRACT:o find holistic treatment with effective pain relief and few side ef-ects, Americans spend billions of dollars annually on complementarynd alternative medicine, including herbal therapies. Despite exten-ive use, the lack of regulatory scrutiny of these herbal supplementsontributes to the paucity of reliable clinical data assessing their effi-acy and safety. This review summarizes the existing studies investi-ating the efficacy of herbal therapies as a treatment for pain. Possi-le side effects, potential drug–herb interactions, and informationbout common herbal therapies are also summarized. MEDLINE,MED, and the Cochrane Library databases were searched for the pe-iod from January 1966 to June 2005. Uses, dosages, routes of admin-stration, and side effects were summarized. Strength of empirical evi-ence also was evaluated. This review found few well-controlledlinical studies. Furthermore, these studies documented limited effi-acy of herbal therapies to treat pain. The information presented hereay be used to further educate nurses and patients on the use oferbal therapies as well as direct future research efforts.2005 by the American Society for Pain Management Nursing

ACKGROUNDatients experiencing pain may try numerous therapies, including conventionalnd alternative approaches, for relief. Pain relief is the most frequently citedeason that people seek complementary and alternative medicine (CAM) (Astin,998). CAM encompasses therapeutic treatments such as relaxation, meditation,iofeedback, hypnosis, imagery, chiropractic, acupuncture, massage, aroma-herapy, and herbal therapies. A 2002 study conducted by the National Centeror Complementary and Alternative Medicine surveyed 31,044 adults and foundhat 36% of respondents used some form of CAM therapy during the last 12onths (Barnes, Powell-Griner, McFann, & Nahin, 2004). These therapies might

e chosen because other conventional therapies were previously ineffective orroduced side effects that were intolerable. Therefore, clinicians must be awaref CAM therapies used to treat pain to answer questions from patients effec-ively and to avoid possible interactions with medical (drug) therapies pre-
cribed for patients.
Pain Management Nursing, Vol 6, No 4 (December), 2005: pp 145-167

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EASONS FOR USINGOMPLEMENTARY ANDLTERNATIVE MEDICINES

AM users choose alternative therapies so their healthare is more congruent with their personal values,eliefs, and overall philosophic orientation towardealth and life (Astin, 1998). This philosophical orien-ation may result from personal values, past healthare experiences (i.e., disillusionment with conven-ional therapies because of their lack of efficacy or sideffects), or desire to have control over health careatters (Astin, 1998; Barnes et al., 2004).

Many herbal therapy users have a chronic disease. study by Boon and colleagues (2000) reported thatome patients with breast cancer chose CAM to boostheir immune system, increase quality of life, preventecurrence of cancer, provide a feeling of control overife, aid conventional medical treatment, or treat breastancer. The most frequently cited health problemshat lead to CAM use are anxiety, back problems,hronic pain, and urinary tract disorders (Astin, 1998).ccording to studies by Barnes et al. (2004) andimby, Launso, Henningsen, and Langgaard (2003),omen and older adults are most likely to seek CAM

herapy, and CAM users generally perceive the treat-ents have fewer side effects than do conventionaledicines (Eisenberg, et al., 2001).

Unfortunately, those who use CAM face potentialdverse side effects, including drug–herb interactions.hus, clinicians in the pain field should be familiarith the uses and potential risks associated with CAM.ore than half of patients first seek information re-

ated to CAM therapies from their primary physicianEisenberg et al., 2001). Hyodo and colleagues (2003)ound that 93% of Japanese clinical oncologists sur-eyed in 2002 had been asked about CAM options. Inhis study, 80.2% responded they were unable to ad-ise their patients appropriately about the use of CAMroducts. Similarly, Eisenberg, Kessler, Foster, Nor-

ock, Calkins, and Delbanco (1993) reported that phy-icians do not discuss the use of unconventional ther-pies because they lack adequate knowledge of theseechniques. Other barriers to discussion regardingAM exist, including patients perceiving that clini-ians lack interest (Verhoef, Hilsden, & O’Beirne,999), are closed-minded, lack knowledge (Eliason,uebner, & Marchand, 1999), and would not under-

tand or would not approve of the alternative therapyEisenberg et al., 2001).

Surprisingly, negative attitudes toward or experi-nces with conventional medicine do not predict CAMse (Astin, 1998), despite one stereotype that CAM
sers are disgruntled patients. CAM users are fre- v
uently no more dissatisfied or distrustful of conven-ional practitioners and hospitals than nonusers (Astin,998). Most complementary therapies are used in con-

unction with conventional medicine (Eisenberg et al.,001). In a national survey, 79% of respondents be-

ieved that the combination of conventional and alter-ative therapies is more effective than either approachlone (Eisenberg et al., 2001), and presumably thisesire for a more holistic approach to health care ishat accounts for $21.2 billion in U.S. consumer

pending in 1997 on CAM professional services (Rees,001), including massage, acupuncture, chiropracticreatment, and herbal therapies.

ERBAL THERAPY USE FOR PAINerbal therapies are more likely to be used by thoseith a better education, poorer health status, and aolistic orientation to health; those wanting reliefrom symptoms or seeking improvement in their gen-ral condition; and those who had a transformationalxperience that changed their world view (Astin,998; Kimby et al., 2003; Oldendick et al., 2000). Theost commonly used natural products are echinacea,

inseng, ginkgo biloba, and garlic supplements (Bar-es, et al., 2004). In the United States, approximately4 billion per year is spent on herbal products, with annnual growth of more than 30% (Rees, 2001). Duringhe 1990s, there was an estimated 380% increase inhe sale of herbal substances. In 2002, a survey found9% of adults had used natural products such as herbaledicine, functional foods (garlic), or animal-based

upplements (Barnes, et al., 2004). Approximately $76illion was spent in 2002 for just three of these sup-lements alone: androstenedione, kava, and yohimbeDangerous Supplements: Still at Large, 2004).

The use of herbal therapies comes with potentialisks that are worth noting to consumers of herbs foredicinal purposes. Active ingredients in herbal ther-

pies or drugs may produce herb/herb or herb/drugsnteractions that have undesirable side effects (Ernst,998; Fugh-Berman & Ernst, 2001). For example,hen combined with levodopa, kava can cause an

ncrease in the number and duration of “off” periods;t. John’s wort taken with sertraline (Zoloft) may pro-uce nausea, vomiting, or anxiety (Fugh-Berman &rnst, 2001). Herbal therapies and drugs are oftenade of more than one active element. This further

omplicates what pharmacologic ingredient is causinghe interaction or undesirable side effect (Izzo & Ernst,001; Fugh-Berman & Ernst, 2001).

A lack of standardization of herbal remedies alsoakes it challenging to understand what causes ad-

erse interactions. Contamination, misidentification of

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147Use of Herbal Therapies to Relieve Pain

n herbal plant, or an incorrectly substituted plant allaise issues of quality (Drew & Myers, 1997; Ernst,998) and can result potentially in an unwanted sideffect. Of 400 users of complementary medicine sur-eyed, Abbot, White, and Ernst (1996) found 8% ofhose who tried herbal remedies had an adverse reac-ion.

Incorrect preparations, incorrect dosages, lack oftandardization, substitution, or improper processingf plants can result in unwanted combinations of in-redients in herbal therapies (Drew & Myers, 1997;rnst, 1998). The pharmacologically active compo-ent may not necessarily be known, making it difficulto understand how the therapies work (Ernst, 2000).nwanted ingredients may lead to contamination, forxample, when bovine spongiform encephalopathyrom bovine organs was found in dietary supplementsDepartment of Agriculture, 2000; Scott et al., 1999).assileth and Deng (2004) contend that herbs areiluted natural drugs that contain scores of differenthemicals that may not have been documented. AAM user may not anticipate the potential interactionsith other medications or herbal preparations.

A lack of strict government regulation diminishesfforts at prevention of potentially harmful results oferbal remedies. In 1994, Congress passed the Dietaryupplement Health and Education Act (DSHEA) to setegulation standards of herbal therapies for medicalenefit. DSHEA relieved pressure from the U.S. Foodnd Drug Administration (FDA) on herb manufacturerso prove health benefits of herbal therapies, therebyermitting them to make it to the marketplace withoutemonstrating any benefits (Larsen & Berry, 2003).his creates a difficulty, because 59% of respondents

o an Internet survey believe herbal products must bepproved by a government agency similar to the FDAWidespread Ignorance of Regulation and Labelingf Vitamins, Minerals and Food Supplements, Ac-ording to a National Harris Interactive Survey,002).

DSHEA also allows herbal manufacturers to makehree types of claims without FDA approval: (1) nutri-nt content claims, (2) health claims, and (3) nutrientupport or structure-function claims (Kurtzweil, 1998;verview of Dietary Supplements, 2001). Limited fed-ral authority has led to animal products being in-luded in dietary supplements, increasing the possibil-ty of contamination. Consumers need to be wary ofalse claims, insufficient labels, and the potential fornimal products to be included in the herbal therapy.

Those individuals considering herbal therapy use forain control also may struggle to find credible sources of

nformation. A recent U.S. investigation suggests that
nformation provided by health food stores can be dan- d
erously misleading, because potentially uneducatedealth food store employees may freely give advice aboutreatment for life-threatening illnesses (Phillips, Nichols, King, 1995). Likewise, prominent herbal therapy prod-ct web sites often convey incorrect information (Morris Avorn, 2003). A review of Internet web sites found73 (81%) of 338 sites made one or more health claimshat may or may not be proven.

Labels on herbal products also are not a reliableource of information, often missing important detailsuch as product’s safety, effectiveness, or possible sideffects (Zuk, 2000). This lack of information runs con-rary to what the general population believes is in-luded on herbal product labels. In a study of knowl-dge of regulations and labeling of food supplements,8% of survey respondents believed the governmentequires label warnings on potential side effects orangers (Widespread Ignorance of Regulation andabeling of Vitamins, Minerals and Food Supple-ents, According to a National Harris Interactive

urvey, 2004). Ultimately, relaxed regulation placeshe onus on clinicians to educate and protect patients.s people with pain frequently turn to CAM for relief,ain management nurses must be aware of the risksnd benefits of CAM for pain control.

ETHODSiterature Searcho identify articles on the use of herbal therapies toeduce pain, a literature search of MEDLINE (January966 to June 2005), AMED (Allied and Complementaryedicine, January 1985 to June 2005), and the Co-

hrane Library (November 2003 to June 2005) data-ases was conducted. Reference lists of articles iden-ified from the initial search were also reviewed fordditional articles. Research conducted with humansr animals was reviewed. Only English language pub-

ications were considered. Search criteria comprisedhe term painwith the common name, Latin name,nd common synonyms for the herb in question (e.g.,or Black cohosh, search criteria pain and baneberry,imicifuga, and bugbane each were used). Most arti-les were identified using the herb’s common or Latiname.

nclusion Criteriall English-language titles and abstracts, from January966 to the present, were evaluated for inclusion inhis review. The first articles on herbal therapies toeduce pain were published in 1990. All pain syn-romes were considered for this review. Publicationsritten in English in which an herb was studied to
etermine its effect on reducing pain or investigated in

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human or rodent trial were included. The reviewesulted in a range of articles addressing several typesf pain syndromes treated with the use of herbalherapy.

trength of Evidenceethodologic quality of the studies reviewed was eval-ated using a scientific evidence scale published byhe U.S. Department of Health and Human ServicesJacox et al., 1994). The type of evidence and thetrength and consistency of the evidence were re-orded for all of the studies included in this review.ypes of evidence were (1) meta-analysis, (2) at leastne well-designed experimental study, (3) well-de-igned quasi-experimental studies, (4) well-designedonexperimental studies, and (5) case reports andlinical examples (Table 1). Strength and consistencyf evidence were (1) consistent findings from multi-les studies, (2) findings that are generally consistent,3) findings are generally inconsistent, (4) little or novidence (Table 1).

ossible Uses and Safety Informationhis review of commonly used herbal therapies used

o treat pain includes information about possiblenown uses, dosages, and routes of administration. Itlso includes safety and adverse effect information.his information was collected primarily from the Nat-ral Medicine Comprehensive Database (2003) andeveral other published sources (Nutrition in Cancer

ABLE 1.trength of Evidence (Jacox et al., 1994)

Types

I. Meta-analysis of multiple, well-designed controlled studa. Studies of patients with cancerb. Studies of other clinical populations

II. At least one well-designed experimental studya. Studies of patients with cancerb. Studies of other clinical populations

III. Well-designed, quasiexperimental studies such as nonseries, or matched case-controlled studies

a. Studies of patients with cancerb. Studies of other clinical populations

IV. Case reports and clinical examplesa. Studies of patients with cancerb. Studies of other clinical populations

Strength and consistency of evidenceA. There is evidence of type I or consistent findings fromB. There is evidence of types II, III, or IV, and findings areC. There is evidence of types II, III, or IV, but findings areD. There is little or no evidence, or there is type V eviden

are, 2004; Skidmore-Roth, 2004; The Complete Ger- f

an Commission E Monographs: Therapeutic Guideo Herbal Medicines,1998; Koenig, 2003). Several webites were identified, and content from them was in-orporated into the review. These are listed in Table 2.

ESULTSn our search of herbal therapies, 34 publications de-cribing the use of 24 herbal therapies to treat pain weredentified (Table 3). Ten of the 24 (42%) herbal therapiesad research evidence available investigating the abilityf the herbal therapy to manage pain. For the remaining6 herbal therapies (58%), no known research on theirse in pain management was identified at the time of thiseview. The herbal therapies that were proven effectiveere useful when specifically treating arthritis (Brzeski,adhok & Capell, 1991; Deal et al., 1991), polyneurop-

thy (Low, Opfer-Gehrking, Dyck, Litchy, & O’Brien,995), postmastectomy pain syndrome (Dini, Bertelli,ozza, & Forno, 1993; Watson & Evans, 1992), neurop-thy (Scheffler, Sheitel, & Lipton, 1991), or low-back painChrubasik, Eisenberg, Balan, Weinberger, Luzzati, &onradt, 2000; Frerick, Keitel, Kuhn, Schmidt, Brede-orst, & Kuhlmann, 2003). The quality of the identifiedtudies ranged from a meta-analysis of multiple studiesroducing consistent findings (Type I, A) to case reportshat had generally consistent findings (Type V, B; Table). Overall, most of the research had at least one well-esigned experimental study that produced evidencehat was generally consistent. This review found only

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Deal et al., 1991; Low et al., 1995; Jeffrey & Belcher,002; Sindrup, Madsen, Bach, Gram, & Jensen, 2001).

Studies for only 10 of 24 herbs used to manage painuccessfully were reviewed for efficacy. Of these 10erbals, several studies used a placebo-controlled studyethodology to investigate the herbal therapy’s effec-

iveness (Altman & Marcussen, 2001; Brzeski, Madhok, &apell, 1991; Chrubasik et al., 2000; Deal et al., 1991;ini et al., 1993; Ellison et al., 1997; Frerick et al., 2003;ow et al., 1995; Scheffler, Sheitel, & Lipton, 1991;atson & Evans, 1992). In addition, several studies found

hat herbal therapies were no more effective at managingain compared with a placebo or general pain medica-ion (Bliddal et al., 2000; Ernst & Pittler, 1998; Kaziro,984; Paice, Ferrans, Lashley, Shott, Vizgirda, & Pitrak,000; Sindrup et al., 2001).

dverse Effect and Interactionsany of the herbal therapies had significant adverse side

ffects that should be considered when using these treat-ents. For example, Arnica is considered poisonous if

njected and may also cause liver damage (Skidmore-oth, 2004). In 2004, Ephedra was banned because of its

ncreased risk for heart palpitations, tremors, and insom-ia. This was the first time U.S. officials blocked the salef an over-the-counter herbal supplement (Governmentnnounces Ban on Ephedra, 2004). Overall, commonide effects caused by the investigated herbal therapiesncluded nausea, vomiting, burning sensations, gastroin-estinal irritation, intestinal blockage, and insomnia. Ad-erse interactions with numerous drugs and the possibil-ty of worsening medical conditions were common to

any of the herbal therapies we investigated. For exam-le, herbal therapies may worsen diabetes for some pa-

ABLE 2.AM-Related Informational Web Sites

Organization

merican Botanical Councilenters for Disease Control and Prevention, Public HealtDepartment of Health and Human Servicesemorial Sloan-Kettering Cancer Centerational Center for Complementary and Alternative Medicffice of Complementary and Alternative Medicineffice of Dietary Supplements, National Institutes of Healociety of Integrative Oncology.S. Food and Drug Administration, Public Health Serviceof Health and Human Services.S. National Library of Medicine, National Institutes of H

AM, Complementary and alternative medicine.ata from Larsen & Berry, 2003

ients or estrogen-sensitive hormone disorders in some p

omen (Natural Medicine Comprehensive Database,003; Nutrition in Cancer Care, 2004; Skidmore-Roth,004; The Complete German Commission E Mono-raphs: Therapeutic Guide to Herbal Medicines, 1998).

A review conducted by Fugh-Berman and Ernst2001) of suspected interactions of herbal therapiesnd other treatments found warfarin was the drugost likely to be involved in adverse interaction with

n herbal therapy, and St. John’s wort was the herbalherapy most likely to cause an adverse interaction.lthough many herbs have potential side effects, sev-ral herbal therapies reviewed have a status of “Gen-rally Recognized as Safe” for food use in the Unitedtates (chamomile, cinnamon, cloves, ginger, mustard)Natural Medicine Comprehensive Database, 2003).

ISCUSSIONhe use of herbal therapies is an increasingly popularethod to treat pain, either alone or as a complement to

raditional medical approaches. Unfortunately, researchemonstrating the efficacy of herbal therapies to treatain is limited. The strongest evidence identified in thisnalysis was Type I, A, found in only one study. For theajority of the herbal therapies reviewed, there was no

mpirical evidence for the analgesic efficacy of theseompounds. Questions still remain about their underly-ng mechanisms to provide analgesia (Ernst, 2000). Ashe use of herbal therapies grows, empirical researchemonstrating their benefits in pain control lags. Thestablishment of the National Center for Complementarynd Alternative Medicine supports research of herbalherapies and other CAM.

In regard to the safety of herbal therapies, several

Web Site

http://www.herbs.orgices, U.S. http://www.cdc.gov

www.mskcc.org/aboutherbshttp://nccam.nih.gov/http://www3.cancer.gov/occam/http://dietary-supplements.info.nih.govhttp://www.integrativeonc.org/

artment http://www.fda.gov/

http://www.nlm.nih.gov

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ossible drug and herbal interactions were identified.

http://www.herbs.org

http://www.cdc.gov

http://www.mskcc.org/aboutherbs

http://nccam.nih.gov/

http://www3.cancer.gov/occam/

http://dietary-supplements.info.nih.gov

http://www.integrativeonc.org/

http://www.fda.gov/

http://www.nlm.nih.gov

TABLE 3.Herbal Therapies for the Relief of Pain

Agent Possible Uses Dose/Routes Studies Safety/Adverse Reactions

● Arnica* (Arnicamontana)

● Also known as:Arnica flos,Leopard’s bane,Mountain tobacco,Wundkraut

● Used for generalcounterirritant, anti-inflammatory, and painreliever (Data fromKoenig, 2003)

● Topically, to decreaseinflammation in bruises,sprains, wounds, acne,boils, and rashes (Datafrom Skidmore-Roth,2004)

● Topically: Used as acream, 15% arnicaoil (Natural MedicineComprehensiveDatabase, 2003)

● Typical strength is2 g of flowerheads in100 mL water

● Arnica gave rise to greater pain thana placebo and caused moreswelling when used to treatimpacted wisdom teeth (Data fromKaziro, 1984). Type III, B**

● Topical application of Arnicamontana gel was a safe, well-tolerated, and effective treatment ofmild to moderate osteoarthritis ofthe knee (Data from Knuesel,Weber, & Suter, 2002). Type II, B

● Significant reduction of painexperienced by patients whounderwent hand surgery (Data fromSindrup et al., 2001). Type II, B

● Analysis of eight trials found, onbalance, homeopathic arnica is nomore effective than placebo (Datafrom Ernst & Pittler, 1998). Type I, B

● Considered poisonous if injected (Datafrom Skidmore-Roth, 2004)

● Serious liver and kidney damage canoccur (Data from Skidmore-Roth, 2004)

● Interacts with antihypertensive drugs(Data from Skidmore-Roth, 2004)

● Black Cohosh(Cimicifugaracemose)

● Also known as:Baneberry,Cimicifuga, Bugbane

● It is a smooth-musclerelaxant, anantispasmodic, anantitussive, a diuretic,an antidiarrheal, and anantiarthritic (Data fromSkidmore-Roth, 2004)

● Oral: 300-2000 mg ofthe dried rhizome orroot three times daily(Natural MedicineComprehensiveDatabase, 2003)

● No published research related topain

● Likely safe when used orally andappropriately, safe in studies lasting up to6 months (Natural MedicineComprehensive Database, 2003)

● Adversely interacts with hormonesensitive cancers/conditions, but has noknown drug interactions (Natural MedicineComprehensive Database, 2003)

● Camphor(Cinnamomumcamphora)

● Also known as:Camphora,Cemphire, Camphortree

● Applied topically as ananalgesic and anantipruritic (NaturalMedicineComprehensiveDatabase, 2003)

● Muscle rheumatism,respiratory tract diseases,circulatory regulationdisorders (The CompleteGerman Commission EMonographs: TherapeuticGuide to HerbalMedicines, 1998)

● Topically:0.1%–0.3%, 3 to 4times daily (NaturalMedicineComprehensiveDatabase, 2003)

● Inhalation:tablespoon ofsolution per quart ofwater, medicatedvapors are breathed(Natural MedicineComprehensiveDatabase, 2003)


● Likely safe when used topically in lowconcentrations short-term. Unsafe whenused orally (Natural MedicineComprehensive Database, 2003)

● Orally, camphor can cause significanttoxicity, symptoms can occur rapidlystarting with nausea and vomiting, oraland intestinal burning, feeling of warmth,and headache (Natural MedicineComprehensive Database, 2003)

● Oral preparations are no longer availablein the United States (Natural MedicineComprehensive Database, 2003)

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● Capsaicin (Capsicumfrutescens)

● Also known as:African Chillies,African Pepper,Capsaicin Fruit,Garden Pepper,Sweet Pepper,Mexican Chilies,Grains of Paradise

● Stimulate digestionwhen used orally, as anantiflatulent, for colic,diarrhea, cramps, toimprove peripheralcirculation, reducingblood clottingtendencies, andpreventing heart disease(Natural MedicineComprehensiveDatabase, 2003)

● Topically to reduce pain

● Oral: Capsicum fruitis usually in doses of30–120 mg, 3 timesdaily (NaturalMedicineComprehensiveDatabase, 2003)

● Topical: For painsyndromes, creamscan be applied 3–4times daily (NaturalMedicineComprehensiveDatabase, 2003)

● Available in 0.075%and 0.025% creams

● Systemic capsaicin is effective forshort-term treatment of BurningMouth Syndrome but with majorgastrointestinal side effects (Datafrom Petruzzi et al., 2004) Type II, B

● Topically applied capsaicin creammay decrease subjective neck pain(Data from Mathias et al., 1995)Type IV, B

● Capsaicin is ineffective in relievingpain associated with HIV-associatedperipheral neuropathy (Data fromPaice et al., 2000). Type II, B

● Topical 0.075% capsaicin creamappeared to be more effective thanthe vehicle cream in relief ofpostmastectomy pain syndrome in adouble-blind study (Data fromWatson, 1994). Type II, B

● Open-label trial where 68.4% ofpatients received good pain relieffrom 0.025% capsaicinadministered to treatpostmastectomy pain syndrome(Data from Dini et al., 1993). TypeIII, B

● Double-blind, 8-week trial foundtopical capsaicin 0.075% cream issafe and effective in managingpainful diabetic neuropathy (Datafrom Scheffler, Sheitel & Lipton,1991). Type II, B

● Analysis of several trials foundtopical capsaicin is generally notsatisfactory as a sole therapy forchronic painful conditions; it mayserve as an adjuvant (Data fromWatson, 1994). Type I, B

● Long-term, open, nonrandomizedstudy might indicate that theanalgesic effect of capsaicin inpost-herpetic neuralgia is mediatedby both interference withneuropeptide metabolism andmorphologic changes of nociceptiveafferents (Data from Peikert,Hentrich, & Ochs, 1991). Type II, B

● Likely safe when used orally in amountstypically found in food (Natural MedicineComprehensive Database, 2003)

● May cause gastrointestinal irritation,sweating, and flushing of the head andneck when taken orally (Natural MedicineComprehensive Database, 2003)

● Interferes with the activity of acid-inhibiting drugs, antihypertensive drugs(Natural Medicine ComprehensiveDatabase, 2003)

● May increase the effects of antiplateletdrugs, barbiturates, cocaine, and drugswith sedative properties (Natural MedicineComprehensive Database, 2003)

● Topically, may increase pain, may causeburning of the eye or mucous membraneif accidentally applied

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TABLE 3.Herbal Therapies for the Relief of Pain (Cont’d)


● After 2 weeks, 80% of capsaicin-treated patients with osteoarthritisor rheumatoid arthritis in a double-blind randomized study experienceda reduction in pain (Data from Dealet al., 1991). Type II, B

● A two-arm, double-blind, placebo-controlled, crossover study foundtopical capsaicin cream decreasespostsurgical neuropathic pain to a 3to 1 margin over placebo. There weresome toxicities (Data from Ellison etal., 1997). Type II, B

● A vehicle-controlled, double-blind,multicenter study found 0.075%capsaicin cream is safe and effectivein treating painful diabetic neuropathy(Scheffler, Sheitel, & Lipton, 1991).Type II, B

● In a 12-week, double-blind, placebo-controlled randomized study ofcapsaicin cream on distal painfulpolyneuropathy found no differencebetween capsaicin cream and theplacebo (Data from Low et al., 1995).Type II, B

● In a double-blind, randomized,placebo-controlled multicenterparallel group study, treatment of lowback pain with capsicum plaster wasstatistically and clinically beneficialcompared with a placebo (Data fromFrerick et al., 2003). Type II, B

● Meta-analysis found capsaicin creamto be effective in easing painassociated with diabetic neuropathyand osteoarthritis. Capsaicin’seffectiveness may be attributed toplacebo effects (Data from Zhang &Li Wan Po, 1994). Type I, A

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● Chamomile(matricaria recutita)

● Also known as:Cammilla, Kamillen,Pin Heads,Camomilla,Allemande,Manzanilla

● Skin and mucousmembraneinflammations, irritationsof the respiratory tract(The Complete GermanCommission EMonographs:Therapeutic Guide toHerbal Medicines, 1998)

● Reduces gastrointestinalspasms andinflammatory diseasesof the gastrointestinaltract (The CompleteGerman Commission EMonographs:Therapeutic Guide toHerbal Medicines, 1998)

● Antispasmodic formenstrual cramps (TheComplete GermanCommission EMonographs:Therapeutic Guide toHerbal Medicines, 1998)

● Oral: 2–8 g of thedried flower head(Natural MedicineComprehensiveDatabase, 2003)

● Topical: Used as arinse. No knowntypical dosage

● Tea: Steep 3 g in 150mL boiling water for5–10 minutes(Natural MedicineComprehensiveDatabase, 2003)

● Chamomile extract spray does notsignificantly ameliorate painassociated with postoperative sorethroat (Data from Kyokong et al.,2002) Type II, B

● Has a Generally Recognized as Safestatus for food use in the US (NaturalMedicine Comprehensive Database, 2003)

● Generally safe when consumed inamounts commonly found in foods(Natural Medicine ComprehensiveDatabase, 2003)

● Theoretically, large doses may increasethe risk of bleeding when used withanticoagulants (Nutrition in Cancer Care,2004)

● Theoretically, may increase additive andside effects of benzodiazepines (Nutritionin Cancer Care, 2004)

● Cinnamon(Cinnamomum)

● Also known as:Cinnamon bark,Batavia cassia,Ceylon Cinnamon,Panang Cinnamon,Saigon Cinnamon

● Improve appetite (TheComplete GermanCommission EMonographs:Therapeutic Guide toHerbal Medicines, 1998)

● Treat dyspepsia,abdominal pain, nausea,and other digestivecomplaints (Data fromKoenig, 2003)

● Thought to be,antispasmodic,antiflatulent,antidiarrheal,antimicrobial, andanthelmintic (NaturalMedicineComprehensiveDatabase, 2003)

● Oral: 2–4 g ofcinnamon bark(Natural MedicineComprehensiveDatabase, 2003)

● Topical: No knowntypical dosage

● Tea: 0.5–1 g of thebark in 150 mL ofboiling water, for 5–10 min, then strain(Natural MedicineComprehensiveDatabase, 2003)


● Has a Generally Recognized as Safestatus for food use in the US (NaturalMedicine Comprehensive Database, 2003)

● Likely safe when consumed in amountscommonly found in foods and possiblysafe when used orally and appropriatelyin amounts slightly greater than thosefound in food (Natural MedicineComprehensive Database, 2003)

● Might interfere with antacids (NaturalMedicine Comprehensive Database, 2003)

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● Cloves (Syzgiumaromaticum)

● Also known as:Clove, Caryophylli,Caryophyllus, Clousde Girolfe, FloresCaryophyllum

● Used for gastrointestinalupset, includingflatulence, nausea, andvomiting (NaturalMedicine ComprehensiveDatabase, 2003)

● Reduces inflammatorychanges of the oral andpharyngeal mucosa (TheComplete GermanCommission EMonographs: TherapeuticGuide to HerbalMedicines, 1998)

● Counterirritant for pain(The Complete GermanCommission EMonographs: TherapeuticGuide to HerbalMedicines, 1998)

● Used for toothache ormouth and throatinflammation (TheComplete GermanCommission EMonographs: TherapeuticGuide to HerbalMedicines, 1998)

● Oral: 120–300 mg,limit ingestion to 3.6mg/kg clove oil perday (NaturalMedicineComprehensiveDatabase, 2003)

● Topical: Commonlyused in mouthwash,15% clove tincturecan treat athletes’foot (NaturalMedicineComprehensiveDatabase, 2003)


● Has a Generally Recognized as Safe statusfor food use in the US (Natural MedicineComprehensive Database, 2003)

● Likely safe when consumed in amountscommonly found in food and possiblysafe when taken orally in higher doses formedicinal purposes (Natural MedicineComprehensive Database, 2003)

● May be irritating to respiratory tract whensmoked (clove cigarettes) (Natural MedicineComprehensive Database, 2003)

● Concomitant use of anticoagulants andantiplatelets could theoretically increasethe risk of bleeding and the effects ofthese drugs (Natural MedicineComprehensive Database, 2003)

● Cod-liver Oil ● Used for hyperlipidemia,hypertriglyceridemia,hypertension, coronaryheart disease,osteoarthritis, andsystemic lupuserythematosus (NaturalMedicineComprehensiveDatabase, 2003)

● Oral: For loweringtriglycerides, 20 mLper day. For loweringblood pressure, 20mL per day (NaturalMedicineComprehensiveDatabase, 2003)

● n-3 polyunsaturated fatty acidsdirectly attenuate the neuronal andglial processes that underlieneuropathic and inflammatory pain(Data from Shapiro, 2003). Type II,B

● People with musculoskeletal painexperience less pain if they takecod liver oil (Data from Eriksen,Sandvik, & Bruusgaar, 1996) TypeII, B

● Cod liver oil as supplemental toNSAID therapy in treatingosteoarthritis showed no significantbenefit vs placebo (Data fromStammers, Sibbald, & Freeling, 1992)Type II, B

● Likely safe when used orally andappropriately (Natural MedicineComprehensive Database, 2003)

● Increased risk of bleeding when used withanticoagulants/antiplatelet drugs (NaturalMedicine Comprehensive Database, 2003)

● Decreased effectiveness of antidiabetesdrugs (Natatural Medicine ComprehensiveDatabase, 2003)

● May have additive effects onantihypertensive drugs (Natural MedicineComprehensive Database, 2003)

● May cause nosebleeds, halitosis, andheartburn (Natural MedicineComprehensive Database, 2003)

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Also known as: n-3Fatty Acids, Cod Oil,Fish Oil, Liver Oil,Omega-3 Fatty Acids,Polyunsaturated FattyAcids● Devil’s Claw

(Harpagophytumprocumbens)

● Used to treat joint painand inflammation (Datafrom Skidmore-Roth,2004)

● Loss of appetite,dyspepsia, supportivetherapy of degenerativedisorders of themusculoskeletal system(The Complete GermanCommission EMonographs:Therapeutic Guide toHerbal Medicines, 1998)

● Oral: To stimulateappetite, 1.5 g ofroot per day: 1–4.5 gof root per day forother uses

● Tea: 4.5 g in 300 mLwater boiled for 8hours

● Devil’s Claw lacks the anti-inflammatory properties possessedby NSAIDS (Data from Whitehouse,Znamirowska, & Paul, 1983). TypeII, B

● Devil’s Claw extract is effective intreating pain associated witharthrosis of the hip or knee (Datafrom Wegener & Lupke, 2003), TypeII, B

● Effective in treatment of slight tomoderate muscular pain (Data fromGobel et al., 2001) Type II, B

● Effective in treatment of chronicnonradicular back pain (Data fromLaudahn & Walper, 2001) Type II, B

● Possibly safe when used orally andappropriately for short term. Welltolerated for up to 16 weeks (NaturalMedicine Comprehensive Database, 2003)

● May decrease blood glucose levels indiabetes (Natural MedicineComprehensive Database, 2003)

● May increase bile production in patientswith gallstones (Natural MedicineComprehensive Database, 2003)

● Adversely effects acid-inhibiting drugs,blood pressure therapy, and cardiacdrugs (Natural Medicine ComprehensiveDatabase, 2003)

● Orally, devil’s claw is well tolerated. Mostcommon adverse effect is diarrhea(Natural Medicine ComprehensiveDatabase, 2003)

● Dong Quai (Angelicasinensis)

● Also known as:Chinese Angelica,Dang Gui, Dong Qua,Dong-Quai, TangKuei, Tan Kue BaiZhi

● Used primarily forgynecologic ailmentsincluding menstrualcramps, irregularity,retarded flow, weaknessduring the menstrualperiod, and symptomsof menopause (NaturalMedicineComprehensiveDatabase, 2003)

● It is also used orally asa “blood purifier” tomanage hypertension,rheumatism, ulcers,anemia, andconstipation (NaturalMedicineComprehensiveDatabase, 2003)

● Oral: 3–4 g daily withmeals (NaturalMedicineComprehensiveDatabase, 2003)

● Tea: Extract of dongquai in a dose of 1mL three times daily(Natural MedicineComprehensiveDatabase, 2003)


● Orally, dong quai is well tolerated (NaturalMedicine Comprehensive Database, 2003)

● Theoretically, may increase effects ofwarfarin and may potentiate the effects ofother anticoagulants and antiplateletdrugs (Nutrition in Cancer Care, 2004;Data from Paice et al., 2000)

● Interacts with hormone sensitive cancers/conditions, especially for women withhormone sensitive conditions (NaturalMedicine Comprehensive Database, 2003)

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● Echinacea (echinaceaangustifolia)

● Also known as:American ConeFlower, Indian Head,Purple Cone Flower,Black Sampson,Kansas Snakeroot,Red Sunflower

● Supportive therapy forcolds and chronicinfections of therespiratory tract andlower urinary tract (TheComplete GermanCommission EMonographs:Therapeutic Guide toHerbal Medicines, 1998)

● Externally for poorlyhealing wounds andchronic ulcerations (TheComplete GermanCommission EMonographs:Therapeutic Guide toHerbal Medicines, 1198)

● Also used for migraines,dyspepsia, pain, anddizziness (NaturalMedicineComprehensiveDatabase, 2003)

● Oral: Varyingdosages for variousillnesses (NaturalMedicineComprehensiveDatabase, 2003)

● Topical: Semi-solidpreparationcontaining at least15% pressed juice ofEchinacea purpureaherb

● Tea: Prepared bypouring 8 oz ofboiling water over atea bag and steepingfor 10–15 min(Natural MedicineComprehensiveDatabase, 2003)


● Orally, echinacea is usually well tolerated(Natural Medicine ComprehensiveDatabase, 2003)

● Has been used safely in trials lasting upto 12 weeks when used topically andappropriately (Natural MedicineComprehensive Database, 2003)

● Theoretically, may interfere withimmunosuppressive therapy (Nutrition inCancer Care, 2004)

● May experience allergic reactions, fever,nausea, vomiting, unpleasant taste,abdominal pain, diarrhea, sore throat, anddizziness (Natural MedicineComprehensive Database, 2003)

● Theoretically may increase hepatotoxicityrisk when coadministered withacetaminophen (Data from Paice et al.,2000)

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● Epsom Salt(Magnesium)

● Also known as:Chelated Magnesium,Magnesium Sulfate,Milk of Magnesia

● Used for treating andpreventinghypomagnesemia, mayalso be used orally as alaxative or for treatingsymptoms of asthma(Natural MedicineComprehensiveDatabase, 2003)

● Reduces swelling,muscle ache, and painresulting from bruised orirritated tissues (Datafrom Koenig, 2003)

● Topically, used fortreating infected skinulcers (Natural MedicineComprehensiveDatabase, 2003)

● Reduce neuropathic andother pain when puremagnesium is used IV

● Oral, topical, orparenteral

● Dosages are veryillness specific andvaries (NaturalMedicineComprehensiveDatabase, 2003)

● Tea: Steep 4.5 g ofroot in 300 mL boiledwater for 8 hours atroom temperatureand then strain(Natural MedicineComprehensiveDatabase, 2003)

● Infusion may be used as an adjunctfor reducing analgesic consumptionafter spinal anaesthesia (Data fromApan et al., 2004) Type II, B

● Use as an adjuvant analgesic inpatients undergoing opencholecystectomy resulted in betterpain relief during first postoperativehour but did not significantlydecrease postoperative morphinerequirement (Data from Bhatia et al.,2004) Type II, B

● In a rat model, magnesium amplifiesthe analgesic effect of low-dosemorphine in conditions of sustainedpain (Data from Begon et al., 2002)Type II, B

● Found magnesium can be anadjuvant for perioperative analgesicmanagement to reduceperioperative pain (Data from Karaet al., 2002). Type II, B

● For patients with chronic limb pain,the addition of magnesium to a Bier’sblock with lignocaine improves andprolongs pain relief (Data from Tramer& Glynn, 2002). Type II, B

● The addition of magnesium sulfate tothe opioid fentanyl prolongedanalgesia with no increase of sideeffects (Data from Buvanendran et al.,2002). Type II, B

● 500-mg and 1-g bolus doses of IVmagnesium were well tolerated andpotentially effective in patients withneuropathic pain due to cancer(Data from Crosby, Wilcock, &Corcoran, 2000). Type V, B

● Likely safe when used orally andappropriately.

● Parenteral magnesium sulfate is an FDA-approved prescription product (NaturalMedicine Comprehensive Database, 2003)

● Interacts with malabsorption syndromes,renal disease,excretion-enhancing/reducing drugs, andskeletal muscle relaxants (NaturalMedicine Comprehensive Database, 2003)

● Orally, magnesium can causegastrointestinal irritation, nausea,vomiting, and diarrhea (Natural MedicineComprehensive Database, 2003)

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● Gamma LinolenicAcid (Octadeca-6,9,12-trienoic acid)

● Also known as:Gamolenic Acid, GLA

● Rheumatoid arthritis,hyperlipidemia, heartdisease, syndrome-X,systemic sclerosis,diabetic neuropathy,and cancer prevention(Natural MedicineComprehensiveDatabase, 2003)

● Also used for ADHD,depression, postpartumdepression, chronicfatigue syndrome(Natural MedicineComprehensiveDatabase, 2003)

● Oral: For rheumatoidarthritis 1.1 g daily,for diabeticneuropathy 360 to480 mg per day, forhyperlipidemia 1.5–6g daily (NaturalMedicineComprehensiveDatabase, 2003)

● Control group, placebo study foundGLA may produce mildimprovement in rheumatoid arthritis,but the placebo, olive oil, may haveunrecognized benefits (Data fromBrzeski, Madhok, & Capell, 1991).Type II, B

● Meta-analysis of a small number ofstudies suggest that GLA iseffective treatment for patients withrheumatoid arthritis (Data fromRothman, DeLuca, & Zurier, 1995).Type I, B

● A review of 11 studies found thereis some potential benefit for the useof GLA in rheumatoid arthritis. Morestudies on dosage and duration areneeded (Data from Little & Parsons,2001). Type I, B

● Meta-analysis found moderatesupport for GLA for reducing pain,tender joint count and stiffness. Ingeneral, GLA herbal medicines wererelatively safe to use (Data fromSoeken, Miller, & Ernst, 2003). TypeI, C

● Appears safe when taken in oral doses of2.8 g per day or less for up to a year(Natural Medicine ComprehensiveDatabase, 2003)

● May interact with herbs that havecoumarin constituents or affect plateletaggregation to theoretically increase therisk of bleeding (Natural MedicineComprehensive Database, 2003)

● Taking with other anticoagulants orantiplatelet drugs might increase risk ofbruising and bleeding (Natural MedicineComprehensive Database, 2003)

● Ginger (ZingiberOfficinale)

● Also known as:African Ginger, BlackGinger, Gingembre,Ginger Root,Zingiberis rhizoma

● Motion sickness, nausea,dyspepsia, flatulence,chemotherapy-inducednausea (Natural MedicineComprehensiveDatabase, 2003)

● Can be used for treatingthermal burns (NaturalMedicineComprehensiveDatabase, 2003)

● The essential oil of gingeris used topically as ananlgesic (NaturalMedicine ComprehensiveDatabase, 2003)

● Oral: 550–1100 mgthree times daily(Natural MedicineComprehensiveDatabase, 2003)

● Topical: No typicaldosage

● Extract as effective as placeboduring first 3 months of study, butat end of 6 months, extract groupexperienced better relief from painassociated with symptomaticgonarthritis (Data from Wigler etal., 2003) Type II, B

● Randomized, placebo-controlled,cross-over study found nodifference between ginger extractand a placebo in treatingosteoarthritis of the hip or knee.Ibuprofen was significantly moreeffective than ginger extract (Datafrom Bliddal et al., 2000). Type II,B

● Generally Recognized as Safe Status inthe US (Data from Altman & Marcussen,2001)

● Usually well tolerated when used intypical doses (Data from Altman &Marcussen, 2001)

● Theoretically, may increase the risk ofbleeding, or interfere with diabetic,cardiac, therapy for heart conditions andacid-inhibiting drugs (Data from Altman &Marcussen, 2001)

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● Randomized, double-blind, placebo-controlled, 6-week study foundhighly purified ginger extract had astatistically significantly effect ofreducing pain in patients withosteoarthritis of the knee comparedwith a control group that received aplacebo (Data from Altman &Marcussen, 2001) Type II, B

● Ginkgo Biloba(Ginkgo biloba)

● Also known as:Baiguo, Fossil Tree,Ginkyo, Yinhsing,Kew Tree,

● Used as an antitussiveand expectorant (Datafrom Altman &Marcussen, 2001)

● Fatigue (The CompleteGerman Commission EMonographs:Therapeutic Guide toHerbal Medicines, 1998)

● Thought to increaseblood flow to the brainand to treat/preventAlzheimer’s/dementia

● Oral: 120–240 mgginkgo tablets orcapsules in 2 or 3divided doses (Datafrom Altman &Marcussen, 2001)

● A study of rats looked at severalmodels of nociceptive pain, tail-electric stimulation assay, andcapsaicin-induced paw licking,results suggest Ginkgo bilobaextract may be of clinical value asan anti-inflammatory and analgesicalone or in conjunction with NSAIDs(Data from Abdel-Salam et al., 2004)Type II, B

● May increase bleeding with NSAIDS (Datafrom Abebe, 2002), acetaminophen (Datafrom Abebe, 2002), dipyridamole, andwarfarin (Nutrition in Cancer Care, 2004)

● Ginkgo fruit and pulp can cause rednessof the mouth, rectal burning, and painfulanal sphincter spasms (Natural MedicineComprehensive Database, 2003)

● May increase blood pressure when usedwith thiazide diuretics (Nutrition in CancerCare, 2004)

● Reportedly causes seizures (NaturalMedicine Comprehensive Database, 2003)

● Theoretically, might interfere with theeffectiveness of anticonvulsants (NaturalMedicine Comprehensive Database, 2003)

● Can cause coma when combined withtrazodone (Data from Hu et al., 2005)

● Ginseng (Panaxquinquefolius)

● Also known as:American Ginseng,Ren Shen, Sang, RedBerry

● For symptomatictreatment of: memorydeficits, disturbances inconcentration,depressive emotionalcondition, dizziness, andheadache (TheComplete GermanCommission EMonographs:Therapeutic Guide toHerbal Medicines, 1998)

● Increase physicalendurance and lessenfatigue, to improveability to cope withstress (Data fromSkidmore-Roth, 2004)

● Oral: 0.25–0.5 g ofthe root 2 times daily(Natural MedicineComprehensiveDatabase, 2003)


● No adverse reactions have been reportedspecifically with the use of Americanginseng (Natural Medicine ComprehensiveDatabase, 2003)

● Expected to increase risk of bleeding iftaken with NSAIDS (Data from Abebe,2002)

● Varying dosages for various illnesses(Natural Medicine ComprehensiveDatabase, 2003)

● May interfere with antipsychotic drugs,hormones, MAOs (Nutrition in CancerCare, 2004)

● Ginseng may diminish the effect ofimmunosuppressants (Data fromSkidmore-Roth, 2004)

● May cause anxiety, insomnia,restlessness, headache (Data fromSkidmore-Roth, 2004) 159

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● May reduce concentration of bloodalcohol (Data from Lee, 1987; Data fromLee, 1993) and warfarin (Data from Hu etal., 2005)

● May reduce opioid-induced analgesia(Data from Abebe, 2002)

● May induce mania when usedconcomitantly with phenelzine (Data fromHu et al., 2005)

● Japanese Mint(Mentha arvensis)

● Also known as: Brookmint, Chinese MintOil, Cornmint Oil,Minzol

● Orally to reduceflatulence (NaturalMedicineComprehensiveDatabase, 2003)

● Topically, formusculoskeletal orneuropathic pain,pruritus, and urticaria(Natural MedicineComprehensiveDatabase, 2003)

● Oral: 3–6 drops of oildaily (NaturalMedicineComprehensiveDatabase, 2003)

● Topically: Rubseveral drops of oilon affected areas ofskin (NaturalMedicineComprehensiveDatabase, 2003)

● Inhalation: 3–4 dropsof oil in hot water(Natural MedicineComprehensiveDatabase, 2003)


● Possibly safe when the oil is used orallyor topically and appropriately (NaturalMedicine Comprehensive Database, 2003)

● May worsen bronchial spasms,gallbladder conditions, or liver disease(Natural Medicine ComprehensiveDatabase, 2003)

● No known interactions with drugs (NaturalMedicine Comprehensive Database, 2003)

● Can cause upset stomach when takenorally (Natural Medicine ComprehensiveDatabase, 2003)

● Kava Kava (Pipermethysticum)

● Also known as: Ava,Ava Pepper, AwaRoot, Kava, Yagona

● Treat anxiety disorders,stress, insomnia, andrestlessness (NaturalMedicineComprehensiveDatabase, 2003)

● Orally, for depression,headaches, commoncold, cancer prevention,and musculoskeletalpain (Natural MedicineComprehensiveDatabase, 2003)

● Oral: 100 mg 3 timesa day (NaturalMedicineComprehensiveDatabase, 2003)

● Tea: 2–4 g in 150 mLboiling water for 5–10minutes, then strain(Natural MedicineComprehensiveDatabase, 2003)


● Taken orally, may induce hepatotoxicityand liver failure (Natural MedicineComprehensive Database, 2003; Nutritionin Cancer Care, 2004)

● Banned in Switzerland, Germany, andCanada (Natural Medicine ComprehensiveDatabase, 2003)

● Decreases platelets, lymphocyte, bilirubin,protein, increased red blood cell volume(Data from Skidmore-Roth, 2004)

● Adverse interactions with alprazolam, hepatotoxic drugs, and levodopa (NaturalMedicine Comprehensive Database, 2003)

● Given hepatotoxic effects, avoidconcurrent use with acetaminophen(Natural Medicine ComprehensiveDatabase, 2003).

● Expected to enhance CNS depression/sedation caused by opioids (NaturalMedicine Comprehensive, 2003)

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● Ma Huang (Ephedradistachya)

● Also known as:Ephedra, CaoMahuang, HerbalEcstasy, Sea Grape

● Used for weight lossand enhancing athleticperformance (NaturalMedicineComprehensiveDatabase, 2003)

● Also used for allergies,allergic rhinitis,respiratory tractconditions, colds, flu,fever, headache, jointand bone pain (NaturalMedicineComprehensiveDatabase, 2003)

● Oral: 15–20 mg ofephedra taken up tothree times daily(Natural MedicineComprehensiveDatabase, 2003)

● Tea: 1–4 g in 150 mLboiling water for 5–10minutes and thenstrain (NaturalMedicineComprehensiveDatabase, 2003)


● FDA recently banned ephedra (1/1/2004)● Increases toxicity with beta-blockers,

monoamine oxidase inhibitors, caffeine,and St. John’s Wart (Nutrition in CancerCare, 2004)

● Side effects—insomnia, motorrestlessness, irritability, headaches,nausea, vomiting, disturbances ofurination, tachycardia; in high doses,increase in blood pressure, cardiacarrhythmia, herb dependency (TheComplete German Commission EMonographs: Therapeutic Guide to HerbalMedicines, 1998)

● Reports of serious life-threatening ordebilitating adverse effects, psychosis,and hepatitis (Natural MedicineComprehensive Database, 2003)

● Mustard (Brassica) ● Topically, used as apoultice for bronchialpneumonia, pleurisy,arthritis, lumbago,aching feet, rheumatism,and as a counterirritant(Natural MedicineComprehensiveDatabase, 2003)

● To treat inflammationand joint pain (Datafrom Skidmore-Roth,2004)

● Topical: Prepare amustard plaster;100 g of mustardflour mixed withwarm water to makea paste. Put mustardpaste into a linen andapply for 10 min(Natural MedicineComprehensiveDatabase, 2003)

● Orally: No knownsuggested dose(Natural MedicineComprehensiveDatabase, 2003)


● Has Generally Recognized as Safe statusin the US (Natural MedicineComprehensive Database, 2003)

● Can irritate asthma and the GI tract(Natural Medicine ComprehensiveDatabase, 2003)

● Orally, large amounts of black mustardseed can lead to vomiting, stomach pain,diarrhea, somnolence, cardiac failure,breathing difficulties, coma, and possiblydeath (Natural Medicine ComprehensiveDatabase, 2003)

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● Oil of Wintergreen(GaultheriaProxumbens)

● Also known as:Boxberry, CanadaTea, Deerberry,Mountain Tea,Partridge Berry

● Topically, wintergreenoil is used as acounterirritant formusculoskeletal painand as an antiseptic(Natural MedicineComprehensiveDatabase, 2003)

● May be useful in thetreatment of neuropathicpain (Data fromSkidmore-Roth L, 2004)

● Topical: Apply asgels, lotion, orointments 3–4 timesdaily (NaturalMedicineComprehensiveDatabase, 2003)

● Orally: No knownsuggested dose(Natural MedicineComprehensiveDatabase, 2003)


● Symptoms of toxicity include tinnitus,nausea, and vomiting (Natural MedicineComprehensive Database, 2003)

● May aggravate gastrointestinalinflammation, and increases INR andbleeding if used with warfarin (NaturalMedicine Comprehensive Database, 2003)

● Likely unsafe when used orally formedicinal purposes (Natural MedicineComprehensive Database, 2003)

● St. John’s Wort(Hypericumperforatum)

● Also known as:Amber, DemonChaser, Goatweed,Tipton Weed,Hypericum,Millepertuis, John’sWort

● Depressive moods,anxiety and/or nervousunrest (The CompleteGerman Commission EMonographs:Therapeutic Guide toHerbal Medicines, 1998)

● No studies have yetexamined the effects ofSt. John’s Wort onchronic pain in theabsence of depression(Data from Koenig,2003)

● Also used fordysthymia, exhaustion,fibrositis, headache,heart palpitations,muscle pain, OCD, andneuralgia (NaturalMedicineComprehensiveDatabase, 2003)

● Oral: for milddepression, 300 mgtimes daily (NaturalMedicineComprehensiveDatabase, 2003)

● For long-termmaintenance therapy,300–600 mg havebeen used (NaturalMedicineComprehensiveDatabase, 2003)

● Found no significant effect of St.John’s wort on painfulpolyneuropathy or measures of painprocessing (Data from Sindrup etal., 2001) Type II, B

● Likely safe when used orally andappropriately, short term for up to 8weeks (Natural Medicine ComprehensiveDatabase, 2003)

● May cause serotonin syndrome when usedwith some selective seratonin reuptakeinhibitors (Nutrition in Cancer Care, 2004)

● Increases the effects of triptans andopioids (Natural Medicine ComprehensiveDatabase, 2003)

● Decreases the effects of amitriptyline,barbiturates, digoxin, irinotecan, andprotease inhibitors (Natural MedicineComprehensive Database, 2003)

● Increase side effects of antidepressants,cyclosporine, nefazodone, paroxetine, andsertraline (Natural MedicineComprehensive Database, 2003)

● Side effects can include insomnia,restlessness, anxiety, irritability, fatigue,headache (Natural MedicineComprehensive Database, 2003)

● Avoid with all concurrent chemotherapy● May decrease blood concentrations of

cyclosporine, midazolam, tacrolimus,amitriptyline, indinavir, warfarin,phenprocoumon and theophylline (Data fromHu et al., 2005)

● May cause breakthrough bleeding andunplanned pregnancy when usedconcomitantly with oral contraceptives(Data from Hu et al., 2005)

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● White Willow (Salixalba)

● Also known as:Willow Bark, BayWillow, Reifweide,Violet Willow

● Diseases accompaniedby fever, rheumaticailments, headaches(The Complete GermanCommission EMonographs:Therapeutic Guide toHerbal Medicines, 1998)

● For pain caused byinflammation, muscles,and joint aches (NaturalMedicineComprehensiveDatabase, 2003)

● Oral: 1–3 g driedbark 3–4 times daily(Natural MedicineComprehensiveDatabase, 2003)

● Tea: 1–3 g bark in150 mL of boilingwater, then strain(Natural MedicineComprehensiveDatabase, 2003)

● Willow bark extract may be a usefuland safe treatment for low backpain (Data from Chrubasik et al.,2000) Type II, B

● No efficacy shown for use of willowbark extract in treatment of osteo-and rheumatoid arthritis (Data fromBiegert et al., 2004) Type II, B

● Possibly safe when used orally andappropriately, short term (NaturalMedicine Comprehensive Database, 2003)

● Theoretically, may interact with kidney orliver dysfunction and an anticoagulant/antiplatelets and oral drugs (NaturalMedicine Comprehensive Database, 2003)

● Salicylates are part of the compound thatmakes up aspirin

● Yohimbe(Pausinystaliayohimbe)

● Also known as:Johimbi, Yohimbehe,Yohimbine

● Used to treatimpotence, fatigue,hypertension, diabeticneuropathy, andpostural hypotension(Natural MedicineComprehensiveDatabase, 2003)

● Oral: 15–30 mg daily(Natural MedicineComprehensiveDatabase, 2003)


● Not recommended because of insufficientproof of efficacy and significant adverseeffects (The Complete GermanCommission E Monographs: TherapeuticGuide to Herbal Medicines, 1998)

● Decreases effects of antidepressants,antihypertensives, hyperglycemic agents,and monoamine oxidase inhibitors(Nutrition in Cancer Care, 2004)

● Can cause excitation, tremor, insomnia,anxiety, hypertension, tachycardia,dizziness, gastric intolerance, salivation,sinusitis, irritability, headache, urinaryfrequency, fluid retention, nausea, andvomiting (Natural MedicineComprehensive Database, 2003)

● Higher doses have significantly moreadverse effects (Natural MedicineComprehensive Database, 2003)

NSAID, Nonsteroidal anti-inflammatory drug; FDA, Food and Drug Administration; ADHD, attention-deficit hyperactivity disorder; CNS, Central nervous system; GI, gastrointestinal; HIV, human immunode-ficiency virus; CAM, complementary and alternative medicine; INR, international normalized ratio.*This table includes only herbal supplements, dietary supplements or other forms of CAM therapy were not included.**Refer to Table 1 for study review criteria.

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nderstanding these interactions is complicated byhe fact that the precise composition of many herbalherapies is not fully known. Impurities and lack ofuality testing may result in elements in herb mix-ures that are not intended to be included. Further-ore, patients may be lured into a false sense of

ecurity believing that because herbal therapies arenatural” and are not regulated by the FDA, they arenherently safe. These misconceptions may leaderbal therapy users to believe the therapies areafer than they really are.

atient Care Strategiest is important for nurses to openly communicateith patients who use CAM therapies. With use oferbal therapy on the rise, nurses are encouragedhen taking drug histories to routinely ask for in-

ormation about a patient’s use of CAM therapies Drew & Myers, 1997). It is important to be non-udgmental and to keep in mind that patients mayot consider “natural” substances in the same ways pharmaceuticals. When addressing adverse drugeactions, question possible CAM use, do not dis-ount long-term use of CAM preparations as causingide effects because there may be batch-to-batchifferences, and contact Drug and Poison Informa-ion Centers for information on CAM relating to auspected adverse drug reaction (Drew & Myers,997). Education on what is understood abouterbal therapies may also greatly benefit the patient.ducation about alternative means to treat pain,
uch as medication or another CAM therapy, may a
esults of a national study. JAMA, 279, 1548-1553.

(a1

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lso be suggested. To learn more about CAM, a list ofducational web sites is included (Table 2).

imitationshis study is limited by several methodologic con-traints. Publications were identified using onlyhree search engines; more publications may haveeen identified through more diverse search means.n addition, only publications written in Englishere reviewed. There may be a larger body of re-

earch in non-English speaking countries, where usef herbal therapies is more prevalent. Review andranslation of these articles were beyond our re-ources.

ONCLUSIONhe use of CAM, especially herbal therapies, to reduceain has dramatically increased. Although use has in-reased, scientific evidence of the efficacy of herbalherapies to moderate pain is still limited. This reviewummarized the empirical evidence available for 24erbal therapies and also detailed uses, dosages, routesf administration, and side effects related to theseerbal therapies. This information will help pain man-gement nurses educate themselves about herbal ther-pies to be better equipped to advise and treat patientsho use herbal therapies.

cknowledgments

he authors thank Randy Boston and Ronald Sims for their
ssistance.
EFERENCESAbebe, W. (2002). Herbal medication: Potential for ad-

erse interactions with analgesic drugs. Journal of Clinicalharmacy & Therapeutics, 27, 391-401.Abbot, N. C., White, A. R., & Ernst, E. (1996). Comple-entary medicine. Nature, 381, 361.Abdel-Salam, O. M., Baiuomy, A. R., El-batran, S., & Ar-

id, M. S. (2004). Evaluation of the anti-inflammatory, anti-ociceptive and gastric effects of ginkgo biloba in the rat.harmacological Research, 49, 133-142.Altman, R. D., & Marcussen, K. C. (2001). Effects of a

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Wirth HerbalTher 2005