Allopathic medicine has alternative medicine roots

Whether we like it or not, the lines between allopathic and alternative medicine continue to blur. Just last week I recommended glucosamine-chondroitin to a patient who suffers from osteoarthritis and wrote a prescription for Lovaza, a prescription-strength preparation of fish oil. And today I was asked about red yeast rice from a patient interested in controlling her cholesterol through “natural means.”

Like nutrition, complementary and alternative medicine, or CAM, is somewhat of a “dismal science.” It seems nearly everyone has a different opinion about CAM and that from infomercial actors to the local barber everyone has different remedies to recommend.

Inevitably we know that many “alternative” therapies are likely to be safe and effective — after all, many modern day medicines originated as natural remedies — for example, aspirin, which was derived from willow bark. But the problem is that the “signal-to-noise” ratio is too low. That is, there is so much junk out there that it makes it difficult to separate the occasional good from the mostly bad.

In the face of this uncertainty and our ever-increasing time constraints, the approach that many young doctors like myself make is to simply dismiss the entire field. Back in September, during the first few months of my internship, I found myself in our urgent care center evaluating a 50-something year-old man with knee pain. After diagnosing him with osteoarthritis, my supervising doctor recommended that I prescribe glucosamine. “Glucosa-what?,” I asked skeptically. “Glucosamine — it’s a natural remedy. I find that a lot of my patients really benefit from it.”

I tried my best not to laugh at the suggestion. Doctors are supposed to recommend therapies based on evidence, not anecdotes. Why should I peddle unproven “alternative remedies” when effective medications are available? But the truth is that I knew nothing about the data for or against glucosamine, or about glucosamine for that matter. In the absence of any information, and in the midst of a busy clinic day, my knee-jerk response was to dismiss his recommendation.

Doctors are commonly viewed by patients and by the public in general as experts in health, and CAM is no exception. But the truth is that doctors receive very little formal training in CAM. And this lack of training is exacerbated by the fact that CAM is often treated as distinct from mainstream medicine and is viewed skeptically, if not disparagingly, by many physicians. The difficulty many doctors and patients have with CAM is that they do not know how to separate the good from the the bad. But, in reality, allopathic medicine and CAM are really not that different. The major distinguishing characteristic is that the FDA has the authority to regulate allopathic medicines but not herbal ones. But why should this matter to us as practicing clinicians?

The basic notion that CAM is fundamentally no different from conventional medicine allows us to use the same methods to evaluate the merits of CAM as we use for allopathic medicine. Take for instance glucosamine. Several large scale clinical trials, including double blind placebo-controlled trials (the gold standard in medicine), have been done to evaluate the use of glucosamine, chondroitin, and glucosamine-chondroitin for the treatment of osteoarthritis. While some of these trials have not demonstrated any benefit, a review of the data published in JAMA in 2000 concluded that despite limited data “…some degree of efficacy appears probable for these preparations.”

This example illustrates the point that evaluating the clinical use of a CAM therapy really isn’t much different than evaluating an allopathic one. Many CAM therapies have been evaluated in clinical studies, and sometimes even double-blind placebo-controlled trials. Often those that haven’t have at least been studied for their safety. Our jobs as clinicians then is to apply a formula we have become accustomed to — find the relevant scientific literature and then weigh the known risks and benefits in the context of the individual patient.

I’ve come to realize that I don’t need to know everything about complementary and alternative medicine. (Even if I wanted to, I couldn’t.) But to be an effective clinician what is required is to listen to my patients, keep an open mind, and, when called upon, evaluate the best available evidence and determine how it applies to the patient in front of me. Call it complementary. Call it alternative. But in the end it is what medicine is all about.

Shantanu Nundy is an internal medicine physician who blogs at BeyondApples.org.

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  • http://mannursediaries.blogspot.com Chris (The Man-Nurse Diaries)

    That’s the way I think. I take simvastatin for hereditary dyslipidemia; but I also take pharmaceutical-grade high-EPA fish oil. And it seems like the evidence is in favor of increasing your vitamin E and selenium intake to prevent LDL oxidation.

  • Med Student

    What exactly is an allopathic medicine? I apologize for the question in semantics, but i didn’t know that MD’s had their own special medicine. DO’s have osteopathic treatments, but no specific medicine. Just a question, thanks.

  • Brian

    Well, actually, no, the major distinguishing characteristic is that, by and large, “allopathic” medicine has generally been shown to, you know, actually work. Oh, and also, be acceptably safe.

  • ninguem

    Turn it around. If it has evidence that it works, is it still “alternative medicine”?

  • Med Student

    I think they are using “allopathic” to refer to mainstream medicine (evidence based), which is the type most often used by both MDs and DOs. An allopathic treatment might be the use of a beta blocker for HTN, as opposed to an alternative/herbal treatment that is not subject to the same standards of evidence/peer-review.

  • Anonymous

    This is a reasonable and balanced opinion. I think the important thing about CAM for a clinician, in addition to having a general idea what the major stuff does, is to know its potential interactions with allopathic medicine (which, to answer a previous comment, means “other” medicine and is the basis for western medicine… it’s to contrast it from homeopathy, which means “same”).
    For instance, know that St. John’s wort induces p450, increasing metabolism of important drugs like birth control, cyclosporin, etc. Know that licorice can drive up blood pressure by allowing cortisol to act as a mineralocorticoid. Those sort of things are important to know because your patient is going to be taking these things, often because the college kid working at the store recommended it. Likewise, because most patient assume that they are safe and bought it at a health food store, they aren’t likely to volunteer the information without being asked.

    It isn’t adventageous to set up a turf war of allopathic vs. CAM. But make sure that any CAM the patient takes wont interact with the prescription stuff because, while most CAM stuff is reasonably safe, some of them can definitely make allopathic medicine much less safe.

  • H

    Alternative medicine has cheaper and safer placebos that allopathic medicine.

  • Bay Area Pre-PA student

    A) What are the research findings regarding Glucosamine and/or chondriotin efficacy per oral compared to direct local injection. Metabolically and biochemically, do the sugars and protein pre-cursors survive in a bio-available form or are they catabolized into basic sugars and proteins and thus not necessarily reconstructed in vivo into the glucosamine utilized at the local target site for repair. Does your GI system know to keep it intact or will it just treat it like any other macronutrient – reducing it to basic building blocks?
    This is where formulation of supplements and herbal preparations becomes important I think – and without verification and validity by a third party like the FDA, who knows what the composition is? Not to say FDA doesn’t have their own demons to deal with. Do our RDA/DV amounts need to be re-evaluated?
    B) I’d love nothing more than to eventually be involved in an integrative type medical practice, so long as we have some science behind our application. Though it will take time, if we can hold all treatments up to the same standards, we can tease out the highly efficacious non-pharma treatments. Herbals probably vary depending on if whole plant, extract or leaf derived; cultivation practices and geography as well as soil content or contamination. The scientist in me would like to see more consistancy and transparency. “Trick or Treatment” proved to be an objective read when it comes to herbal/supplement remedies and demonstrates truth is not black nor white, but shades of gray. Food for though. Great post and commentary.

  • ninguem

    Original meaning of allopathy was a practitioner treated a disease by agents that would produce, in a healthy person, symptoms opposite or antagonistic to those of the disease.

    As opposed to homeopathy, where a practitioner treated a disease by agents that would produce, in a healthy person, symptoms similar to those of the disease.

    Osteopathy, is where a practitioner shows up at the office wearing a string tie, leisure suit, and white belt and shoes. Or so it seemed when I was training.

  • Anonymous

    Sometimes I wonder if, in the treatment of diabetes, high blood pressure, high blood LDL and VLDL cholesterol, etc., lifestyle changes like cleaning up one’s diet, increasing exercise, and losing body fat is “alternative” medicine, since I keep reading in blogs and forums (often complaining) about doctors prescribing drugs as a first line treatment instead of a second line treatment when the lifestyle changes would be effective at treating the problem. Then again, I have also read blogs and forums describing how doctors who do recommend lifestyle changes as a first line treatment tend to find that most patients just come back later having not changed at all, except for worse numbers and more body fat.

  • http://www.amberleafwellness.ca Elizabeth

    It’s so nice to see a more balanced perspective on alternative medicine and “allopathic” medicine. Now, if only we, the alternative practitioners AND the “allopathic” doctors, could work together, we could do so much for our clients/patients to get them healthier and keep them safe.

  • Bay Area Pre-PA student

    Following up my last comment:

    Albeit somewhat over-inflated, here is an amusing example of the need for transparency and verification of herbal/supplement remedies: http://www.sciencebasedmedicine.org/?p=4240
    Enjoy

  • http://www.consentcare.com Martin Young

    Please, please, please read “Bad Science” by Ben Goldacre! I have just discovered this book – and I think it is essential reading for all with any interest in this discussion – which should be all of us!

    He sets the record straight with explanation of how statistics and studies can be manipulated to support any belief, and that is where nutrition and CAM fads cannot compete with good hard science.

    I cannot recommend this book any higher!! Especially for student and young doctors. It will enhance your careers!

    And “NO!” I have NO financial interest in saying this!

  • http://www.prescribinginformation.com Dr S

    I have worked in the US and India and the US is much closer to adopting an integrated model. “Chondroitin-Glucosamine” is considered “allopathy” in India. I, too, am looking forward to building more physician relationships across the disciplines in medicine.

  • Anonymous

    Good Day.
    Comming from an era and from a small rural towni was raised by my parents treating all or most ailments with alternative medicine which proved to have worked very effectively. As an adult involved as HIV/Aids peer educator and serving on the Nelson Mandela Metropole Mayoral Committee, I believed that there must be alternatives to ARV’s. I found complimentary products been tested at laboratories and the University of Cape Town and Pretoria. It kills all the strains of the virus, is non toxic and the virus cannot mutate. From anacdotal evidence and test results from patient records the Cd4 count improved immediately and viral load reduced to below detectable values. I have seen persons literally raised from a death bed having a Cd 4 count of 12 and 54 respectively. Also witnessing a patient diagnosed with cancer treated and still alive today after sent home from Hospice to soend her last dying moments with her family. If I did not witness it personally i would never believe it. Contact me for further information. Elridge Muller. 0766988037. ridgemuller@gmail.com. Medical doctors who currently prescribe it for their patients can be contacted to confirm their experience with the products.

  • http://skeptvet.com/Blog SkeptVet

    Several intersting points here. Unfortunately, the fact that some, even many, pharmaceutical originated as compounds ffound in plants is emphatically NOT a reason to say CAM and scientific medicine are “not that different.” Once a compound is purified and examined through an appropriate series of in vitro, animal model, and clinical trials tests and is shown to be safe and effective, it becomes medicine. When someone decides a tea or ground up dried leaves from a plant must be beneficial becase somebody one said it was and then that became a folk tradition, and they market it as such without appropriate testing and regulations, then it is CAM. The only reason the label CAM exists is that there are many therapies that people believe passionately in but which have not yet been scientifically tested or which have been and have failed, and yet people still wish them to be viewed as legitimate medicine.

    Second point is that much CAM has been tested and failed. The NCCAM has spent over $2.5 billion in over a decade and has yet to validate any significant CAM therapy. Much of this testing should never have been done because there was no sound hypothesis to examine. Homeopathy, for example, can only work if everything we know about physics and chemistry, and which works in many other domains besides medicine, is actually wrong. So wasting money on clinical trials of the impossible is a political boondoggle, not good, open-minded science.

    Finally, a small point, but you reference concerning glucosamien is well out of date. The NCCAM GAIT trial (http://nccam.nih.gov/research/results/gait/) and a number of systematicc reviews since (e.g. http://www.ncbi.nlm.nih.gov/pubmed/20170770) have added abundant evidence that it is almost certainly a placebo.

  • Anonymous

    Of course it’s interesting finding the balance between those people who are the zealots on either side who want to play ‘skeptic’ and those who want to play ‘practitioner’. Both could use large doses of the drug called ‘reality’.

    Let me preface by saying I find the term CAM rather ludicrous. It denotes a tone of pseudo-intellectual snobbery so prevalent in those who have a defensive reaction the minute they leave their zone of comfort.

    It would do some of the readers well to note that about 1/2 of all physicians in Europe that are MD’s also prescribe homeopathic remedies to their patients and have less than 1/2 of the levels of iatrogenic illness we have here. Linkage? Maybe. Hey that would make a great study!

    I see it on both sides of the coin. I’ll use CAM practitioner here to denote a Chiropractor (Graduate of 4 years+ of graduate level clinical training), Naturopath (Again 4+ years of graduate level clinical training) as those are the ones I am familiar with. Speaking for Chiropractic, I know they have 3 & 4 year post graduate specialties, I just don’t know enough about them to speak effectively.

    In medical school we are two years of butt in seat didactics, and then two years of clinical. Guess what, the ‘CAM’ practitioners I have described herein are trained using the same books, same classes and have clinicals/rounds just like we did.

    As a DO (you know one of those allopathic physicians with 4+ years of graduate training), I have worked with great physicians in these professions and I’ve worked with some real crack-pots.

    I’ve also worked with some complete idiots in the allopathic professions as well. There are crazies in both fields to be sure and pseudo-intellectualism only restricts real science from coming forth.

    Oddly so many of the ‘skeptics’ have copied and pasted their words almost word-for-word on their websites from other ‘skeptics’ website. This of course invalidates any content therein as they have broken the first rule of Skeptical practice.

    My suggestion to the zealots on both sides is to grow up, attend (proctor) a class of the other folks, i.e. actually go to a chiropractic college or a naturopathic college and monitor a few classes in A&P, biochemistry or microbiology.

    While certainly any CAM practice needs to be scientifically validated, the EBM allopathic pharmacopoeia responsible for over 100,000 deaths annually bares scrutiny as well. Funny how most ‘skeptics’ seem to gloss over that figure so readily obtainable. [1]

    Real science demands scrutiny in both directions. My suggestion is that the skeptics obtain knowledge by either getting a MS, PhD, MD, DC, DO or whatever research or clinical degree would suit them to actually learn how to conduct the research on both sides of the collective coin and to allow them to understand the data they are viewing

    One last humorous point, I get a huge kick out the want-to-be skeptics who say, “CAM is all placebo”. Why is it then that you have to be careful of pharmacokinetic interactions then? Surely if it was all placebo there should be no interaction as they are bioactively/biochemically neutral right?

    Have a better one!

    Competing Interests: None declared

    1. JAMA – Johns Hopkins School of
    Hygiene and Public Health, Dr. Barabara Starfield.

  • Brian

    It would do some of the readers well to note that about 1/2 of all physicians in Europe that are MD’s also prescribe homeopathic remedies to their patients and have less than 1/2 of the levels of iatrogenic illness we have here. Linkage? Maybe. Hey that would make a great study!

    Considering homeopathy is expensive water, that’s not altogether surprising. I suspect a study would be rather a waste of time, as the variable you wish to investigate (i.e., whether Euro M.D.s embracing homeopathy results in reduced iatrogenic problems) has nothing to do with the variable you ought to investigate (i.e., whether Euro M.D.s embracing homeopathy results in more effective treatment of disease). Not to mention the fact that even if it could be demonstrated that homeopathy results in better outcomes, it is quite likely less an indication of the efficacy of homeopathy, and more an indication that sometimes, doing nothing at all is better than aggressively treating (i.e., “Don’t just do something, sit there!”).

    It’s also worth noting that, even though I don’t think you were trying to make this case, the number of M.D.s that adopt homeopathy as part of their practice is absolutely meaningless in determining whether or not it actually works. Just ’cause something’s popular, don’t make it right.

    As a DO (you know one of those allopathic physicians with 4+ years of graduate training), I have worked with great physicians in these professions and I’ve worked with some real crack-pots.

    I’ve also worked with some complete idiots in the allopathic professions as well. There are crazies in both fields to be sure and pseudo-intellectualism only restricts real science from coming forth.

    The fact that there are some very smart, effective people in so-called “alternative” disciplines and some “complete idiots” in the “allopathic” disciplines has no bearing on the scientific validity of CAM. It is just as easy to say that there are some excellent allopathic physicians and crackpot “alternative” practitioners. That is not, in and of itself, sufficient reason to believe or doubt the validity of one or the other.

    Oddly so many of the ’skeptics’ have copied and pasted their words almost word-for-word on their websites from other ’skeptics’ website. This of course invalidates any content therein as they have broken the first rule of Skeptical practice.

    With all due respect, I have no idea what this means. If I quote, paraphrase, or worse, plagiarize another source, it doesn’t affect the validity of the source.

    I’m not entirely sure what you mean by “Skeptical practice”, either. It seems as though you’re arguing that the skepticism of so-called “allopathic” doctors is rooted in a directive to doubt EVERYTHING. That’s not true at all. I doubt homeopathy, for example, because there is not only no evidence for its efficacy, but also the very foundations of homeopathy stand in stark contrast to very basic principles of chemistry, physics, and biology.

    My suggestion to the zealots on both sides is to grow up, attend (proctor) a class of the other folks, i.e. actually go to a chiropractic college or a naturopathic college and monitor a few classes in A&P, biochemistry or microbiology.

    The fact that chiros and naturos receive equivalent (or nearly so) training in A&P, biochemistry, or microbiology is, again, not a referendum on the legitimacy of their respective crafts. I don’t care how accurate the A&P info is, the second you start arguing that chiropractic works by “unblocking” energy pathways, you’ve jumped the tracks. Just because parts of their training are legitimate does not mean all of their training is legitimate.

    While certainly any CAM practice needs to be scientifically validated, the EBM allopathic pharmacopoeia responsible for over 100,000 deaths annually bares scrutiny as well. Funny how most ’skeptics’ seem to gloss over that figure so readily obtainable.

    No one’s glossed over that fact. It is a well-known fact (and indeed, a legal obligation to communicate) that medical interventions carry a varying amount of risk of injury, or worse, death. There is also the risk of human error. There’s a reason why medicine has long been called, lovingly, “Artful poisoning”. Saying that medical care has resulted in deaths doesn’t particularly help your case, and is, I should note, a common canard amongst CAM apologists.

    The fact that CAM results in far fewer deaths doesn’t even raise my eyebrows. How should it? When did a placebo ever kill anyone?

    One last humorous point, I get a huge kick out the want-to-be skeptics who say, “CAM is all placebo”. Why is it then that you have to be careful of pharmacokinetic interactions then? Surely if it was all placebo there should be no interaction as they are bioactively/biochemically neutral right?

    Largely, yes. Of course, the exception would be using herbal treatments, as many of them are pharmacologically active.

    But the idea that there are potential pharmacological interactions between, say, homeopathic remedies and other medications is, quite simply, laughable. Same for chiropractic, acupuncture, reiki, or, really, any silly “energy” modality.

    Competing interests: Total pharma shill, obviously.

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