Alternative medicine problems patients need to know about

Americans spend an astounding 34 billion dollars on alternative medicine annually.  Given that so many of us put our faith in alternative care, I wanted to clear up some common misconceptions about it to help people make wiser choices when and if they turn to it.

What is alternative medicine?

In general, alternative medicine is used to describe practices outside the bounds of conventional medicine.  It’s also often connoted to include practices that haven’t been shown to be effective.  Mainstream scientists often criticize alternative medicine as charlatanism, arguing that anything alternative that’s been proven to work is in fact … mainstream medicine.  Advocates of alternative medicine, in contrast, typically point to their personal experiences as proof of the effectiveness of many such “unproven” interventions.

Many people feel more comfortable using natural compounds rather than man-made ones because of a belief that what’s natural is, by definition, healthier and safer — but this is a dangerous assumption.  Numerous natural compounds are, in fact, poisonous (e.g., cyanide).  And natural compounds that have health benefits often have a narrow therapeutic index (meaning the amount that brings benefit is only slightly less than the amount that causes toxicity, making it alarmingly easy for their use to cause harm), like digitalis, a drug derived from the foxglove plant that’s been used to treat heart failure since the late 1700s.

Many patients tell me they “don’t like to take pills” but paradoxically think nothing of ingesting “natural” herbs or plants.  This distinction has always struck me as absurd.  Both man-made and natural compounds have effects on biological systems.  Nothing about natural compounds makes them more or less effective or safe.  How confident we can be that a given compound is both effective and safe has nothing to do with where it comes from but rather with how rigorously its effectiveness and safety have been studied.

This, then, is the main problem I have with alternative medicine, that in general its interventions haven’t been subject to rigorous study.  I’m open to believing anything, no matter how far-fetched it may seem (after all, who would have believed that television would be possible five hundred years ago?).  I don’t even need to know an intervention’s mechanism of action.  I just need to know that in well-designed studies it’s been proven effective.

And safe.  Prima non nocere:  first, do no harm—medicine’s most important credo.  When you’re the one with the authority to recommend treatments, you take very seriously the possibility that what you recommend may cause harm.  I’m even open to the use of interventions that haven’t been proven ineffective as long as there’s reason to believe they’re safe.

But safety is a tricky thing.  First, it never exists as an absolute.  That is, an intervention can be safe for some people but deadly to others (e.g., penicillin is safe for almost everyone who takes it—except for those who are severely allergic).  Further, “safe” is often a value judgment that varies from person to person and for one person from situation to situation.  We may think it obvious that anything with a risk of death isn’t safe—but then again, what if that risk of death is less than 1% and we’re talking about performing a cardiac catheterization in a patient who’s just had a heart attack?

Alternative medicine enthusiasts often point to centuries of use to justify their belief in the safety of many alternative medicine practices (if acupuncture kills or maims, why hasn’t it been reported?), but without carefully designed studies, how do we know, for example, that black cohosh doesn’t increase the risk of auto-immune diseases like lupus?  Certainly, numerous examples exist in which man-made compounds were subject to rigorous study in clinical trials, labeled acceptably safe, and then later discovered not to be (remember phen-fen?).  But this is the exception rather than the rule.

Do alternative therapies work?

Interestingly, as more and more studies of alternative therapies are being conducted, we’re discovering that many of them do work—but not necessarily for the things people believe.  Acupuncture, for example, has been suggested to be effective in reducing the nausea associated with chemotherapy.  But trials also show for back pain there’s a good chance it’s no better than placebo.

On the other hand, even when clinical trials show an intervention works, it still may not.  Some kinds of experimental designs inherently produce less convincing results than others.  And even double-blind, prospective, randomized, placebo-controlled trials—the gold standard of clinical trial design—often turn out to contain flaws, even those published in well-respected scientific journals.  Often these flaws are small enough not to impact the validity of results—but sometimes they do.  This is why treatments must often be studied multiple times in multiple ways before they gain acceptance in the scientific community.

People turn to alternative therapies for many reasons.  Perhaps because of a bad experience with traditional medicine.  Perhaps because personal experience strongly suggests they work (when my wife was pregnant with our son and feeling intense nausea, I tried applying pressure to her wrist at a standard “acupressure” site and was astounded to hear her say, repeatedly, the nausea vanished when I pressed and returned when I released).  Perhaps because traditional medicine has no more to offer.  Especially when the diagnosis is terminal, what’s to lose?

If you’re going to go the alternative route, do as much research as you can.  Look for treatments that have been shown in some kind of study or studies not to cause significant harm.  Look for treatments that at least have some anecdotal reports of success for the specific problem you have.  (And I don’t mean reports offered by people selling alternative interventions.  Though many, if not most, alternative medicine practitioners are genuinely interested in helping others and believe in the effectiveness of the therapies they offer, snake-oil salesmen abound.  Beware overconfident statements about efficacy.  Remain suspicious about any claims that a given intervention treats or cures a multitude of disparate conditions.)

Traditional treatments aren’t inherently superior to alternative ones—they’re just better studied.  Which doesn’t mean that they’re effective or safe beyond any doubt—just that they’re more likely to be.  The praises we should be singing aren’t to any one specific intervention, traditional or alternative, but to the scientific method itself, a way of making valid observations about cause and effect in the phenomenal world.  It’s both a lot harder to do well than many of its proponents understand, yet simultaneously a far more valid means of assessing efficacy than anecdotal reports and length of use could ever be.

Alex Lickerman is an internal medicine physician at the University of Chicago who blogs at Happiness in this World.  He is the author of The Undefeated Mind: On the Science of Constructing an Indestructible Self.

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  • BladeDoc

    The belief in the absolute safety of acupuncture is likely a result of the “ignorance is bliss” school of thought. A decent review of the multitude of the reported complications of acupuncture was easily found in brief lit search. For example see http://archfami.ama-assn.org/cgi/content/full/8/6/553

  • Mirannda

    Excellent article, well-written and unbiased.

    Alternative Medicine in Canada is moving towards government regulation (expected date: 2013). This means that there will be a certain standard established by the Transitional Councils of each group (Traditional Chinese Medicine/Acupuncture, Naturopathy, and Homeopathy) to assist with registering practitioners. It is interesting to learn (through researching each group) that there currently aren’t any educational standards for individuals who claim themselves to be homeopathic doctors, and even Traditional Chinese medical doctors (who mostly learn through apprenticeship). In Canada, Naturopathic Doctors have regulation through the Drugless Practitioners’ Act, but will now be moving to government regulation like their other alternative medicine counterparts.

    What alarms me the most is that some of these alternative medical practitioners make unsubstantiated claims (as demonstrated in a current mini-documentary by the Canadian CBC program Marketplace on Homeopathy: http://www.cbc.ca/news/story/2011/01/14/marketplace-homeopathy.html). I am especially concerned about vaccination; a homeopathic vaccine (which hasn’t undergone the same rigors of scientific evaluation as traditional vaccines) may risk the lives of young children.

    Thank you again for bringing this very timely issue to attention on this blog. It is very important for MDs to know whether their patients are on any alternative therapies which may pose a hazard to health when mixed with traditional therapeutic interventions (i.e. the herb jiaogulan, popularly consumed as a steeped tea, is dangerous for heart transplant patients).

    Kind regards,

    M.

  • http://naturalmedicineisthebestmedicine.blogspot.com Erika

    Very well-written article.

    As a student of naturopathic medicine at Bastyr University, I would like to contend that complementary or alternative medicine (CAM) is not necessarily “unproven”. In fact, many natural therapeutics have astoundingly good evidence but are still not mainstream therapies. Some examples: St. John’s wort (Hypericum perfoliatum) for mild to moderate depression, Glucosamine sulfate for osteoarthritic pain, Saw palmetto (Serenoa repens) for mild to moderate BPH, Elderberry (Sambucus nigra) syrup for influenza treatment. These all have very good evidence in terms of double-blind placebo-controlled trials, and St. John’s wort even has a Cochrane review supporting its use. Note that the studies only showed positive effect when using correct dosages for the appropriate symptoms. This is much of the problem with CAM research – either researchers use absurdly low doses or try using a treatment for something for which it was not intended (e.g., Saw Palmetto for severe BPH, or Echinacea purpurea for cold/flu treatment. Only Echinacea angustifolia, a different but related species has the appropriate constituents – alkylamides – to treat viral infections).

    There is much misinformation about the field of CAM and especially CAM research.

    I wrote two lengthy blog posts for anyone who is interested: http://naturalmedicineisthebestmedicine.blogspot.com/2010/05/is-naturopathic-medicine-science-based.html, and http://naturalmedicineisthebestmedicine.blogspot.com/2010/10/evidence-based-naturopathic-medicine.html.

    As for determining the efficacy of natural therapeutics, Natural Medicines Comprehensive Database is my go-to resource.

  • http://drpullen.com medical blog

    We all remember the issues with Chinese ephedrine and weight loss, as well as strokes etc. Many of these need to be subject to the same FDA oversight as traditional meds.

  • Brian

    Most of the people I know that use Alternative Medicine have tried every doctor around to solve their problem, to no avail. No one I know (although of course thats just me) use it as a first try. Personally I’ve used it because when I’ve gone to many MDs, who did blood tests and other tests and found nothing and just shook their heads. Clueless. So we go and try anything we can to figure it out for ourselves.

    Believe me Im nt the person that heads there first. But when the western MDs are clueless, which in many cases they are when confronted with some symptoms (not their fault) then people like me have to try something.

    We have no other choice.

  • winnie

    I’m wary when a practitioner recommends treatment that they sell. It’s a conflict of interest to be selling your own line of supplements to patients you diagnose and treat.

    • pj

      Ummmm, does that apply to surgeons as well, when they recommend a procedure THEY get paid to do????

      When your car is in the shop, do you consider it a conflict of interest if the mechanic installs parts that he/she sells????

      Where do you draw the line?

  • Smart Doc

    Excellent article.

    I have seen patients severely poisoned from “Chinese herbal remedies” containing a potent potpourri of various God-knows-what toxins.

  • http://www.TheHealthCulture.com Jan Henderson

    Thank you for such a balanced, objective discussion of this subject.

    It can be difficult to do double blind studies on the efficacy of some alternative treatments. The NEJM published a study on tai chi and fibromyalgia last year (http://bit.ly/hsHKZM PDF). A commentary in the same issue pointed out that a valid control group would need to be identical to the treatment group in every way except for the “active” element. But with something as complex as tai chi, where the activity has many components, what is the active element? Is it the exercise, the breathing, the concentration, the support of the group, the relaxing imagery, the charisma of the teacher, or some synergy among these elements? “Would the matched control include awkward movements, halted berating, participant isolation, unpleasant imagery, or a tepid teacher?”

    My sense is that many MDs get upset by the idea of alternative therapies because there are patients with serious, curable diseases who seek alternative care to the exclusion of conventional medicine. This appears to be the exception, however. According to 2010 NIH statistics (http://bit.ly/gLnDyX), the majority of patients seek CAM for back pain, followed by neck pain, joint pain, and arthritis. These are people who seek pain relief without surgery or drugs – especially, as Brian points out above, when regular medical care has not brought relief.

    Many patients with psychosomatic complaints receive psychosomatic relief from alternative practitioners who have the time to listen to them. This has nothing to do with the practice being alternative. General practitioners used to perform the same service before medicine became a profit-driven industry.

    • Kevin N.

      Imagine an emergency department with no MD/DOs, but rather one staffed with acupuncturists, chiropractors, naturopaths, reiki masters, etc. Imagine this ED is right next to a REAL emergency department.

      Now here’s the text for those of you who say you prefer alternative medicine. You’re in an ambulance with some acute medical problem. Pick one, it doesn’t matter. Acute chest/abdominal/pelvic pain. Or, acute onset shortness of breath. Say you’re pregnant and you’re bleeding. Or you have a lethargic toddler with a fever. Diarrhea for 3 days, and now you’re severely dehydrated. Trauma. There’s lots of blood. Pick ANY of these!…and you’re in the ambulance…and you’re pulling up to the two EDs described above. Which one do you choose?

      • Taylor

        I don’t care what is wrong with me: SOB, broken foot, stomach ache, I am going to the REAL ER! I much prefer and trust MDs.

      • http://www.TheHealthCulture.com Jan Henderson

        Kevin N – I hope I can say this as non-provocatively as possible. No reasonably sane person would choose alternative care in an emergency. I would really like to know why some doctors are so defensive about alternative therapies. I’m honestly curious. It baffles me.

  • CJ

    Homeopathy, has been proven to work to significant and sometimes substantial benefit in 100′s of studies. These studies have been published in 78 respected, peer-reviewed journals like Cancer, Int’l. J. of Oncology, Rheumatology, The Lancet, Archives of Emergency Medicine, Pediatrics and British J. of Clinical Pharmacology. Anyone interested in reading some of them can see them at:

    http://www.nationalcenterforhomeopathy.org/articles-research
    http://www.extraordinarymedicine.org
    http://avilian.co.uk/

    Homeopathy has been proven safe for infants, children, nursing mothers and pregnant women (EECH Study, 2009; Reilly, et al., 2005).

    WHO recognized homeopathy as the second most used system of medicine in the world today with 1/2 billion patients and 1/2 million practitioners. People use homeopathy because it is safe, effective and inexpensive.

    As a user of homeopathics myself for many years I can say it has never let me down–not for chronic problems, like high blood pressure, or acute illnesses and not for injuries. My traditional doctor confirms my successful homeopathic treatment with conventional tests.

  • http://www.littlepatientbigdoctor.com Haleh Rabizadeh Resnick

    I just wrote Little Patient Big Doctor: One Mother’s Journey (recently partly profiled on CNN) where I encourage people to be open to alternative remedies but simultaneously work with their doctors and partner with them.

    I agree with you entirely that an alternative, natural treatment can be dangerous but as you pointed out when treatments offered by traditional medicine don’t work or have significant side effects – sometimes doing or taking something alternative can be the answer. In those cases, I want doctors to not squelch a person’s hope (we know at the very least the placebo effect works) and have the type of communication with a patient that a patient will share what types of alternative treatments they are using so that it can be monitored in part by a doctor.

  • Molly Ciliberti, RN

    There is only one medicine and that is Western Medicine, all the rest is bunk science. It is time to stop calling mumbo jumbo, snake oil by another name medicine or science. Placebo effect has been proven and we also know that some things heal by themselves. People who seek help from these bunk medicine folks do so at their own risk.

  • http://www.chiropractorguelph.com Mark Kubert, DC

    “…an intervention can be safe for some people but deadly to others…”

    Small statement, big impact. Although it’s great to have randomized controlled trials we still need to be aware of the individuality of each patient. Some will respond well to a particular treatment, others won’t, and still for others the treatment may be completely contraindicated.

    In my chiropractic practice the first thing I want to know: “Is this the best place place for this patient to be?” Mechanical back pain – yes. Back pain due to kidney infection – refer. We all need to know our strengths and limitations as they apply to each individual patient.

  • pj

    To the author- The reference to acupuncture’s effectiveness on back pain was from 1998.

    Here’s a more current article with different results. There was another one which escapes me now showing more relief w/true vs. sham acupuncure for low back pain-

    “September 26, 2007 — Verum or sham acupuncture was almost twice as effective as conventional therapy for low back pain, according to the results of a large, randomized, multicenter, blinded trial reported in the September 24 issue of the Archives of Internal Medicine.”

    • http://happinessinthisworld.com Alex Lickerman, MD

      pj,
      Thanks for this reference. I’ve since reviewed other articles and agree that better evidence for acupuncture’s beneficial effects on chronic low back pain exists than I suggest in my article.

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