Naturopathic Medicine Primer

Naturopathic medicine is a branch of health care that focuses on the prevention and treatment of disease using modalities such as botanical medicine, nutrition, physical medicine and hydrotherapy which promote the body’s inherent ability to heal. While pharmaceuticals are used by naturopathic doctors (NDs), they are usually not the first line approach. NDs study botanical medicine extensively during their four-year medical school training, and many graduate at the level of registered herbalists due to the comprehensiveness of the botanical curriculum. 

Botanical medicine has been influenced by traditions used throughout the centuries all over the world in places like Northern Europe, India, China and North America. NDs are trained to formulate botanical medicine specific to the individual, and while there is no one way to formulate, there are guiding principles that govern naturopathic botanical medicine formulation.

The Six Principles of Naturopathic Medicine

In order to understand how NDs formulate botanical medicine, it is necessary to understand the philosophy of naturopathic medicine which is governed by six guiding principles:

The Therapeutic Order of Naturopathic Medicine

Keeping in mind the six principles of naturopathic medicine, NDs have created guidelines for treating patients called “The Therapeutic Order of Naturopathic Medicine.” NDs generally try to start with treatments which tend to be lower force interventions with fewer or no side effects (see numbers 1-5 below). Higher force interventions (see numbers 6-7 below), such as pharmaceuticals, may be required at some point during the treatment, but these often come with unwanted side effects and so often are used only once lower force interventions have not succeeded. Botanical medicine can fall anywhere along the therapeutic order depending on what herbs are being used and at what concentrations. The therapeutic order of natural medicine is:^[2]

1. Establish the foundations for optimal health: remove obstacles to cure, assess nutrition, exercise, sleep, access to nature and social support
2. Stimulate the self-healing mechanisms: utilize the body’s inherent ability to heal
3. Support & restore weakened body systems: aid damaged organ systems to heal
4. Address physical alignment: restore structural integrity
5. Natural symptom control: use natural substances, such as herbs and supplements, to palliate symptoms
6. Synthetic symptom relief: use drugs, such as pharmaceuticals, to palliate symptoms
7. High force interventions: use modalities such as surgery or chemotherapy to suppress a pathology

Principles of Botanical Formulation

The basic tenets of botanical formulation are guided by the six principles of naturopathic medicine as well as the therapeutic order. Creating the right formula for each patient is a unique endeavor and is based not only on a patient’s symptoms and diagnoses, but also the totality of the whole person. Selecting which herbs to use in a formula requires knowledge of each herb, as well as how combinations of herbs work together and what proportions to use in a formula.

Selecting the herbs

Herbal Actions

The knowledge of hundreds of years of herbalist tradition is contained in the herbal materia medica, a collection of profiles on each herb detailing actions, contraindications, and other information gathered over the centuries.^[3] Plants produce primary metabolites (proteins, lipids and carbohydrates) and secondary metabolites (molecules, called constituents, that are produced in response to the environment).^[4] Examples of constituents include: tannins, flavonoids, volatile oils and alkaloids, to name just a few.^[4] Constituents are molecules which give the herbs their medicinal properties and actions, and are one of the main criteria in selecting herbs for a particular formula. For example, if the patient is suffering from a bacterial infection, herbs with antibacterial properties will be selected. If the patient is suffering from inflammation, an anti-inflammatory herb will be selected. Thus, it is vital to understand the both the phytochemistry of a plant and the pharmacology of how that plant interacts with the human body in order to formulate a safe and effective formula.^[5] Below is a list of some of the properties of herbs and examples of herbs with those actions. Most herbs have numerous constituents and properties, and therefore may be listed more than once in the table below.

Herbs and Organ Systems

Many herbs are associated with organ systems and are used to address a variety of problems within that system. So, in addition to creating formulations based on the actions of an herb, using herbs associated with particular body systems and related conditions is quite common. Below is a small sample of herbs organized by body system and condition.

Part of the herb

It is also critical to know which part of the herb to use, as different parts of the plant can contain considerably different constituents that have very different effects. For example, the root, the seed, and the leaves of Urtica dioica (stinging nettle) are all used medicinally, but for three different health problems. The root is a mild aromatase inhibitor and is used in treatment of benign prostate hyperplasia, the leaf is a diuretic and is used to reduce edema, and the seeds are nephroprotective and nutritive.^[6] Another example is Taraxacum officinalis (dandelion) where the leaf is used to improve kidney function, the flowers are a mild analgesic, and the root is used to improve liver function.^[4]

Solubility of herbs

Solubility is a critical component of botanical medicine. In order to extract the correct constituents with the actions you require, it is necessary to understand the phytochemistry of the plant and the solubility factors.^[8] The menstruum is the solvent or base in which you are going to extract the constituents of the herbs you select, although sometimes no menstruums are needed if you are going to grind up the whole herb and put it in capsules. The most commonly used menstruums include:

• water (teas)
• alcohol or alcohol + water (tinctures)
• glycerin (glycerites)
• oil (oil infusions)

The menstruum is selected primarily based on which constituents will be soluble in it. For example, hydrophilic constituents will be soluble in water, while lipophilic constituents will be soluble in oil. Below is a solubility chart by constituent which shows what the best menstruum for each constituent is. Note that this is a small representation of the many constituents that exist in plants and that are used medicinally.

Constructing a formula

Different herbalists and NDs follow a variety of protocols for constructing a formula, but most botanical medicine formulations will contain multiple herbs. Herbs work in concert together and using only one herb is akin to trying to have a nutritious meal with only food type. Whichever formulating protocol is used, the percentage of herbs must always add up to 100%. There are some doctors who take the approach of using a large number of herbs in small percentages: for example, 10 different herbs at 10% each. But a more common approach amongst NDs is to use the following formula protocol as a basic guideline (although not every formula will have every type of herb listed):

Dosing

Deciding on the most effective and safest dosing of a formula requires many years of expertise. Important factors include:^[6]

• Age of patient: lower doses are given to children and the elderly
• Strength of the herbs: certain herbs are considered “low dose” and should be used in only very small concentrations in a formula. (Examples include: Atropa belladonna, Bryonia diocia, and Datura stramonium)
• Form of the herb and menstruum: different extractions have different concentrations of herbs, so the higher the concentration, the lower the dose.
• Acute or chronic condition: generally acute conditions are dosed higher for shorter periods of time where chronic conditions are dosed lower but long term.

As with pharmaceutical dosing, it is important to dose strong enough and long enough for the medicine to work. If a person with an infection was given just one antibiotic pill, as opposed to a ten-day course taking three pills a day, the antibiotic would not be effective in getting rid of the infection. The same goes for botanical medicine, which means knowledge of correct dosing is critical in terms of getting the desired results.

Contraindications & Safety

Not all herbs or menstruums are safe for all patients to use. If your patient is a recovering alcoholic or has religious objections, using an alcohol-based tincture is inappropriate, and alternatives like glycerites or teas should be considered. Another important factor is whether or not a patient is pregnant. Just like pharmaceuticals, certain herbs are considered unsafe in pregnancy, while others are considered safe only during certain times of a pregnancy. It is critical to know the safety profile of each herb and to formulate accordingly.

Another critical consideration is knowing if any of the herbs will affect medications that the patient is already taking. For example, Hypericum perforatum (St. John’s wort) is a versatile plant that can be used for depression, nerve damage, or viral infections, but it is a potent cytochrome P450 (metabolic enzyme) inducer. Thus, it can reduce the plasma levels of other medications that depend on these enzymes, such as warfarin.^[6] Dosing St. John’s wort to a patient on warfarin could have life-threating consequences and should be avoided. Some conventional medication databases such as UpToDate have drug interaction checks that include major herbs, such as St. John’s wort, but overall the list of herbs on these interaction checkers is scarce. It is up to the formulating doctor to check the materia medica and to have an extensive working knowledge of the safety and contraindications of all the herbs they are working with.

Putting it All Together

Having an understanding of the various components of botanical medicine formulation is critical in understanding the final product. Let’s put it all together by looking at a sample patient and designing a formula:

“Jane” is an 18-year-old female who has been suffering from acne on her face and chest since puberty. Her acne worsens right before and during menstruation, but occurs all month long. She has premenstrual syndrome and painful menstrual cramps. Jane has developed dark facial hair growth on her chin over the past few years that she constantly plucks out with a tweezer and that exacerbates her acne.

When a naturopathic doctor goes to formulate botanical medicine for Jane, he or she is going to do so using both the principles of naturopathic medicine as well as the therapeutic order. One of the main principles is to treat the whole person. Jane’s acne problem is not happening independently of the rest of her body, so it is necessary to look at the entire picture and try to put the pieces together. When NDs treat skin diseases, they often look at the role of hormonal function, as well as alterative and gastrointestinal function.

Alterative herbs are often lead herbs in acne formulas, as they help support the liver and emunctory functions, which is why burdock has been selected as the lead herb in this formula. In Jane’s case, her acne is also related to her menstrual cycle and her hormones, therefore the supporting herbs have been chosen to address this part of her health picture. Chasteberry is a female reproductive tract regulator and helps to shift the ratio of estrogens to progestogens, thereby balancing out female hormones.^[6]

Saw palmetto is an herb that acts as a 5-alpha-reductase inhibitor and decreases the conversion of testosterone to dihydrotestosterone (DHT).^[6] Jane’s facial hirsutism indicates that her testosterone levels may be elevated, and saw palmetto will be used in the formula to help balance them. The area on her body which is most affected is the face and chest, so cleavers will be used to help stimulate lymphatic flow in the head and cervical region. A tincture of alcohol will be appropriate in this case to extract the constituents desired. Dosing will be two dropperfuls of tincture three times a day for one month with a follow up visit at that time to determine if changes in dosing or the formula need to be made. Below is a summary of the final acne tincture formula:

Practical Tips

1. Botanical medicine has been used successfully and safely for centuries throughout the world to treat a wide variety of conditions.
2. Formulating botanical medicine is an art and a science. Training and a robust knowledge of the herbs should be obtained before formulating medicine for patients.
3. Dermatologist and/or doctors wanting to use botanical medicine should work together with registered herbalists and naturopathic doctors to safely and effectively prescribe botanical medicine to their patients.