Herbals and Cannabis Study Notes

Herbals and Cannabis - NURS 615

Student Learning Objectives

  • Demonstrate an understanding of concepts related to complementary and alternative therapies (CAM).

  • Identify current, evidence-based sources for understanding and analyzing the efficacy of herbal products and other CAM techniques.

  • Identify common herbals used by the lay public along with drug-drug interactions and other concerns, especially when combined with traditional western medicines.

Overview

  • History of Herbal Medicine

  • Definitions

  • Herbal Safety

  • Evidence for Use of Herbs

  • Herbal Therapy

  • Herbal Preparations

  • Common Herbs for Medicine

  • Considerations for the Advanced Nurse Practitioner (ANP) Prescriber

History of Herbal Medicine

  • Ancient Usage: Ancient Egyptians utilized many herbal remedies.

  • Greco-Roman Tradition: Herbal therapies were based on the principle of the four humors.

  • Growth in the U.S.: Significant growth in the use of herbal medicine in the last 20 years.

    • Perception of Safety: Belief that herbal medicines are safer and have fewer harmful side effects.

    • Self-medication: U.S. patients often self-medicate and frequently do not inform their healthcare providers about their use of herbal products.

Herbal Medicine Definitions

  • Phytomedicine: The practice of using plants or parts of plants to achieve a therapeutic cure.

    • Definition: An herb is any plant part or plant used for its therapeutic value.

  • Pharmacognosy: A branch of pharmacology that studies the chemicals from plants, molds, fungi, insects, and marine animals for their medicinal value.

Herbal Medicine

  • Western Herbal Medicine: Classified according to therapeutic properties and constituents of the plant.

  • Chinese Herbal Medicine: Principles based on the plant’s growth cycle, characteristics, and the individual’s underlying condition.

    • Concepts: Health is sustained by free flow of energy (Qi).

    • Key Principles: Yin and Yang, concepts of wind, dampness, heat, cold, dryness, and wetness.

    • Classification of Herbs: By energies, quality, season, tastes, directions, and actions on the body.

Ayurvedic Medicine

  • Definition: The study of life; "ayur" means life and "veda" means to study; recognized as the oldest form of medicine.

  • Application: Herbs are used in massage oils, food, aromatherapy, and taken orally.

Ayurvedic Medicine (continued)

  • Tridosha System: Consists of three doshas:

    • Vata (air/ether): Corresponds to the nervous system and movement.

    • Pitta (fire/water): Represents transformation, circulation, warmth, and digestion.

    • Kapha (water/earth): Represents nourishment, solidity, and the formative aspects of tissues, fluids, and bones.

  • Therapy Goal: Counteract excess or deficiency with food and spices, then specific herbal therapy.

Herbal Safety for the APRN

  • Guidelines Established: By the American Herbal Guild for safe herbal practice.

  • Variations in Components: Significant variations based on growing conditions exist.

  • Regulation: In the United States, herbs are classified as food and are not regulated by the FDA.

Evidence for Use of Herbs

  • Natural Standard: Evidence-rating method graded A to F;

    • “A” indicates strong scientific evidence of the benefit, while “F” indicates strong negative scientific evidence.

    • Reference: www.naturalstandard.com

  • Healthnotes' The Natural Pharmacy: Evaluates current state of evidence regarding herbs and nutritional supplements.

  • Rakel Evidence vs Harm Scale: Utilizes Strength of Recommendation Taxonomy (SORT) to rate scientific evidence of integrated medicine treatments.

  • Cochrane Database of Systematic Reviews: Produces systematic reviews of evidence by the Cochrane Collaboration.

  • German Commission E Monographs: German authorities evaluate efficacy and safety of herbs and supplements.

  • American Botanical Council: A nonprofit educational and research organization devoted to the science of herbal medicine.

Evidence-Based Model (EBM)

  • Definition: EBM is the gold standard of care.

  • Evaluating CAM Therapies:

    • Ayurvedic or TCM uses whole plant properties synergistically with patient symptoms.

    • Scientific methods are limited in measuring practices not physically defined by Western science.

    • Outcomes in TCM and Ayurvedic medicine are empirically rather than experimentally measured.

    • Example: Changes in a person’s tongue coat or pulse.

Western Herbs and Their Uses

  • Anxiety: Kava, mugwort, wormwood, pill-bearing spurge, and passion flower.

  • Insomnia: Mugwort, melatonin, valerian, passion flower, and chamomile.

  • Depression: St. John’s wort.

  • Confusion and Forgetfulness: Ginkgo, ginseng, and chaparral.

  • Gastrointestinal Issues:

    • Constipation: Cascara, castor bean, and senna.

    • Indigestion and Heartburn: Caraway, licorice, and papaya enzyme.

  • Pain Management:

    • Arthritis: Glucosamine and chondroitin.

    • Muscle and Ligament Pain: Wintergreen oil and liniments.

    • Headache and Migraine: Feverfew.

Traditional Chinese Medicine (TCM)

  • Holistic Approach: Effective when combined with other TCM therapies such as acupuncture, manipulative therapies (tui na), food, and movement (qi-gong and tai ji).

  • Four Energies: Cold, hot, warm, and cool.

  • Five Flavors: Pungent (or acrid), sweet, sour, bitter, and salty.

  • Four Movements: Upward, downward, floating, and sinking.

  • Meridians: Energy pathways that correspond to the 12 organ systems, allowing herbs to enter and circulate.

Traditional Chinese Herbs

  • Classification: Based on ability/action to clear heat, stop wind, or reduce fire.

  • Herbal Formulas:

    • Classic formulas incorporate various herbs working together.

    • Categories of herbs include: King herbs, Minister herbs, Assistant herbs, and Guiding herbs.

Traditional Chinese Herbs (continued)

  • Administration Forms:

    • Decoctions, powders, tablets.

    • Key Rules: Consider timing, temperature, and avoid taking the herbal formula with tea.

Ayurvedic Herbs

  • Tridosha Theory: Tastes are a powerful tool in treatment.

  • Six Basic Tastes: Sweet, sour, salty, pungent, astringent, and bitter.

  • Food Healing:

    • Sweet, sour, and salty foods reduce Vata.

    • Bitter, pungent, and astringent foods enhance Vata.

    • Astringent, bitter, and sweet foods reduce Pitta.

    • Sour, salty, and pungent foods enhance Pitta.

    • Bitter, pungent, and astringent foods reduce Kapha.

    • Sweet, salty, and sour foods enhance Kapha.

Herbal Preparations

  • Bolus: Suppository inserted into the rectum.

  • Compress and Fomentation: Applying herbs externally to the body.

  • Liniments: Warming herbal extracts rubbed into the skin.

  • Oils: Concentrated extracts used for massaging.

  • Capsules or Pills: Common oral forms of herbal medicine.

  • Poultices and Plasters: Topical applications of herbs applied moist, left on for 12 to 20 hours.

  • Mixtures for Smoking: Herbs intended for smoking.

  • Teas: Strongest medicinal effect among preparations.

  • Tinctures: Herb extracts preserved in alcohol/vinegar.

Complementary, Alternative, and Integrative Therapies (CAM)

  • Definition: Healthcare practices not considered part of conventional allopathic medicine.

    • Complementary Medicine: Nonconventional methods used alongside conventional treatments.

    • Alternative Medicine: Nonconventional methods used instead of conventional treatments.

  • Regulation: CAM therapies regulated by FDA for manufacturing purity and accurate labeling.

Natural Products and Herbals: Aloe, Aloe Vera

  • Uses: Heals burns, decreases pain, softens skin; taken orally as a laxative (associated with fluid and electrolyte side effects).

  • Adverse Drug Reactions (ADRs): Hypersensitivity, fluid and electrolyte imbalances.

  • Interactions: With digoxin, diuretics, corticosteroids, and antiarrhythmics.

  • Monitoring: Renal functions; use cautiously in patients with renal issues.

Natural Products and Herbals: Black Cohosh

  • Uses: Acts as an estrogen substitute (beneficial for menopause).

  • ADRs: GI distress, headaches, weight gain.

  • Interactions: With antihypertensives, estrogen, insulin (may increase the effect).

  • Monitoring: Pregnancy tests, breast exams/mammograms.

Natural Products and Herbals: Echinacea

  • Uses: Immune system stimulant; anti-inflammatory; applicable topically for skin and wounds.

  • ADRs: Bitter taste, GI upset, fever; hypersensitivity in individuals with allergies to ragweed or daisies.

  • Interactions: Decreases the effectiveness of TB, HIV, or cancer medications if used for longer than 6 months.

  • Monitoring: Regular inquires regarding use.

Natural Products and Herbals: Feverfew

  • Uses: Inhibits platelet aggregation; blocks factors causing migraines (not for acute treatment).

  • ADRs: GI irritation, post-feverfew syndrome with abrupt withdrawal (symptoms include agitation, headache, fatigue, insomnia, joint pain).

  • Interactions: With digoxin, diuretics, corticosteroids, and antiarrhythmics.

  • Monitoring: Inquire about use of NSAIDs, heparin, or warfarin; must be stopped 2 weeks before planned surgery.

Natural Products and Herbals: Garlic

  • Uses: Allicin (derived from crushed garlic) blocks LDL, raises HDL, lowers triglycerides, suppresses platelet aggregation; vasodilating effects (reducing BP).

  • ADRs: GI irritation, bad breath, and body odor.

  • Interactions: With NSAIDs, heparin, and/or warfarin (risk of increased bleeding); reduces levels of certain HIV medications.

  • Monitoring: Regular inquiries regarding concurrent usage of NSAIDs, heparin, or warfarin.

Natural Products and Herbals: Ginger Root

  • Uses: Useful for vertigo, nausea/vomiting (N+V - including morning sickness and post-surgical), increases GI motility, reduces GI spasms, has anti-inflammatory effects.

  • ADRs: Use cautiously in pregnancy (high doses may cause uterine contractions); CNS depression and dysrhythmias at excessive doses.

  • Interactions: With NSAIDs, heparin, and/or warfarin (risk of increased bleeding); enhances hypoglycemic effects of antidiabetic medications.

  • Monitoring: Inquire about concurrent use of NSAIDs, heparin, or warfarin; monitor for hypoglycemia.

Natural Products and Herbals: Ginkgo Biloba

  • Uses: Promotes vasodilation, relieving pain associated with occlusive arterial disease; reduces bronchospasm; potentially improves blood flow to the brain (memory improvement unproven).

  • ADRs: GI upset, headache, lightheadedness.

  • Interactions: With NSAIDs, heparin, and/or warfarin (risk of increased bleeding); should not be used by individuals with seizure disorders as it lowers seizure threshold and interferes with antiepileptic medications.

  • Monitoring: Inquire about concurrent use of NSAIDs, heparin, or warfarin; question clients about the use of tricyclic antidepressants (increased seizure risk).

Natural Products and Herbals: Glucosamine

  • Uses: Stimulates cartilage and synovial fluid production; decreases joint/cartilage inflammation and degradation; treats osteoarthritis, often used alongside chondroitin.

  • ADRs: Mild GI upset; caution required in those with shellfish allergies.

  • Interactions: Avoid use with NSAIDs, heparin, and/or warfarin (risk of increased bleeding).

  • Monitoring: Inquire about concurrent use of NSAIDs, heparin, or warfarin; monitor for hypoglycemia.

Natural Products and Herbals: Kava

  • Uses: Acts on GABA receptors in the CNS, promoting sleep, reducing anxiety, and fostering muscle relaxation without sedation.

  • ADRs: Dry, flaky skin; jaundice; potential hepatotoxicity at high doses.

  • Interactions: Sedative effects can intensify when taken with CNS depressants.

  • Monitoring: Inquiry about use of other CNS depressants; monitor liver function.

Natural Products and Herbals: St. John’s Wort

  • Uses: Influences serotonin production, providing antidepressant effects (mild depression); analgesic effect for pain/inflammation; topical anti-infective usage.

  • ADRs: Mild dry mouth, lightheadedness, constipation, GI upset, photosensitivity (risk of rash).

  • Interactions: Can cause serotonin syndrome if combined with other serotonergic drugs (cocaine, amphetamines); reduces effectiveness of OCPs, cyclosporine, warfarin, digoxin, CCBs, steroids, HIV medications, and anticancer drugs.

  • Monitoring: Inquire about ingestion of other serotonergic medications; educate patients about risk of photosensitivity.

Natural Products and Herbals: Saw Palmetto

  • Uses: Reduces prostatic hyperplasia.

  • ADRs: Mild GI effects; classified pregnancy category X.

  • Interactions: Additive effects with finasteride; interacts with antiplatelet and anticoagulant medications.

  • Monitoring: Inquire about PSA tests and concurrent use of NSAIDs, ASA, heparin, and warfarin.

Natural Products and Herbals: Valerian

  • Uses: Increases GABA activity, promoting sleep and reducing anxiety; effects similar to benzodiazepines.

  • ADRs: Drowsiness (effects increase over time), lightheadedness, potential for depression; risk of physical dependence.

  • Interactions: Use cautiously in clients with mental health disorders; avoid in pregnancy and lactation; can potentiate CNS depressants.

  • Monitoring: Inquire about concomitant use of CNS depressants; monitor for drowsiness impacting the operation of heavy machinery.

Natural Products and Herbals: Cannabis

  • Uses:

    • Qualifying conditions: Cachexia/anorexia, chemotherapy-induced nausea and vomiting, pain (related to cancer or rheumatoid arthritis), chronic pain (fibromyalgia), neuropathies (from HIV/AIDs, MS, or diabetes), spasticity (from MS or spinal cord injury), epilepsy, sleep disorders, and PTSD.

  • ADRs: Tachycardia, increased appetite, drowsiness, dizziness, hypotension, urinary retention, dry mouth/dry eyes, hallucinations, paranoia, anxiety, impaired attention/memory; potential exacerbation of chronic respiratory disorders and cardiac diseases; concerns regarding dependency and cancer risks.

  • Interactions: Additional interactions similar to those previously mentioned.

  • Monitoring: Do not recommend in jurisdictions where not allowed; ensure the patient has a Medical Marijuana Program (MMP)-designated caregiver to assist with medical use. FDA approved dronabinol and nabilone for nausea and anorexia in cancer treatment; cannabidiol approved for seizures.

Endocannabinoid System

  • Cannabinoid Receptors: Two main types -

    • CB1 Receptors: Located in the central nervous system (CNS).

    • CB2 Receptors: Located in immune cells and tissues.

Considerations for the APRN

  • Respect patients' rights to choose their therapies.

  • Engage in continuous education regarding CAM therapies.

  • Comprehend known risks associated with CAM therapies.

  • Make referrals to trained/certified CAM providers where appropriate.

  • Maintain an open and inquisitive mind towards CAM therapies.

References

  • ATI Nursing. (2019). RN Pharmacology for Nursing Review Module Edition 8.0.

  • Woo, T. M., & Robinson, M. V. (2020). Pharmacotherapeutics for Advanced Practice Nurse Prescribers. F.A. Davis Company.