Prescribers and users need to take herbal medicines and their potency seriously. Sylvia Thompson reports
The conviction last week of former GP Pascal Carmody for the sale and supply of prescription-only medicines without a licence has highlighted yet again the dangers to the public of buying medicines and, in particular, herbal medicines without first consulting the appropriate health professional.
The "huge problem" of medicinal drugs being offered for sale on the internet was also raised in the Seanad last week by Junior Health Minister Tim O'Malley.
Suggesting the problem of internet purchasing was getting worse, O'Malley said there were enormous implications for safety, especially regarding vulnerable people with psychiatric illnesses who might start getting medicines on the internet that would not be suitable for them.
The herbal medicines that Carmody was convicted for selling without correct authorisation included St John's Wort, melatonin and an Ultra Diet energiser containing ephedrine. Each of these herbal medicines was made prescription only by the Irish Medicines Board (IMB) in 1993, 1996 and 1999 respectively.
Many people will remember the controversy surrounding St John's Wort when it was made a prescription-only drug. Commonly used in the treatment of mild depression (often self-diagnosed), many people continue to buy it in Britain.
However, the IMB made it prescription only in 1999 because "it was promoted for the treatment of depression. . . which is widely considered a condition requiring clinical intervention".
At that time, the IMB also noted that St John's Wort interacted with medicinal products such as oral contraceptives and anesthetics.
In 2003, the IMB amended its regulations to allow medicine herbalists to "dispense St John's Wort to individual patients as part of a professional consultation".
Medical herbalist Rosari Kingston believes there is a strong need for public education - and indeed education of medical doctors regarding herbal medicines.
"People may take St John's Wort as a cure for depression and then if it doesn't work they draw the conclusion that all herbs don't work, whereas St John's Wort may be appropriate for mild cases of Seasonal Affective Disorder but not for depression linked to the menopause which is linked to different hormones," she explains.
Kingston believes there is a further issue at play here which is that some conventionally trained doctors believe they can "dabble" in herbs. "Many conventionally trained doctors don't realise how potent herbs are. If you look at the cases that have gone to court relating to herbal medicines and homeopathy, you'll see that many of them were practitioners who had their origins in conventional medicine," says Kingston who is a member of the Irish Institute of Medical Herbalists (IIMH).
Anna Maria Keaveney, medical herbalist and IIMH member, adds: "There is a belief out there that anybody can read a book and prescribe herbs but the clinical knowledge of herbs and their effects on different people is crucial."
The use of some herbs in over-the-counter products such as teas, capsules and creams adds to public confusion regarding their potency.
Many people believe that just because herbs are used in cooking and as an ingredient in herbal teas, they are not to be taken as seriously as conventional medicines.
However, once the EU Traditional Herbal Medicines Directive comes into force in this country, some herbal teas may even be removed from the market if their potency is deemed inappropriate for general consumption.
Dr Brendan Fitzpatrick is a conventionally trained GP who uses some homeopathic and herbal remedies in his practice. He admits that the public may not have a good understanding of the differences between homeopathy and herbal medicine.
"Herbal medicines tend to be in stronger concentrations and one has to be careful about the length of time they are used, whether they interact with medications or have an additional effect to conventional medicines," he explains.
Dr Fitzpatrick views the health professional's role in seeing patients, diagnosing their condition and reviewing their progress when given treatment as paramount.
Even herbal preparations such as Echinacea should not be taken for long periods without a break, according to Dr Fitzpatrick.
Medical herbalists believe that it is essential that an expertise in herbal medicine is established in the community and that medical herbalists and conventional doctors establish ongoing dialogue about herb/drug interactions.
Through its website, The Irish Institute of Medical Herbalists (www.iimh.org) answers queries about herb/drug interactions.
Meanwhile, the IMB will continue to be on the alert for the unlicensed sale of medicines - herbal or conventional.
In relation to last week's case (Carmody was fined €1,500, given a 10-month suspended sentence and ordered to pay €10,000 in costs and expenses), the IMB's chief executive, Pat O'Mahony, said, "We hope this verdict sends out a clear message that the IMB will take the necessary legal action to prevent risks to public health and breaches of medicinal legislation."
How to discourage self-prescribing
Empowering patients to understand their illnesses by asking health professionals informed questions, looking for second opinions and learning the value of suggested treatments is all very well. But, when it comes to self-diagnosing anything other than minor complaints and self-prescribing medication, the boundary between patient and professional has been crossed.
Last week's court case against former Co Clare GP Pascal Carmody was not the first and will certainly not be the last of unlicensed medicines being supplied to shops, pharmacies and doctors. The more insidious worldwide practice of selling medicines over the internet also gained attention last week in the Seanad.
During the Seanad debate, Senator Brendan Ryan (Labour) said he would like to see a study carried out into the market for internet drugs in different countries and whether the market varied according to the price of prescription drugs in the public health service.
"I wonder is there any evidence that where people have access to comparatively cheap prescription medicines through their public health services you find a decline in demand and, by contrast, you find a huge demand in a country like the US which probably has the cruellest health service in the world," said Senator Ryan.
Addressing the issue, Dr Tim O'Malley said he had a meeting with the Irish Medicines Board (which is very aware of the problem), the Irish Patients' Association (IPA), the Revenue and the Garda on the matter.
Stephen McMahon of the IPA later told The Irish Times that the IPA would issue a report to the Department of Health on the dangers of medicines on the internet within the next two weeks.
"There will be two strands to this report - the first will be one of building the public awareness about the dangers of going online to buy medicines and the second will deal with what we need to do to counter the ever-growing market in these products," said McMahon.