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When is a drug not a drug?

Slightly changed from an LA Times letter to the Editor of the Sunday Magazine, regarding an article by Matthew Heller, Healthy, Wealthy, but Wise? The article concerned the controversy about regulation of ephedra and ephedrine, which speed up metabolism, and therefore help weight loss, as well as cause heart problems and even death in some people. I was an ethnobotany (Special Concentrations) major as an undergrad, have a naturopathic doctor’s degree, and a PhD in botany, so herbs and drugs are subjects I feel very strongly about. Hence the rant.

The hoopla over weight loss drugs is just the beginning. There are tens–hundreds–of potentially dangerous things people can take for their “health.” Go into any health food store and take a look at the products that “support vitality.” The flyers, although not the labels, suggest anything from bigger and better Viagra substitutes to cures for old age. The only reason there isn’t more of a problem is that most of them don’t work. If even one of them was as effective as ephedrine for what it claims to do, the National Guard would have to be called out to contain the stampede.

Supplements are called that because they’re supposed to be benign, like food, rather than dangerous, like drugs. Disregarding for now whether such a neat division is real, some natural products are harmless and some aren’t. Dosage is the critical issue. Coffee is natural and rather benign, but a teaspoon of pure alkaloid caffeine would kill you. The milky juice in the central stem of lettuce contains compounds similar to opiates, but salads don’t have the same effect as heroin, and even the most fanatical just-say-no campaigner has never refused a plate of greens.

Ephedrine is no different. A little bit, such as in a tea made of ephedra, is no worse (and maybe no better) than a cup of coffee. However, it is utter bilge to call the pure alkaloid harmless. A statement like that can only be rendered true with a lot of fine print about not exceeding recommended dosages.

If we were all rational, all the time, none of this would be a problem. Labels would never make big promises, and would clearly list the maximum dose and possible side effects. Consumers would never look for hope in a bottle. But even in a perfect world, well-intentioned ignorance could still cause problems. Kava, for instance, is an excellent tranquilizer and generally harmless, yet it turns out to cause liver damage in a few people. This is analogous to the bad effect of aspirin on a few children, and could be dealt with the same way, by providing clear information. However, some people feel that a total ban is the right response.

The appropriate response is a thorny issue. It would be nice to find a middle ground between requiring prescriptions for lettuce and allowing the sale of an herbal Viagra that causes parts to fall off. The Germans have dealt with this issue by demanding proof of safety, but not of effectiveness, which means that people who would like to pay for pink sugar pills, can do so. That is perhaps as it should be.

Who decides on the regulations is also problematic. Science would like to, but it has its own brand of ignorance. In the 1950s, for instance, the official position ridiculed people who took vitamins. After decades of evidence on the benefits of vitamins, including such things as the recent discovery that vitamin B6 helps prevent spina bifida, officialdom takes a different line. Given their track record, I’m not at all sure that the AMA or the FDA deserves to have a lock on what is defined as good or healthy.

Difficult as these issues are, they’d become easier if we could get our minds around a few simple facts. Drugs are drugs, whether packaged by Nature or Merck. Low-dosage drug delivery, whether as camomile tea or coca leaves, isn’t the same as high dosage, whether it’s alkaloids or antibiotics. If we grasp that, a more rational approach becomes possible to the whole issue of drugs, whether legal and illegal, herbal or pharmaceutical, and safe or unsafe.

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