Misuse and Abuse Misuse and Abuse Issues Related to Issues Related to

Supplements Taken Supplements Taken ClinicallyClinically

Susan McCabe EdD, RNSusan McCabe EdD, RN

Associate ProfessorAssociate Professor

East Tennessee State East Tennessee State UniversityUniversity

Clinical Use of Clinical Use of BotanicalsBotanicals

As old as documented historyAs old as documented history 60,000 year old Neanderthal burial site60,000 year old Neanderthal burial site

With phytobotanicals presentWith phytobotanicals present Writings of Chinese emperor Huang DiWritings of Chinese emperor Huang Di

Relaxing effects of ValerianRelaxing effects of Valerian Assyrian medical practiceAssyrian medical practice

Multiple preparationsMultiple preparations HippocratesHippocrates

Valerian root for UTI’sValerian root for UTI’s Ancient Greek Ancient Greek

St. John’s Wort for insomniaSt. John’s Wort for insomnia

Clinical Use of Clinical Use of BotanicalsBotanicals

Common and growingCommon and growing Multiple Studies with range of 34-44% of Multiple Studies with range of 34-44% of

adults used one or more botanical CAM adults used one or more botanical CAM within the past yearwithin the past year 1 in 4 persons in US use botanical CAMs1 in 4 persons in US use botanical CAMs In developing countries as many as 8 in 10In developing countries as many as 8 in 10

Out of pocket costsOut of pocket costs CAMsCAMs

$21.2 billion$21.2 billion Traditional Medical CareTraditional Medical Care

$29.3 billion$29.3 billionEisenberg, Davis, Ettner, et al.; 1998, JAMA; 280: 1569-1575; MacLennan, et al. 2000; Prev Med; 35(2): 166-73. Nat Cent Comp & Alt Med; 1999, St. John’s Wort Fact Sheet; Pub#Z-02: NIH; Mackenzie, et al., 2003. Altern Ther Health Med. 9(4): 50-56.

St. John’s St. John’s WortWort

1995 = 1995 = $20 $20 millionmillion 1997 = 1997 = $200 $200 millionmillion 1998 = 1998 = $400 $400 millionmillion

Who Is Using CAM’sWho Is Using CAM’s Multiple studies have long supported Multiple studies have long supported

differences between CAM users and differences between CAM users and Non-usersNon-users Common CAM UserCommon CAM User

Age 35-54Age 35-54 Gender femaleGender female Education over high schoolEducation over high school Income mid to upperIncome mid to upper Service utilization higher than non-usersService utilization higher than non-users Use phytobotanical as complementary agent not Use phytobotanical as complementary agent not

alternativealternative Perception of CAM botanicals as less “drug-like“Perception of CAM botanicals as less “drug-like“ Medical conditions not easily treated (chronic pain, Medical conditions not easily treated (chronic pain,

mental health, cancer, HIV)mental health, cancer, HIV)Astin, JAMA. 1998;279:1548-1553 Blais, Maiga & Aboubacar, 1997. Can j Public Health; 88(3): 159-62.; Cauffield, 2000. Pharmacotherapy; 20(11): 1289-94.; Ni, Simile & Hardy. 2002. Med Care; 40(4): 3353-8.; Swartzman, Harsham, Burkell & Lundy, 2002. Med Decis Making; 22(5): 451-2.

Who is Using CAM’sWho is Using CAM’s But there is another group of CAM But there is another group of CAM

users we are just beginning to users we are just beginning to understandunderstand Underserved population groupsUnderserved population groups

Self-assessed low health statusSelf-assessed low health status Limited to no healthcare accessLimited to no healthcare access Self medicating/ self diagnosingSelf medicating/ self diagnosing Almost all for psychiatric related concernsAlmost all for psychiatric related concerns

ExamplesExamples CAM use in IV drug usersCAM use in IV drug users

45% use a CAM regularly45% use a CAM regularly Homeless street kidsHomeless street kids

70% use a CAM regularly70% use a CAM regularlyBreuner, Barry & Kemper, 1998. Arch Pediatr Adolesc Med; 152(11): 1071-5. Gray, et al., 2002; Eff Clin Pract.; 5(1): 17-22.; Manheimer, et al. 2003. Am J Drug Abuse; 29(2): 401-13. ; Wolsko, et al., 2000. J Altern Complement Med; 6(4): 321-26.

Who is Using CAM’sWho is Using CAM’s At risk groups taking medicinal At risk groups taking medicinal

herbsherbs Mentally ill – at risk for mental illnessMentally ill – at risk for mental illness

Three of top ten conditions for which people take Three of top ten conditions for which people take CAMsCAMs

Depression, anxiety, substance abuseDepression, anxiety, substance abuse CAMs used CAMs used more than conventional therapiesmore than conventional therapies

in individuals with anxiety & depressionin individuals with anxiety & depression 60-80% of patients seeing mental health 60-80% of patients seeing mental health

providers self-added CAMs to treatment regimesproviders self-added CAMs to treatment regimes CAM use highest in individuals with unmeet CAM use highest in individuals with unmeet

mental health needsmental health needs No conventional careNo conventional care

Astin, 1998. JAMA, 279: 1548-1553.; Gray,et al., 2002; Eff Clin Pract.; 5(1):17-22.; Kessler, Soukup, Davis, Foster, et al., 2000. Am J Psychiatry;158(2): 289-94.; Sturm, et al. 2001. J Behav Health Res,28(1):81-8

Who is Using CAM’sWho is Using CAM’s CAM Use is also Significant CAM Use is also Significant

among Children among Children 12% - 21% of children age 4-1812% - 21% of children age 4-18 Factors influencing useFactors influencing use

Maternal age < 31 yearsMaternal age < 31 years Parent/caregiver born outside USAParent/caregiver born outside USA Use of CAM by parentsUse of CAM by parents

Most common CAMMost common CAM Herbals = 41%Herbals = 41% High dose vitamins = 35%High dose vitamins = 35%

Ottolini, et al. 2001. Ambul Pediatr.; 1(2): 122-5.; Sawni-Sikand, et al.; 2002. Ambul Pediatr.; 2(2): 99-103.

Do Not Report CAM use to Do Not Report CAM use to ProvidersProviders

66-72% Do not report use66-72% Do not report use Reasons for non-disclosureReasons for non-disclosure

““It wasn’t important for the doctor to know” = It wasn’t important for the doctor to know” = 61%61%

““The doctor never asked” = 60%The doctor never asked” = 60% ““It was none of the doctors business” = 31%It was none of the doctors business” = 31% ““The doctor would not understand” = 20%The doctor would not understand” = 20% ““The doctor would disapprove” = 14%The doctor would disapprove” = 14% ““The doctor would not treat me anymore” = The doctor would not treat me anymore” =

2%2%

Eisenberg, et al. 2001. Ann Intern Med.; 135(5): 344-51.; Sawni-Sikand, et al.; 2002. Ambul Pediatr.; 2(2): 99-103.

Clinical Use of Clinical Use of BotanicalsBotanicals

Widespread use of botanicalsWidespread use of botanicals Little participation with health care Little participation with health care

systemsystem Questions about Questions about

Quality, safety and efficacy of these productsQuality, safety and efficacy of these products Opens potential for misuse and abuseOpens potential for misuse and abuse

Many phytobotanicals easily availableMany phytobotanicals easily available Lots of advise and “thought” availableLots of advise and “thought” available

Little evidence available to providers or patientsLittle evidence available to providers or patients Some phytobotanicals dangerousSome phytobotanicals dangerous Some exoticSome exotic

Substance use migrates from traditional cultural areas of Substance use migrates from traditional cultural areas of useuse

Abuse potential of non-culturally bound use is area of Abuse potential of non-culturally bound use is area of concernconcern

Eisenberg, et al.; 1998. JAMA. 280:1569-75.; Mahady 2001;J Nutr;131(3s):1120S-3S.

Hard for providers to get Hard for providers to get informationinformation

Amount of reliable information is Amount of reliable information is limitedlimited

Few authoritative sources Few authoritative sources Searching databases is challengingSearching databases is challenging

Inconsistent use of controlled vocabulary and Inconsistent use of controlled vocabulary and indexing proceduresindexing procedures

Lack of standardized terminologyLack of standardized terminology Multiple names of several botanicalsMultiple names of several botanicals

Kava, Yaqona, GrogKava, Yaqona, Grog Khat, QatKhat, Qat

Study of health professionalsStudy of health professionals Of those seeking CAM referencesOf those seeking CAM references

26% Internal Medicine/ primary care providers26% Internal Medicine/ primary care providers 15% Psychiatric/ mental health providers15% Psychiatric/ mental health providers

Murphy, et al., 2003. BMC Complem & Altern Med; 3(3): 917-28. Owen & Fang, 2003. J Med Libr Assoc.; 91(3): 311-21.

Framing the IssuesFraming the Issues

Botanical CAM use is highBotanical CAM use is high Users of Cam’s fall roughly into Users of Cam’s fall roughly into

two categoriestwo categories One category is arguably already One category is arguably already

at-risk for substance misuse/ at-risk for substance misuse/ abuseabuse

Hard for providers to get accurate Hard for providers to get accurate information to help, advise, or information to help, advise, or monitor patients CAM usemonitor patients CAM use

Misuse and AbuseMisuse and Abuse SpectrumSpectrum

MisuseMisuse Self medicated/ regulatedSelf medicated/ regulated

Over treated, under treated, wrong treatmentOver treated, under treated, wrong treatment Unintended consequences of useUnintended consequences of use

Unintended synergismUnintended synergism Clinically significant botanical-drug interactionsClinically significant botanical-drug interactions

AbuseAbuse PsychoactivePsychoactive Intentional synergismIntentional synergism Addictive?Addictive?

Difficult to find reliable data on the abuse potential Difficult to find reliable data on the abuse potential of phytobotanicalsof phytobotanicals

Makes rational, evidence-based decision-making Makes rational, evidence-based decision-making difficult in clinical settingsdifficult in clinical settings

International Centre for Mental Health Policy : Hum Psychopharmacol. 2002 Apr;17(3):131-40.

MisuseMisuse Unintended consequences of useUnintended consequences of use

Unintended synergism & clinically Unintended synergism & clinically significant botanical-drug interactionssignificant botanical-drug interactions

ConsequencesConsequences PhysicalPhysical

Hepatotoxicity - potential risk of severe liver Hepatotoxicity - potential risk of severe liver injury with KAVAinjury with KAVA

PsychiatricPsychiatric Neurotoxicity – potential risk of mania from Neurotoxicity – potential risk of mania from

St. John’s wortSt. John’s wort Genetic Genetic

Mutagenic genotoxicity- Betel quid and KhatMutagenic genotoxicity- Betel quid and Khat

(Li JH, Lin LF., 1998Li JH, Lin LF., 1998 Genetic toxicology of abused drugs: a brief review Genetic toxicology of abused drugs: a brief review Nov;13(6):557-65.Nov;13(6):557-65.)

MisuseMisuse Phytobotanicals with no clear addictive Phytobotanicals with no clear addictive

potentialpotential ExampleExample

Vitamin supplements in self-medicationVitamin supplements in self-medication Long History Documented Misuse Long History Documented Misuse Rational for useRational for use

Attempts to compensate for an unhealthy life styleAttempts to compensate for an unhealthy life style Attempts to maximize health or performanceAttempts to maximize health or performance

No evidence of nutritional benefit derived from excess No evidence of nutritional benefit derived from excess consumption of vitamin supplementsconsumption of vitamin supplements

Misuse occurs in the intentional daily intake in excess of Misuse occurs in the intentional daily intake in excess of recommended by various international and national expert recommended by various international and national expert committeescommittees

Potential consequencesPotential consequences Toxicity in vitamins such as vitamin A and vitamin D Toxicity in vitamins such as vitamin A and vitamin D To a lesser extent, vitamin C and nicotinic acidTo a lesser extent, vitamin C and nicotinic acid

Jarvis, Jarvis, 19851985. Vitamin use and abuse.; Bol Asoc Med P R.; 77(4):168-70 ; Briggs & Brigggs, . Vitamin use and abuse.; Bol Asoc Med P R.; 77(4):168-70 ; Briggs & Brigggs, 19771977. The use and misuse of vitamin . The use and misuse of vitamin supplements.; Aust Fam Physician; 6(2):145-7, 151-2. ; Rudman, et al., supplements.; Aust Fam Physician; 6(2):145-7, 151-2. ; Rudman, et al., 19831983. Megadose vitamins. Use and misuse. N Engl J Med. . Megadose vitamins. Use and misuse. N Engl J Med. 25;309(8):488-90; Can Med Assoc, 25;309(8):488-90; Can Med Assoc, 19711971. The use and abuse of vitamin An Can Med Assoc J. ; 20;104(6):521-2. ; Maitai, . The use and abuse of vitamin An Can Med Assoc J. ; 20;104(6):521-2. ; Maitai, 19841984. The craze . The craze for additional vitamin intake. East Afr Med J.; 61(9):661-2. for additional vitamin intake. East Afr Med J.; 61(9):661-2.

Abuse & Psychoactive Abuse & Psychoactive BotanicalsBotanicals

Often about ethnopharmacologyOften about ethnopharmacology Movement of indigenous drugsMovement of indigenous drugs Deritualization for clinical or Deritualization for clinical or

recreational intentrecreational intent Movement of drug without symbolic, religious, or Movement of drug without symbolic, religious, or

other cultural mediators other cultural mediators Hard for providers to get informationHard for providers to get information

Often miss the abuse aspect of clinical Often miss the abuse aspect of clinical presentationpresentation

Phenomenon of modern agePhenomenon of modern age Service access issuesService access issues InternetInternet TravelTravel

Misuse and Abuse: Misuse and Abuse: All Categories of All Categories of

SubstancesSubstances

Psychoanaleptic (stimulant)Psychoanaleptic (stimulant)

Psychodysleptic (hallucinogenic)Psychodysleptic (hallucinogenic)

Psycholeptic (anxiolytic)Psycholeptic (anxiolytic)

Psychoanaleptic Psychoanaleptic (stimulant)(stimulant)

Psychoactive CNS action of Psychoactive CNS action of botanicals botanicals

Psychoanaleptic (stimulant) Psychoanaleptic (stimulant)

UsesUses

Weight reductionWeight reduction

Adaptogenic usesAdaptogenic uses

Chronic fatigue – secondary to MDD Chronic fatigue – secondary to MDD

Adult ADHDAdult ADHD

Guarana (Paullinia cupana)Guarana (Paullinia cupana)

Ma Huang (Ephedra spp.)Ma Huang (Ephedra spp.)

Khat [Qat] (Catha edulis Forssk)Khat [Qat] (Catha edulis Forssk)

PsychoanalepticPsychoanaleptic

GuaranaGuarana Brasilian cocaBrasilian coca Traditional useTraditional use Now InternetNow Internet

Indicated forIndicated for Weight lossWeight loss Herbal viagraHerbal viagra Chronic fatigueChronic fatigue ADHDADHD

Guarana Naturale® is the original guarana powder ready to mix with drinks

Guarana Active® is the original guarana powder but in tablet form, and is available in blister packs of 20 or 60 capsules.

Psychoanaleptic: Ma HuangPsychoanaleptic: Ma Huang Widely promoted as weight Widely promoted as weight

reduction and energy reduction and energy enhancement herbenhancement herb

FormForm Dietary supplements available on web Dietary supplements available on web

sites and in dietary shops sites and in dietary shops Chinese ephedraChinese ephedra

Black CaffeineBlack Caffeine Ma Huang alone or combinedMa Huang alone or combined

With Guarana, St John's wort With Guarana, St John's wort Numerous reports of adverse Numerous reports of adverse

reactions and acute reactions and acute intoxication related to product intoxication related to product use use Resulted in permanent injury and Resulted in permanent injury and

death death 47%, CV; 18% CNS47%, CV; 18% CNS Severe hypertension single most Severe hypertension single most

frequent adverse effect frequent adverse effect Arditti J, Bourdon JH, Spadari M, de Haro L, Richard N, Valli M; Acta Clin Belg Suppl. 2002;(1):34-6

FDA has proposed limits on FDA has proposed limits on the dose and duration of use the dose and duration of use

of such supplementsof such supplements

So…..So…..

NEW….Guarana extract as a replacement for ma huangNEW….Guarana extract as a replacement for ma huang

               

TWINLAB METABOLIFT NO MA HUANG 120 CAPS

Psychoanaleptic: KhatPsychoanaleptic: Khat Stimulating effect of leaves of the Stimulating effect of leaves of the

Khat bushKhat bush Leaves contain a variety of Leaves contain a variety of

sympathomimetics sympathomimetics Alkaloid cathinone is main active principle of Alkaloid cathinone is main active principle of

this drugthis drug Similar in structure and pharmacological Similar in structure and pharmacological

activity to amphetamineactivity to amphetamine Are chewed in several East African Are chewed in several East African

countries and in Yemencountries and in Yemen Since only fresh leaves are active, until Since only fresh leaves are active, until

recently, Khat abuse was almost unknown recently, Khat abuse was almost unknown outside the regions where the plant growsoutside the regions where the plant grows

(Giannini, Miller, & Turner; 1992. J Subst Abuse Treat; 9(4):379-82.Giannini, Miller, & Turner; 1992. J Subst Abuse Treat; 9(4):379-82. )

KhatKhat Recently, however, khat has made its Recently, however, khat has made its

appearance in the United States and in appearance in the United States and in several European countriesseveral European countries U.S., American soldiers stationed in the Arabian U.S., American soldiers stationed in the Arabian

peninsula may be exposed to it because of the peninsula may be exposed to it because of the alcohol interdiction during the first Gulf Waralcohol interdiction during the first Gulf War

Became popular alternative recreational drugBecame popular alternative recreational drug Increasingly prohibitedIncreasingly prohibited

Importation of qat is illegal in France and Importation of qat is illegal in France and SwitzerlandSwitzerland

But legal in the United States, Great Britain and But legal in the United States, Great Britain and most African countriesmost African countries

Growing concern with addictive potentialGrowing concern with addictive potential Extensive literature base of supportExtensive literature base of support

Growing use in Club Drug Scene as a bumper Growing use in Club Drug Scene as a bumper drugdrug

Al-Motarreb, et al., 2002. Phytother Res. 16(5): 403-13.; Krikorian, 1984. J Ethnopharmacol. 12(2): 115-78.; Griffiths, et al., 1997. Br J Psychiatry, 170: 281-4.; Gianninni, et. Al., 1992. J Subst Abuse Treat. 9(4): 379-82.;

Psychodysleptic Psychodysleptic (hallucinogenic)(hallucinogenic)

Psychoactive CNS action of Psychoactive CNS action of botanicalsbotanicals

Psychodysleptic (hallucinogenic)Psychodysleptic (hallucinogenic) Used to achieve mind distortion statesUsed to achieve mind distortion states

VisionaryVisionary PhenethylaminesPhenethylamines Indole alkaloidsIndole alkaloids IsoaxzolesIsoaxzoles

ImageryImagery CoumarinsCoumarins DibenzyopyransDibenzyopyrans

Trance-likeTrance-like ErgolinesErgolines OpiatesOpiates

Delirium-like Delirium-like Tropane AlkaloidsTropane Alkaloids

PsychodyslepticPsychodysleptic Strong religious use in indigenous Strong religious use in indigenous

culturescultures Alter thought, perception, and mood Alter thought, perception, and mood

Seldom produceSeldom produce Mental confusionMental confusion Memory lossMemory loss DisorientationDisorientation

Strong History of Sacramental & Medicinal UseStrong History of Sacramental & Medicinal Use EXAMPLEEXAMPLE CactiCacti

PeyotePeyote San Pedro (T. Terschechii)San Pedro (T. Terschechii) Salvia Divinorum (Mexican mint)Salvia Divinorum (Mexican mint)

Same characteristics fuel non-Same characteristics fuel non-sacramental usesacramental use Common botanicals with wider abuse Common botanicals with wider abuse

Cannabis sativa Cannabis sativa Tabernanthe iboga (Eboka)Tabernanthe iboga (Eboka) Banisteriopsis caapi (Spruce ex Griseb.) Banisteriopsis caapi (Spruce ex Griseb.)

Psychodysleptic: Psychodysleptic: Tabernanthe ibogaTabernanthe iboga

Eboka (Iboga)Eboka (Iboga) West African shrubWest African shrub Long history cultural use of root as stimulantLong history cultural use of root as stimulant Action from complex indole alkaloids derived Action from complex indole alkaloids derived

from tryptaminefrom tryptamine UseUse

Communication with ancestorsCommunication with ancestors Divination of illnessDivination of illness

Internet availabilityInternet availability As aphrodisiacAs aphrodisiac Memory enhancerMemory enhancer To treat active substance abuseTo treat active substance abuse

Psycholeptic Psycholeptic (anxiolytic)(anxiolytic)

Most familiarMost familiar

Most commonMost common

Psychoactive CNS action of Psychoactive CNS action of botanicalsbotanicals

PsycholepticPsycholeptic Used to achieve analgesic or anxiolytic Used to achieve analgesic or anxiolytic

affect affect Valeriana officinalis L. Valeriana officinalis L. Piper methysticumPiper methysticum Betel nutBetel nut

PsycholepticPsycholeptic ValerianValerian

Strong neuropsychiatry useStrong neuropsychiatry use High-affinity dopamine reuptake inhibitorHigh-affinity dopamine reuptake inhibitor

Synthesized in the late 1970sSynthesized in the late 1970s Initially tested in Europe as a potential Initially tested in Europe as a potential

antidepressantantidepressant Common usesCommon uses

InsomniaInsomnia AnxietyAnxiety DepressionDepression

Little data for abuseLittle data for abuse Some reports “hangover effect”Some reports “hangover effect” No reports associated with habituation or abuseNo reports associated with habituation or abuse Rare questionable reports of withdrawal symptomsRare questionable reports of withdrawal symptoms

Krystal & ressler, 2001. CNS Spectrum6(10): 841-47.

PsycholepticPsycholeptic Piper methysticum (kava kava)Piper methysticum (kava kava)

Plant native to the Pacific Island regionPlant native to the Pacific Island region Has been used ceremonial for thousands of years for Has been used ceremonial for thousands of years for

resolution of political and social disputesresolution of political and social disputes Active ingredients are a group of substances Active ingredients are a group of substances

know as kava lactones know as kava lactones Found to have significant analgesic and anesthetic effects Found to have significant analgesic and anesthetic effects

via non-opiate pathwaysvia non-opiate pathways Common usesCommon uses

Natural anxiolytic, comparing favorably in several studies to Natural anxiolytic, comparing favorably in several studies to a number prescription medications, including a number prescription medications, including benzodiazepinesbenzodiazepines

Known to produce severe motor and psychiatric Known to produce severe motor and psychiatric responsesresponses These are not well-understoodThese are not well-understood Include psychotic and severe dystonic reactions Include psychotic and severe dystonic reactions Yet without interruption in normal cognitive processesYet without interruption in normal cognitive processes

Micronesia

Kava Bar

After Hours Hut

KavaKava Action is unclear Action is unclear

GABA-receptor-binding capacity found to occur in some studiesGABA-receptor-binding capacity found to occur in some studies In vitro kava has been found to block norepinephrine uptakeIn vitro kava has been found to block norepinephrine uptake Appears to have some anti-convulsant capabilitiesAppears to have some anti-convulsant capabilities

Mediated by Na+ channel receptor sitesMediated by Na+ channel receptor sites Animal studies show that kava lactones alter neuronal Animal studies show that kava lactones alter neuronal

excitation through direct interactions with voltage-dependent excitation through direct interactions with voltage-dependent ion channelsion channels

Giving rise to kava's muscle relaxant, anesthetic, anxiolytic and Giving rise to kava's muscle relaxant, anesthetic, anxiolytic and anticonvulsive propertiesanticonvulsive properties

Most common side effect of useMost common side effect of use Usually seen only with long-term, heavy usage of the herbUsually seen only with long-term, heavy usage of the herb IncludeInclude

Scaly skin rash called "kava dermopathy." Scaly skin rash called "kava dermopathy." Potentiate other medications such as barbiturates and Potentiate other medications such as barbiturates and

XanaxXanax Raising fast in Club Drug SceneRaising fast in Club Drug Scene

Multiple FormsMultiple Forms

                             

KAVA KAVA

Abuse PotentialAbuse Potential Physical affects of sustained use /abusePhysical affects of sustained use /abuse

Dermopathy characteristic of heavy useDermopathy characteristic of heavy use Abnormally low body mass index (BMI)Abnormally low body mass index (BMI) Low blood lymphocytes Low blood lymphocytes Abnormally high gamma-glutamyl transferase (GGT)Abnormally high gamma-glutamyl transferase (GGT)

These acute effects emerge at average consumption levels of from These acute effects emerge at average consumption levels of from 310-440 g/week of kava powder.310-440 g/week of kava powder.

Economics of abuse well documentedEconomics of abuse well documented Average consumption of 240-425 g/week Average consumption of 240-425 g/week

19% of available cash resources were spent on kava 19% of available cash resources were spent on kava 11% of cash resources leaving the local community economy11% of cash resources leaving the local community economy The proportion of men drinking kava reached 70% and women The proportion of men drinking kava reached 70% and women

62%62% 20% of the population spending unprecedented amounts of 20% of the population spending unprecedented amounts of

time (14 + hours/week) in activities where kava was consumedtime (14 + hours/week) in activities where kava was consumed These parameters may be useful to monitor kava's These parameters may be useful to monitor kava's

adverse health, social and economic effects adverse health, social and economic effects (Clough; 2003, Drug Alcohol Rev.;22(1):43-51.Clough; 2003, Drug Alcohol Rev.;22(1):43-51. )

KAVAKAVA

Increasingly widespread use of Increasingly widespread use of kavakava

Intentional mixing in club drug Intentional mixing in club drug scenescene Further investigation is necessary to Further investigation is necessary to

gain an understanding of its immediate gain an understanding of its immediate neuropsychiatry effects and long-term neuropsychiatry effects and long-term cognitive effectscognitive effects

Cairney S, Maruff P, Clough; Aust N Z J Psychiatry. 2002 Oct;36(5):657-62.

Betel NutBetel Nut Pan Asian problemPan Asian problem

UsesUses Improved concentrationImproved concentration Intestinal parasitesIntestinal parasites Social setting symbol Social setting symbol

Areca catechu (nut) & Piper betel (leaf)Areca catechu (nut) & Piper betel (leaf) Arecoline + Piperine alkaloidsArecoline + Piperine alkaloids

Unclear actionUnclear action Effects thought to be related to the actions of Arecoline Effects thought to be related to the actions of Arecoline However the actual chewing may produce complex However the actual chewing may produce complex

reactions and interactionsreactions and interactions Commonly chewed in the presence of limeCommonly chewed in the presence of lime

Arecoline and guvacoline in Areca nut Arecoline and guvacoline in Areca nut Hydrolyzed into arecaidine and guvacineHydrolyzed into arecaidine and guvacine Are strong inhibitors of GABA uptakeAre strong inhibitors of GABA uptake Piper betle flower or leaf contains aromatic phenolic Piper betle flower or leaf contains aromatic phenolic

compoundscompounds Have been found to stimulate the release of catecholamines in Have been found to stimulate the release of catecholamines in

vitro are also activated by chewingvitro are also activated by chewing Thus, betel chewing may affect parasympathetic, Thus, betel chewing may affect parasympathetic,

GABAnergic and sympathetic functions.GABAnergic and sympathetic functions.

Betel NutBetel Nut Chewing betel chewing mainly affects the central and Chewing betel chewing mainly affects the central and

autonomic nervous systems producingautonomic nervous systems producing Sense of well-being Sense of well-being EEG shows widespread cortical desynchronization indicating a state EEG shows widespread cortical desynchronization indicating a state

of arousalof arousal Euphoria Euphoria Increases plasma concentrations of norepinephrine and epinephrineIncreases plasma concentrations of norepinephrine and epinephrine Increase in heart rate, blood pressureIncrease in heart rate, blood pressure Heightened alertnessHeightened alertness Sweating with increased temperatureSweating with increased temperature SalivationSalivation Hot sensation in the bodyHot sensation in the body Increased capacity to workIncreased capacity to work

Chewing also leads to habituation, addiction and Chewing also leads to habituation, addiction and withdrawalwithdrawal Mechanisms underlying these effects remain poorly understoodMechanisms underlying these effects remain poorly understood Betel nut withdrawal syndrome well documented in Pacific Medical Betel nut withdrawal syndrome well documented in Pacific Medical

LiteratureLiterature

Source: National Science Council, ROC and S. Karger AG, Basel; Chu ;J Biomed Sci. 2001 National Science Council, ROC and S. Karger AG, Basel; Chu ;J Biomed Sci. 2001 May Jun; 8(3):229-36.; Wiesner Med J Aust. 1987 Apr 20;146(8):453.May Jun; 8(3):229-36.; Wiesner Med J Aust. 1987 Apr 20;146(8):453. ) )

Betel QuidBetel Quid An estimated 10% to 25% of the world's An estimated 10% to 25% of the world's

population chews betel quidpopulation chews betel quid Practice is little recognized in the United Practice is little recognized in the United

StatesStates Growing in areas of immigrationGrowing in areas of immigration Groups such asGroups such as

Immigrants and refugees from India, New Guinea, and Immigrants and refugees from India, New Guinea, and Southeast AsiaSoutheast Asia

Physical hazards associated with the Physical hazards associated with the chewing of the various ingredients of the chewing of the various ingredients of the quid include quid include oral canceroral cancer addictive potential as strong as for cigarettesaddictive potential as strong as for cigarettes

ConclusionsConclusions Patients are using herbal remedies for a variety Patients are using herbal remedies for a variety

of health conditions without medical supervisionof health conditions without medical supervision Psychiatric mental health problems are one of Psychiatric mental health problems are one of

the largest reasons people seek botanical CAMsthe largest reasons people seek botanical CAMs Often intentionally do not inform providersOften intentionally do not inform providers Information is hard for providers to obtainInformation is hard for providers to obtain Very little evidence on which to base clinical Very little evidence on which to base clinical

decision makingdecision making Almost no awareness of abuse potential of Almost no awareness of abuse potential of

several commonly used botanicalsseveral commonly used botanicals More research is needed on herbal remedy use More research is needed on herbal remedy use

among patient populations and on outcomes in among patient populations and on outcomes in patients who use herbal remedies to treat patients who use herbal remedies to treat primary health conditionsprimary health conditions

Thank YouThank You