Afghan Herbal Medicines for Addiction and Depression (AHMAD)
The Afghan Herbal Medicines for Addiction and Depression project will conduct clinical trials of promising herbal medicines drawn from Afghanistan's high-potential medicinal and aromatic plants (MAP) sector, in keeping with traditional Unani medicine. Addiction (overwhelmingly from opiates) and depression (some from Post-Traumatic Stress Disorder from the horrors of Afghanistan's wars, and some from mistreatment of women) represent especially salient targets, and they possess worldwide importance. Unani herbal medicines have been reported in preliminary Iranian clinical studies to be effective and safe in these indications, and they possess certain advantages over synthetic drugs. However, thorough, scientific, multicenter trials need to be done. Validation of herbal medicines can benefit Afghanistan's MAP sector, which has a significant female workforce and which forms an ideal alternative livelihood to the opium economy.
Medicinal and Aromatic Plants
Afghanistan now produces 93% of the world supply of opium. Opium and increasing amounts of heroin account for more than one third of the Afghan economy. In many provinces poppies are being grown, distorting economic priorities and boosting crime, corruption, and addiction. The Taliban insurgents have raked off some profits and benefit from poppy-growing farmers' resentment over the Government's eradication efforts.
Afghanistan's drug production is a global scourge. In Iran and Pakistan, millions are addicted to opiates; and rising levels of heroin injection increase the risk of spreading HIV and other infectious diseases. Thus far Afghanistan has had much less addiction, but the history of narcotics suggests that countries of origin eventually experience growing addiction themselves.
One response of the Government of Afghanistan, donor countries, and international organizations has been to seek to develop alternative livelihoods to growing poppies. Dozens of projects are underway in agriculture and small industry. Several target the MAP sector as a particularly attractive source of alternative livelihoods. A traditional strong performer (Afghanistan was once the world's leading exporter of licorice root, for instance), the MAP sector has suffered from deforestation and the loss of knowhow during the decades of war. But the possibility of growing herbs on tiny plots, the potential for high-value exports, the chance for establishing thousands of small processing and distribution businesses, the large proportion of women involved, and the potential for substituting domestic herbal medicines for expensive imported drugs make MAP especially appealing. The recent Iranian finding, for instance, that the inexpensive petal of Crocus sativus L. is as effective against depression as the extremely expensive saffron derived from the stamen adds another reason to cultivate saffron as an alternative to poppies.
Afghanistan's traditional Unani (Greek) medicine places great reliance on herbal medicines. A common fund of Unani lore from countries stretching from Morocco to Bangladesh includes remedies for hundreds of disorders. Unlike Traditional Chinese Medicine (TCM) and India's Ayurveda, which have tended to overshadow Unani, it favors treating with a single herbal extract at a time. That makes scientific evaluation much easier. In addition, Afghanistan possesses germ plasm for many kinds of herbs that are common in the West (also an heir of ancient Greek medicine) as well, and thereby offers an interesting opportunity for pharmacognosy. Afghanistan's MAP sector thus has high value-added potential via the development of new drugs and other products.
Herbal Treatments of Addiction and Depression
As major mental disorders worldwide, addiction and depression have attracted a great deal of drug research and development. Current drugs represent a considerable improvement over those of the past, but they still have significant side effects and do not convey satisfactory results in many cases. Moreover, research has shown that addiction and depression are often comorbid and that one readily leads to the other. So remedies that can treat both seem worth investigating.
In spite of very limited funding and the dismissiveness of some colleagues, various teams of scientists throughout the world have been testing herbal remedies for addiction and depression for many years. However, this has been in the framework of TCM, Ayurveda, or European/North American traditions. Tapping into the potential of Unani medicine with the genetic repertory of Afghanistan's flora therefore represents a very promising approach.
In recent years the Iranians (Akhondzadeh S et al.), aware of the potential of their MAP resources, which are virtually identical to those of Afghanistan, have conducted a very interesting series of pioneering clinical studies of traditional herbal treatments said to be effective in treating neurological and psychiatric disorders. Although Akhondzadeh S et al. point out that their trials are small and preliminary, they conclude that the herbal medicines have roughly the same level of effectiveness as standard treatments such as fluoxetine (Prozac) and methylphenidate (Ritalin). However, they tend to have lower levels of side effects. They also prove effective at treating a wider range of symptoms than synthetic drugs. For instance, in the treatment of withdrawal from opiates, adding extract of passion flower to the standard treatment successfully treated mental symptoms (anxiety, agitation, and insomnia) that are closely linked to relapse to addiction and that were not resolved by the standard drug.
In theory, of course, Nature has evolved the phytochemicals in the plant extracts to convey the antistress effects or other benefits that play a role in the physiology of the plants themselves. The natural image and the relatively low side effects of herbal medicines can lead to acceptance by patients, adherence to therapy, and reduced likelihood of relapse. Herbal medicines also have advantages in terms of cost and accessibility.
Collaborative Clinical Trials
Afghanistan's medical system was never well funded, and it has been seriously degraded by decades of warfare. The few hospitals lack equipment and supplies; and trained physicians and nurses, and technical staff are in very short supply. However, with the assistance of international donors, hospitals and clinics are being built. Thousands of medical and nursing students are starting to graduate. The low cost of patient care and the major disease burden make conducting clinical trials in Afghanistan a reasonable proposition. Even amid the chaotic conditions of reconstruction, several clinical trials of infectious diseases have been carried out.
The AHMAD project proposes to organize a collaboration between an American medical center and an Afghan partner to conduct parallel clinical trials in the U.S. and Afghanistan of selected herbal medicines for the treatment of addiction and depression. While it might prove possible to identify a single suitable Afghan partner institution, a better approach might involve setting up a small office in Kabul that would make arrangements with various hospitals and clinics throughout Afghanistan for specific clinical trials, depending on the circumstances. Collaboration at the laboratory testing level is also possible, but not required for AHMAD. In general, AHMAD would afford opportunities for exchanges of personnel, for training, and for technology transfer, including of botanical specimens. The flow of benefits would be two-way, so that the U.S. partner would be gaining substantially from its involvement, not just offering charitable contributions. In turn, this would enhance the likelihood of long-term partnership.
The first, scientifically appropriate step would be to replicate the studies of the Iranians. Since herbal medicines of proper quality might not yet be available from Afghan sources, it would be advisable initially to obtain from Iran the exact medicines used in the Iranian studies themselves. After replicating these studies, informed decisions can be made about larger trials or the investigation of other herbal medicines. Also, issues concerning modalities of application, combination with other therapies, interactions with drugs, and special patient groups deserve careful investigation. For instance, research on aromatherapy-whether inhaled, transdermal (aromatherapy massage), or with oral capsules-has received little funding in the U.S. But aromatherapy is reported to achieve excellent effects in neurological and psychiatric disorders, and it has become widely used in the United Kingdom. An herbal extract that performs only reasonably well in capsule form might, administered via aromatherapy massage, prove unusually effective. Why that would be true is just one of a number of intriguing and important scientific questions that would arise in the course of AHMAD. This could also mean that, when optimally administered, herbal medicines might prove even more effective than in the Iranian studies.
Over time, it can be anticipated that Afghan herbal medicines will gain sufficient quality to be used.
Although the Iranians conducted studies of herbal treatments of a full range of neurological and psychiatric conditions, including Alzheimer's, Attention Deficit Hyperactivity Disorder, and General Anxiety Disorder, it seems advisable to focus on addiction and depression for several reasons:
AHMAD would run for 5 years and would be funded by U.S. Government or private sector funders, international donors to Afghanistan, or the Afghan Counternarcotics Trust Fund.
Conclusion
The Afghan Herbal Medicines for Addiction and Depression project envisions a collaboration between a U.S. medical center and an Afghan partner or partners to conduct clinical trials of medicinal plant extracts from Afghanistan to treat addiction to opiates and depression. Its potential benefits include:
Note
Akhondzadeh S et al. Crocus sativus L. in the treatment of mild to moderate depression: a double-blind, randomized and placebo-controlled trial. Phytotherapy Research;2005(19):148-51