Alternative or Not? A Conversation with Stephen Bent, MD

Raise your hands if the answer to the following question is “yes.”

How many of you have ever taken a vitamin pill, ingested a supplement, drunk an herbal brew or maybe sniffed a little aromatherapy?

I’m seeing a lot of hands raised. No surprise there. Americans are estimated to spend $15 billion annually on alternative therapies.

Now, pretend I’m your doctor. I ask the same question. Well, there are a lot fewer hands raised. Why is that, do you suppose?

Perhaps we’re all a little embarrassed that the doctor will feel slighted. Or maybe it’s because we don’t know why we’re taking what we do, other than because it’s supposed to work. It’s an act of faith, or perhaps one of self-delusion.

But the big question remains. Do we really know what works?

UCSF’s Stephen Bent, MD, is helping us find out.

Bent, an assistant professor of medicine and an affiliate of the Osher Center for Integrative Medicine at UCSF, spends his time – when not seeing patients at the Veterans Affairs Medical Center in San Francisco – researching the safety and efficacy of alternative therapies. His particular interest is herbal remedies.

There are a lot of reasons why his work is important. For one, it might save lives. Remember the deaths linked to ephedra, an herbal ingredient used in weight loss remedies and eventually banned by the FDA? How about St. John’s wort, which interacts with many other drugs, posing risks we can’t imagine or predict?

The key point is this: Herbal remedies are drugs, and we need to respect their ability to do harm as well as their potential to do good.

As for how much good they might do, Bent is the answer man.

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Osher Center for Integrative Medicine

National Center for Complementary and Alternative Medicine (NCAM)

National Institutes of Health

Saw Palmetto No Better Than Placebo for Enlarged Prostate

UCSF News Release, February 8, 2006

Restriction or Ban of Ephedra Supported by First Comparative Herbal Study

UCSF News Release, February 3, 2003

Alternative Medicine

Wikipedia

Natural Standard: The Authority on Integrative Medicine

Natural Medicine Comprehensive Database

 

 

 

Podcast transcript

Jeff Miller: Hello, I’m Jeff Miller. Welcome to Science Café. Today we welcome Steve Bent, assistant professor of medicine at UCSF. He’s also affiliated with the UCSF Osher Center for Integrative Medicine. He also has his clinical practice in internal medicine at the Veterans Affairs Medical Center. Welcome, Steve.

Steve Bent: Thank you.

Miller: I’m very much looking forward to this interview. Steve is our expert in evaluating alternative therapies, and he also has an NIH Career Development award in this area. I’d like if you could explain that as we start, so that everyone knows what exactly that is.

Bent: So a Career Development Award is given by the NIH to help develop a young investigator’s interests in a particular area, and my area of interest was evaluating the safety and efficacy of herbal medicines. And so that’s my primary area of interest, but I also have other areas of interest in alternative medicine more broadly.

Miller: What piqued your interest in this area initially?

Bent: Well, that’s somewhat of a complex question. It dates back to my experiences in high school when I had some fairly progressive thinking teachers who liked to teach about meditation and other kinds of alternative practices. And so I got interested in how those might be helpful for people, and then carried that interest on into medical school and residency, where I was noticing that patients weren’t always feeling very well healed by some of the therapies we offer, and I thought it might be interesting to evaluate whether some of these alternative things couldn’t be helpful for some people.

Miller: So in high school did you know that you wanted to be a doctor?

Bent: I didn’t. I was very interested in a lot of the science-based topics, and sort of followed that line of study, but I didn’t really decide to become a doctor until I got further on in college.

Miller: Well, now that you are one, when you think back about your childhood, is there anything that you see now that pushed you in this direction?

Bent: Well, I had an older brother who went that direction and is a doctor now. And I think I enjoy being around people, I enjoy a practice where I have relationships with patients, and I enjoy science, so I think that mixes well together.

Miller: Did you have any family members who were in the medical field at all?

Bent: Not before my brother, no.

Miller: And you grew up where?

Bent: I grew up in Short Hills, New Jersey, on the East Coast, and went to school in the South, and then out here for residency.

Miller. OK. The last time I checked, I read that about $15 billion is being spent annually by Americans for so-called alternative therapies, and I guess a subset of that would be herbal remedies, which I think I read is around $2.5 billion. What is going on here? Is this self-delusion, self-care, self-control…? How would you define it?

Bent: Well, it’s interesting. I think you may be referring to a landmark study in 1992 that came out of Harvard that showed that people actually spend more out-of-pocket on alternative therapies than they do on traditional medical therapies.

Miller: And before we get to far, let’s define “traditional” and “alternative.” Because depending on your perspective, what is considered traditional or alternative can be variably defined.

Bent: Right. That’s a good point. And there is a variable amount of definition in different studies, but typically alternative medicines are viewed as things that are not commonly offered at hospitals and clinics. Now that’s changed a lot in the past decade, because some clinics have started to embrace these therapies, and there gets to be this sort of funny definition where if something is proven effective, it no longer becomes alternative. But really I think alternative just generally refers to practices that haven’t previously been commonly taught to physicians and provided by medical providers.

Miller: In the West.

Bent: Correct.

Miller: So, again, self-delusion, self-control, self-care?

Bent: So why are so many people using all of these?

Miller: Why? Yes.

Bent: Well, I think if you look at why people are using alternative therapies, most of them are using them for conditions that are not well-treated by traditional medical therapies. So, you find a lot of people with chronic pain, a lot of people with various kinds of mental illness, and other treatments that aren’t… like insomnia, that we really don’t have very many good therapies for. So they go to a traditional doctor a few times, they get the same old ineffective therapies or limited advice and they leave unsatisfied, and so they start looking for other ways of treating things, and that’s where the alternative medicines come in.

Miller: How about the time spent with patients by “alternative therapists”? Have you found there to be a big discrepancy?

Bent: There is. Not surprisingly, visits to alternative therapists are much longer, they’re often in more relaxed settings with more bonding-type relationships between providers and patients, and that may go a long way to explain why some of these treatments are effective.

Miller: Now, UCSF has a reputation of being a pretty reductionist place where we don’t allow too much “woo-woo in the towers,” as someone told me long ago. I wonder, as you approach these scientific studies where you’re evaluating efficacy, if you approach it with the mindset of someone who is out to find evidence that they do not work.

Bent: Well, personally, I try to stay open to everything. I think of myself as being open to anything being potentially effective. But I’m also quite grounded in evidence-based practice, so I really do like to see that any therapy that is touted as effective can be studied in a scientific manner, and if it really is effective it should show effect. So I’m personally open to it, but there hasn’t been a lot of solid scientific evidence for many of these different therapies and that’s one of my goals, to try to bring science to prove that these things work if they really do and then we can provide those benefits to a wider array of people.

Miller: So how do you answer a critic who would say, “Well, you can’t really use Western scientific methods to measure the effectiveness of something like homeopathy”?

Bent: I would argue that for almost any therapy you can design a solid scientific study to prove if it works or not. And I think homeopathy is actually a pretty easy one, because those remedies are very dilute solutions that have no taste and no smell and they’re clear liquids so you can design a placebo quite easily, and that should be a relatively easy one. What’s more difficult is something like acupuncture. It’s hard to create a placebo acupuncture, although people are doing it, and things like individualized Chinese herbal therapies, where providers want to create a therapy that’s specific just to that patient; it’s hard to create a placebo treatment arm to compare to that treatment.

Miller: I mentioned earlier your affiliation with the Osher Center for Integrative Medicine at UCSF. Do you want to take just a minute or two to explain that affiliation and what that Center is all about?

Bent: The Osher Center, which is part of UCSF, has a mission to provide alternative therapies that have evidence of benefit; to provide teaching to medical students, faculty and residents here; and then also to conduct research to further evaluate these therapies. I’m affiliated with them primarily in the research arm and work with many of the faculty there to develop new protocols and evaluate ongoing protocols.

Miller: So the studies that you’re doing here at UCSF are usually in association with the Osher Center?

Bent: Yes, that’s correct.

Miller: Well, I have looked at your list of publications—you have a very long list—but before we go through the individual remedies and treatments, I wonder if there are some general things you might have to say to anyone considering taking a supplement or ingesting an herbal remedy, Chinese or otherwise?

Bent: Well, I think, unfortunately in this country, the herbal remedies and supplements are governed under an FDA Act, called the DSHEA Act, which is the Dietary Supplement Health and Education Act of 1994, and it really provides very limited regulation of these supplements and herbs by the FDA, so that no one is really monitoring or watching these supplements very carefully. Even though they’re on the shelf next to the Tylenol and the ibuprofen, these herbal supplements aren’t being checked by anyone to see if they have a consistent level of ingredients, to make sure that they don’t have contaminants or other problems in their production. So one thing, unfortunately, is that consumers have to be very cautious about the products that they choose and should use ongoing services—there are some web-based services like consumerlab.com, where you can actually check specific products to see if they’re relatively safe. So I think one thing is to be aware of the fact that a lot of these products are not carefully monitored and they’re potentially dangerous for that reason.

The second thing would be I would always advise patients to use these therapies in conjunction with their regular medical providers so they can discuss potential risks and benefits and how they might interact with anything else that they’re doing.

Miller: I think that there have been some studies that say that the willingness of patients to announce what they’re taking is limited.

Bent: Right. And actually most patients don’t discuss these therapies with their providers. I think there’s a feeling almost that the providers might view that as somehow an insult to their Western practice if they’re using something that their providers aren’t giving them. But most providers, I think, are increasingly open to these therapies and would like to know if their patients are using them.

Miller: So disclose, and don’t take anything before checking.

Bent: Disclose. Right. And then I think finally is to try to be mindful of what effects the therapies are having, sort of do your own clinical trial where you try to make very clear how you’re feeling in whatever way you’re treating before the therapy, do a period of using it and see if it has any benefit, and have some realistic expectations and assessment of whether or not the therapy was effective.

Miller: What about efforts that I’ve read within China itself to actually standardize a lot of their herbal remedies and start exporting them in huge amounts? Have you heard anything about that?

Bent: Yes, and the whole concept of standardization, I think, is a good movement, but it’s a very difficult one. If you look at single herb products, let’s say, for example, gingko, you’ll find that there are dozens of different chemical ingredients in that extract. And so if you standardize it usually you pick one thing that you think is the likely effective ingredient, although there’s very little evidence to help you decide which thing that should be. And you try to make sure that each product has the right amount of that particular one thing. But it doesn’t insure that you have the right amount of the other 30 or 40 different chemicals in there, which might also be effective.

Now that’s complicated. But now you take a Chinese herb which has 10 or 20 different herbs in it, each which has 20 or 30 different chemicals, and it’s very hard to really come up with a standardized product.

Miller: Well, we have a long list of remedies and treatments that you have studied, and I’m just going to go through them so that you can tell me what you’ve found, what your studies have shown. Let’s begin with the one I believe that’s the most recent, the saw palmetto study?

Bent: Yes.

Miller: So tell me about that.

Bent: So saw palmetto is an herb that’s grown in the southeastern United States and became very popular in Europe for the treatment of urinary difficulties in men. Most men as they get older have more trouble urinating, and this therapy is widely prescribed in Germany. It’s actually the most commonly prescribed therapy for urinary difficulties in men. There have been about…

Miller: At a standard dose, or was that variable, too?

Bent: No, actually, this is one of the few herbs where there is a consistent dose that’s been used in all prior studies, which is 160mg twice a day.

So there were about 13 prior studies and about half of those found a beneficial effect, although most of the studies had methodological problems that…

Miller: Were these studies in Europe or studies in US?

Bent: They were mostly studies in Europe; in fact, they were all studies in Europe.

So we thought, since this was a promising herb that treats a common condition for which the therapies that are out there are only moderately effective, that this might be a good herb to investigate. So we did a study here, based in San Francisco and with patients who came largely to the VA Hospital here to be enrolled in the study. It was a randomized placebo-controlled trial, where we compared men with this condition—with urinary difficulties—taking saw palmetto or an identical-appearing placebo, and we followed them for a year to see how their symptoms changed.

Miller: And what did you find?

Bent: And we found that there was no difference. There was a small improvement in both groups, but it was identical in the placebo group and the saw palmetto group.

Miller: And did you have any reaction to the published report of this study?

Bent: Well, so the interesting thing about this is that it contradicted earlier findings—earlier findings were largely positive—so the big question is why. Why were our results different? And our main theory is that in the earlier studies—we actually asked many of the investigators in the earlier studies what they used for their placebo, we actually obtained some samples of those placebos, and they were gelatin capsules that contained a vegetable oil. Now saw palmetto is a brown, oily, potent-smelling substance. It smells terrible. You open a can in the room and you can smell it. It’s very hard to create a placebo that looks and tastes and smells like saw palmetto. So we went through great efforts to create a smelly, bad-tasting, brown-appearing placebo that looked just like saw palmetto. And we think the most likely explanation is that prior studies didn’t use an adequate placebo, so patients in the placebo group knew they were getting a fake pill, and the ones who got the saw palmetto gained a placebo effect. In our study, because we had a good placebo, it obscured the placebo effect.

Miller: I want to come back to that placebo effect a little later, but let’s move on to the next one now, something called “longevity treasure,” which was a Chinese herbal remedy, correct?

Bent: Correct.

Miller: For chi.

Bent: Right. So we were approached by a company in China who wanted to market their herbal remedy in this country, and they believed it improved chi in elderly people. Because that’s somewhat of a difficult-to-understand concept—the concept of chi—we asked them what they thought specifically it might help older people with, and they thought it would be energy, memory and sexual function.

So we designed a study—a randomized controlled trial—with specific instruments to measure those outcomes, and we conducted the study in Beijing, China. This study had 240 patients. They were treated for a period of three months, and we measured those outcomes before and after the treatment with the herbal product.

Miller: So what type of questionnaires did you have to measure the effectiveness of the product? Was it strictly reporting, if they were reporting on their sexual function…?

Bent: So, yes, sexual function was a form which they reported and filled out. Memory was a standardized memory test, which was sort of word recall and picture recall. Energy, we used a six-minute walk and a stair climb and some weight-lifting to see how well they physically performed. And then we used a standard measure of overall health, which is called the SF-36, which is 36 questions about how you’re doing overall.

Miller: And was the Chinese company happy with your result?

Bent: Well, there was a very small trend towards an improvement in a measure of depression. It was a small improvement: it was an improvement of two points on the scale. People who are depressed who become not depressed improve about ten points, and in this scale they improved about two points. So the suggestion was that possibly there is some improvement in overall mental well-being, but it was small and because this is just one study we can’t be certain that it wasn’t just by chance.

I don’t think the company was particularly excited, because they were hoping for a more dramatic benefit that would help market their product in this country.

Miller: Let’s talk about these small effects as we go through. I think we had been told, certainly by people who are experts in the area of evaluating alternative therapies, that there is a tendency among the media to pick up the negative headline that slams the product and not to mention this very tiny effect that would get lost as hardly worth mentioning. Do you see that happen more often than not?

Bent: I certainly have heard that criticism, that people feel that media is biased against these products working and they try to pick up on the negative parts of the headline. But my belief is that in order for people to be using an herb or a supplement or any other product, there really ought to be very strong scientific evidence of a benefit. Because if you take a product where there is no evidence, there’s an equal chance that it could be beneficial and harmful. And if we don’t have good evidence that it works, I don’t think it’s right to subject people to the potential risk of a bad outcome. So I don’t think the media has been unfair, I just think that there’s been limited research in establishing the efficacy of many of these therapies.

And I’d also like to offer that I think herbs and supplements, in my mind, are not that alternative. They are similar to drugs. In drugs, when a patient has a problem, we give them a pill and try to make them better. An herb comes in a pill, and most supplements come in pills, too. It’s a way of trying to… a patient walks into your office, give them a package to make them better… I think what really has promise in alternative therapy is giving patients tools to help themselves. Like exercise, like meditation, diets and other therapies where they take a more active role in their overall health.

Miller: But there’s something very appealing about pills, obviously.

Bent: Certainly.

Miller: And, let’s go to the next one: gingko.

Bent: So gingko is one of the herbs that does have fairly strong scientific evidence of efficacy. And it is indicated for patients with dementia, and has been shown in a number of studies to improve measures of dementia. And there aren’t very many good medical therapies to treat this. So I think it is a reasonable thing for patients with dementia to try.

Miller: Are there standards, again, for the production of gingko, so if you buy it at the store you know what you’re getting?

Bent: There is one specific product that has been tested many times. You can find the specific product, again, if you go to some various resources on the internet that help you select which herb you’re going to pick. And I would recommend that when people use herbs or supplements, that they use the exact product that was tested in clinical trials.

Miller: OK. How about kava and valerian?

Bent: So… we did an interesting study with some colleagues here of kava and valerian where we did the whole study over the internet, which I thought was a very interesting technique because you can reach a lot of people very quickly. We actually enrolled almost 400 patients in six weeks, which is quite a dramatic, very fast study. And in this study the patients had both insomnia and anxiety. Kava is primarily targeted to treat anxiety, and valerian is targeted to treat insomnia. And in this study, neither herb was more effective than placebo.

Miller: And, again, that was in 400 patients?

Bent: 400 patients, yes.

Miller: Had there been published studies that indicated otherwise?

Bent: So there actually is…again, kava is another herb where there is fairly strong evidence of efficacy for anxiety. These patients had both anxiety and insomnia, because we were trying to be efficient. Perhaps it doesn’t work as well in patients who have co-existing insomnia. Or the internet population in general—we were surveying people from all over the country—is a different population than in prior studies. So I think there is pretty good evidence that kava works for anxiety. There’s sort of equivocal evidence for valerian for the treatment of insomnia.

Miller: So when you publish these studies, are there attacks from manufacturers?

Bent: Well, you know, most of the manufacturers for herbal products are pretty small shops, and it’s often a struggle to get them to cooperate with the study because they’re just barely making it and for them to commit the resources to devote a supplement to a study is substantial. It’s not like a large pharmaceutical company that funds many trials, ongoing at all times. But, in general, when the studies come out negative, the companies are upset and it gets harder and harder to recruit other companies for future studies.

Miller: But, at least so far, there hasn’t been any indication that sales are dropping anywhere.

Bent: No. Sales figures are difficult to track for herbs. As I said, there’s lots of different small companies, so it’s hard to tell, but it appears that sales, if anything, have been continuing to slowly increase.

Miller: OK, let’s talk about another one that was in the news this year as well as last, ephedra, and then citrus aurantium.

Bent: Yes, so this is an interesting story. Ephedra is an herb that was used in Chinese herbal medicines for centuries, and then became popular in this country a few decades ago as an agent for weight loss and for energy. And it does have some bioactive ingredients; it has something in it called ephedrine, the extract, which is a drug that’s known to do things like increase blood pressure, increase heart rate, and it gives people a feeling of energy, gives them sort of a charge like caffeine would. Unfortunately, because of these effects, it also was associated with many different side effects, and there were some very high-profile athletes who took ephedra supplements and then died. One of them was Cory Stringer, who was a lineman for the Minnesota Vikings, and the other was a pitcher for the Baltimore Orioles named John Beckler. Both died after taking supplements. And so it came under quite a bit of scrutiny from the FDA and was actually the first supplement that was ever banned due to safety concerns for that reason and for a number of different scientific studies showing that it likely did have significant toxic effects.

Miller: And then the citrus aurantium was a replacement, right?

Bent: Yes. So what’s interesting is when that herb was banner, the seven largest manufacturers of ephedra-based supplements immediately switched and took the ephedra out of their supplements and put in another herb, called citrus aurantium. Citrus aurantium has something in it called synephrin. Synephrin is very similar chemically to ephedrine, which was the reason that ephedra was banned. But, again, because the regulation of these products is so limited, the FDA doesn’t really have the power to ask the companies or force them to do studies to document the safety before they’re sold. So, it will take… if citrus aurantium really causes side effects, it will take years if not more to detect the problem and then have the FDA ban it at some later time.

Miller: Is there a particular consumer caution around these remedies that profess to help you lose weight?

Bent: There is no official recommendation in that regard, but in my opinion products that are used as weight-loss aids or energy enhancers commonly have potentially dangerous herbs or often have added pharmaceutical drugs. So some weight-loss products have been found to have diuretics, which cause you to urinate more frequently to help you lose weight. And that’s certainly not the way you want to lose weight.

Miller: OK. St. John’s wort?

Bent: St. John’s wort has been used for a long time, again most popular in Europe, and there have been dozens of studies in Europe, small studies, showing a benefit for depression. Interestingly, there were then two large studies in this country with St. John’s wort, looking at patients with major depression, where it was not effective. What’s even more interesting is that in one of those studies they compared St. John’s wort to a drug called sertraline and to placebo and not only was St. John’s wort not effective, but neither was the pharmaceutical drug, sertraline. So most experts in this area have concluded that St. John’s wort probably is effective for mild depression. It may not be effective for more severe depression. And the one caution about that is that it is also known to interact with lots of different medications, so if you’re taking anything you really ought to be careful when using St. John’s wort.

Miller: The whole drug interaction problem is really largely unexplored for a lot of these…

Bent: That is true. And that’s another reason that I feel like if you are going to use supplements or herbs, you should try to do it in conjunction with a medical provider.

Miller: Echinacea?

Bent: Echinacea is an interesting one. It is used for the common cold, primarily. Why is it so commonly used? Because there are so many colds and there’s really nothing effective for treating the common cold. So everyone hopes for that magic supplement that’s going to shorten their cold from ten days to five or three. The evidence for Echinacea is mixed, but the most recent high-quality studies have not found an effect.

Miller: You mentioned hope, so let’s now talk about the placebo effect. So let’s just say maybe some of these or many of these are not particularly effective—those that are not outright harmful. So if people have a little extra money and they want to take it, if it makes them feel better if it’s evoking the placebo effect, is there anything wrong with that?

Bent: No, not at long as it’s safe. When we did the saw palmetto study, and I was answering questions about that, one of my thoughts about that was, “Gee, I’ve just ruined a perfectly good placebo.” And I think there is something to be said for that. If individuals are taking something that is harmless and they feel better when they’re taking it, why does it matter if there’s scientific evidence of efficacy. And so I try to be open, for my patients who are using various therapies that are relatively harmless; if they’re doing better on it and they feel better on it, then that’s fine.

Miller: So is the placebo effect really the power of the mind?

Bent: Well, there’s a lot of investigation into exactly how it works, but it’s fairly consistent across lots of different types of studies and lots of different types of interventions that when you do something for people that looks like it’s gonna work, if they believe it, it actually makes them feel or perform better.

Miller: Any plans to study the placebo effect, perhaps?

Bent: I have some colleagues at the Osher Center who are looking into that, and looking into the precise sort of chemical mechanisms and neuronal mechanisms of how it actually happens, but I’m not on top of that research.

Miller: We haven’t talked about vitamin supplements at all. I think many people assume that it’s OK to take mega doses of almost everything, but I know that’s not the case. So can we pick out some particularly bad examples of things not to do?

Bent: There have been a lot of studies and people have hoped that they would find some kind of dramatic benefit from various different kinds of vitamin supplementation. There have been some examples recently where high-dose vitamin E, which was originally believed to be helpful for preventing heart disease, has actually been found to be harmful, and increases the risk of bad outcomes. There was also a vitamin called beta carotene, that was believed to potentially prevent cancer, and in smokers it actually increased the risk of cancer. So there is, I think, an increased caution now to sort of routinely recommending that supplements and vitamins are going to help, and I think that’s appropriate and people should only take things that have established evidence of benefit. There has also been a recent review of just the generic multivitamin tablet and whether that’s known to prevent any bad health outcomes, and there’s really very limited evidence that daily use of a multivitamin does anything.

Miller: Well, that should send some shock waves through the industry. But let’s talk about some individual ones. I know the fat-soluble vitamins can accumulate and cause a lot of negative effects, correct?

Bent: If you use high doses—and many people have the belief that if a little bit of some vitamin is good, let’s use tons of it and it’ll be even better—if you use high doses of any particular vitamin you can get toxic effects, yes.

Miller: We haven’t talked about acupuncture much. Have you done any serious studies of that?

Bent: I have not personally been involved in those studies, but I am familiar with much of the research in that area. And there is general consensus that acupuncture is effective for a number of different conditions, primarily for chronic pain and back pain. There was an interesting study that was just published, showing that acupuncture is more effective than standard treatment for chronic back pain. Interestingly, in that same study, sham acupuncture was almost as effective as acupuncture and more effective than…

Miller: OK, let’s stop right there. So what exactly is going on, do you think?

Bent: Well, I think that’s a pretty dramatic representation of the placebo effect. That’s my personal belief of how that works. But the sham acupuncture—you have patients go into the acupuncture room and lie on the table, and there’s a provider there who puts a fake needle up to their skin, it’s like a toothpick, that makes a feeling of a prick in the skin but doesn’t really enter the skin, and they put it at the wrong place, they don’t put it at the actual acupuncture point. And I think the patients have an experience that’s relaxing and believed to be a healing experience, so they leave the room with a nice placebo benefit. Their bodies have relaxed and they feel like they’re supposed to get better and they do get better.

Miller: Well, should any of this be covered by our health plans, if in fact it turns out to have some positive impact?

Bent: Coverage by health plans is an enormous question in many different ways. I think health plans should cover the most effective therapies. If they could cover all things that are proven to be effective that would be great, but I think there has to be some level of triage based on cost.

Miller: What’s next for you in your research areas?

Bent: In this particular area I am interested in the safety of these herbs and supplements, because there’s limited data in that regard. So we’re doing a study now at the VA where we’re examining herb and supplement use among all patients who are taking a blood thinner called Coumadin, because there is some belief that these herbs may interact with that. And that’s one of the medications that has a very narrow safety profile. In other words, if you take too much or too little of it, it can quickly lead to problems. And I think those are the medications we’re most concerned about, ones that just slight variations in the blood dose of those medicines could cause problems for some people.

And then I’m also interested in examining herbs or supplements that are used to treat conditions for which we don’t, as traditional providers, do very well.

Miller: So what would be a list?

Bent: The top one on my list is Valerian, which is used to treat insomnia. I have in my practice so many patients who have trouble sleeping, particularly as they get older, and the therapies that we’ve tried really aren’t particularly effective. So I’m looking for something that might work better. Beyond that, I’m really trying to find therapies that treat important medical conditions for which there’s no existing therapy, so cancer would also be at the top of my list.

Miller: Last question. Is there a place where consumers can go—you’ve mentioned a couple of websites—a clearinghouse where they can get this information easily? Now clearly your studies are all available on the UCSF website, but there’s a lot of information out there and some of it’s contradictory. Is there a single place or maybe a couple of places where they can check?

Bent: There are two very good sources for reviewing herbs and supplements, and those are a company called Natural Standard, which is on the web at Natural Standard, and another one called Natural Medicines Comprehensive Database. Both of those unfortunately are subscription services, so you have to pay a small annual fee. But if herbs and supplements are something that you’re going to be using regularly, it’s a good place to get information and many physicians and medical providers have access to those sites, so if you have specific questions you can ask your provider to look that up for you on those websites.

Miller: Thank you, Steve. This has been very informative. I appreciate you joining me on Science Café.

Bent: Thank you.