Conventional and Alternative Medicine: A Delicate Co-Existence
With nearly half of adult Americans telling surveyors that they’ve tried alternative medicine, it’s about time to get down to some hard questions:
Does it work? Is it worth the money? Should complementary and alternative medicine (CAM) be reserved only for desperate souls for whom conventional medicine has run out of treatments? Or does it have a larger place?
This month we discuss complementary and alternative medicine, why they appeal to some people and whether they have proven benefits or harms.
Defining the Terms and Surveying the Field of Nontraditional Medicine
Some terms to get started:
“Complementary” medicine is practiced along with conventional medicine.
“Alternative” medicine is practiced instead of conventional medicine.
“Integrative medicine” combines treatments from conventional and CAM. It’s also called integrated medicine, and many medical centers have integrated medicine departments.
The definitions all come from an agency that sits at the crossroads of traditional medicine and alternative methods: the National Center for Complementary and Alternative Medicine. NCCAM is part of the National Institutes of Health (NIH), which is the unofficial headquarters of traditional, scientific medicine. Congress told the NIH to set up NCCAM so someone could check out systematically the range of treatments outside of conventional medicine, and see if they work.
Through scientific research, NCCAM tries to prove the usefulness and safety of complementary and alternative medicine interventions and their roles in improving health and health care. Unfortunately, the budget of NCCAM is not even half of 1 percent of the total NIH budget, so its progress in evidence-based CAM can be only incremental.
CAM practices fall into broad categories: natural products; mind and body medicine; and manipulative and body-based practices. Some CAM practices fit into more than one category.
Herbal medicines (also known as botanicals), vitamins, minerals and other so-called “natural products often sold as dietary supplements are popular despite their rather thin record of quantifiable success. And their lack of regulatory oversight can cause problems, as my patient safety blog has noted.
Still, the 2007 National Health Interview Survey (NHIS) found that nearly 18 in 100 U.S. adults had used a nonvitamin/nonmineral natural product — they were the most popular form of CAM among both adults and children.
This isn’t about taking a vitamin to boost basic nutritional needs; it’s about taking supplements such as glucosamine to address joint pain.
The most commonly used product among adults in the 2007 survey was fish oil/omega 3s. Popular products for children included echinacea and fish oil/omega 3s.
Mind and Body Medicine
Mind and body medicine is all about focusing on the interactions among the brain, mind, body and behavior with the intent to use the mind to affect physical functioning and promote health. Such CAM practices include meditation, yoga, tai chi, guided imagery and hypnotherapy. Acupuncture fits into this category, as well as the next category on our list.
The 2007 survey found that nearly 13 in 100 adults had used deep-breathing exercises, nearly 1 in 10 had practiced meditation and 6 in 100 had practiced yoga.
Manipulative and Body-Based Practices
These practices focus on the structures and systems of the body-bones and joints, soft tissues and circulatory and lymphatic systems (tissues and organs, including the bone marrow, spleen, thymus, and lymph nodes, that produce and store cells that fight infection and disease) are the primary concerns here, usually treated with two common therapies.
Spinal manipulation practiced by chiropractors, osteopaths, naturopaths and physical therapists applies controlled force to a joint of the spine to relieve pain and improve range of motion. It’s popular among patients with low back pain. Massage therapy manipulates muscle for a variety of purposes-relieve pain, rehabilitate sports injuries, reduce stress and promote relaxation, for example. Massage therapy is a common component of of integrated medicine.
According to the 2007 NHIS survey, chiropractic/osteopathic manipulation and massage ranked in the top 10 CAM therapies among both adults and children.
Why People Turn to CAM
Patients are open to CAM for different reasons. Some have had a poor experience with conventional medicine-treatment didn’t work, it had unacceptable side effects, the doctor/patient relationship was poor… Some can’t afford traditional medicine and believe that an alternative approach is less expensive (sometimes it is, sometimes it isn’t, especially if there are unintended consequences requiring follow-up with a conventional treatment).
Sometimes, people are simply desperate. Such circumstances are perfectly described in an article by Tom Flanagan in Canada’s C2C Journal of Ideas called “The Scientific Method and Why It Matters”:
“Multiple sclerosis, for example, is a terrible disease that adversely affects both the length and quality of life. We know a lot about its neural mechanisms, but we do not understand its causation. There is no cure, and existing symptomatic treatments are only moderately effective and have unpleasant side effects. Is it any wonder, then, that sufferers turn to Dr. Paolo Zamboni’s venoplasty treatment (enlarging allegedly constricted blood vessels in the neck) even though it is supported mainly by flimsy anecdotal evidence? I might try it, too, if I suffered from MS.”
A recent story in the New York Times Magazine illustrated not only the desperation of a family seeking treatment for their child’s juvenile arthritis, but the conflict captured in its readers’ letters about whether the story promoted bogus alternative treatments at the expense of mainstream medicine or offered hope for other families. It was a balanced portrayal of a medical puzzle that takes open minds to solve.
Some people are persuaded to try CAM from a sense that an alternative treatment “makes sense,” and “should” work; others might be motivated by testimonials and advertising along the lines of “I tried everything to relieve my pain, but only XYZ worked!”
The Times Magazine story referred to a study of rheumatoid-arthritis sufferers who ate a gluten-free, vegan diet. In one month they showed “significant improvement,” compared with the control group. Another arthritis study in the journal Rheumatology repeated the positive effect of a similar diet. So alternative therapies are not wholly without scientific support.
But for every “this is a miracle treatment” claim, there’s a cold reality. One example is the use of glucosamine/chondroitin, supplements popular for their supposed ability to reduce joint pain. The journal BMJ (British Medical Journal) recently conducted a meta-analysis of glucosamine studies. Meta-analyses look at many different studies and are considered a higher order of scientific authority because of the depth of examination.
The BMJ results of 10 trials involving 3,803 patients showed that, compared with a placebo (a fake or inert pill), glucosamine, chondroitin and their combination do not reduce joint pain.
Some patients are simply dabblers who embrace a “can’t hurt” attitude. That’s okay with me, as long as they proceed fully aware of what is known about the treatment. For example, trying out a manipulation called “craniosacral therapy” to relieve pain has no basis in fact, as its “cranial pulsations” cannot reliably and reproducibly be detected. But even it if hurts your pocketbook, it usually won’t hurt you if performed by a credible chiropractor or physical therapist.
But danger lurks: Last year, in an article called “Alternative Medicines,” The Scientist magazine recalled the cases of two patients who ended up hospitalized after a seemingly innocuous colon cleanse. Promoted as a way to “flush” the system (never mind that healthy people’s systems don’t need to be “flushed”), a colon cleanse sometimes is oral, sometimes is an enema. Either way, it can cause significant harm. One patient was left severely dehydrated and with pancreatitis and an inflamed colon; another’s Crohn’s disease flared up shortly after the cleanse, causing days of cramping, diarrhea, and dehydration.
A final group who seek alternative treatments are the “worried well”; these folks aren’t diagnosibly sick, but worry that they might get sick, or that a small problem is symptomatic of a larger, looming health issue. Sometimes they have emotional issues that prompt them to see a health-care professional as much for reassurance and physical contact than for any real assessment of illness. While not all of the worried well are hypochondriacs, they share characteristics of that psychological disorder, in which patients are obsessed with having a serious illness.
Does This Stuff Ever Work?
As much as I and other skeptics support evidence-based treatment, there are things in this world that can’t be explained, and a good outcome from an odd medical treatment is in the realm of possibility. And as the Times Magazine story and letters say, some health professionals are supporters of some kinds of CAM. The growth of integrative medicine is happening for a reason.
Because of the lack of well-designed clinical trials for many CAM therapies, it’s difficult to judge the safety and effectiveness of many of them. The point is to be informed about what you’re doing, why, and the potential consequences.
Statements that manufacturers and providers of complementary therapies make about effectiveness and benefits can sound reasonable and promising without having a scientific basis.
Question manufacturers who promote their products with terms like “scientific breakthrough,” “miracle cure,” “secret ingredient,” or “ancient remedy.” Remember that science usually advances over time by small steps, slowly building an evidence base-a “quick fix” is a fake fix.
Note also the “Miranda warning” usually seen on many of these products, a subject we wrote about in this newsletter. That’s the statement that says:
“These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease.”
It’s put there strictly CYA in case someone gets hurt. But it might give you pause.
Remember, just like conventional medicine, CAM therapies can be risky. Just like conventional medicine, patients must have frank, complete discussions with their practitioners of the goals of CAM and the potential for harm.
To help you decide if CAM is right for you, follow these NCCAM guidelines:
- Select CAM practitioners with care. Find out about the practitioner’s training and experience.
- Be aware that some dietary supplements may interact with medications or other supplements, may have side effects of their own, or may contain potentially harmful ingredients not listed on the label. Also keep in mind that most supplements have not been tested in pregnant women, nursing mothers, or children.
- Tell all your health care providers about any complementary and alternative practices you use. Give them a full picture of what you do to manage your health. This will help ensure coordinated and safe care.
- Find out if the federal government has anything to report about the therapy on the NCCAM website and the NCCAM Clearinghouse.
- Get information about dietary supplements from the websites of the FDA and NIH Office of Dietary Supplements.
- Review FDA recalls and safety alerts. The agency has a rapid public notification system for
- To see if there are any enforcement actions for deceptive advertising regarding a therapy, check the Federal Trade Commission site and its Health Consumer Information section.
To your continued health!
Patrick Malone & Associates