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Alternative medicine

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Alternative medicine
Medicinal herbs in a traditional Spanish market
General information
Fringe medicine and science
Controversies
Classifications
Traditional medicine
Alternative diagnoses
Alternative medicine
MeSHD000529

Alternative medicine is any practice that is put forward as having the healing effects of medicine, but is not based on evidence gathered with the scientific method.[1] Often not part of conventional treatment,[2] alternative medicine is usually based on tradition, belief in supernatural energies, pseudoscience, errors in reasoning, propaganda, or fraud.[3][4][5][6] Alternative therapies lack scientific validation, and their effectiveness is either unproved or disproved.[4][7][8] They have also been defined more broadly as the treatments that are not part of the conventional, science based healthcare system.[9][10][11][12]

Alternative medicine is sometimes grouped with complementary medicine which, in general, refers to the same interventions when used in conjunction with mainstream techniques,[13][14][15] under the umbrella term complementary and alternative medicine, or CAM.[16][17] Integrative medicine (or integrative health) is the combination of the practices and methods of alternative medicine with evidence based medicine.[18] Critics maintain that the terms “complementary” and “alternative medicine” are deceptive euphemisms meant to give an impression of medical authority.[19][20][21]

Alternative medicine methods are diverse in their foundations and methodologies. Methods may incorporate or base themselves on traditional medicine, folk knowledge, spiritual beliefs, or newly conceived approaches claiming to heal.[22]

Many of the claims regarding the efficacy of alternative medicines are controversial. Research on alternative medicine is frequently of low quality and methodologically flawed.[23] The safety of alternative medicine is also controversial. Some alternative treatments have been associated with unexpected side effects, which can be fatal. Alternative treatments are used in place of conventional science based medicines, but even with the very safest alternative medicines, delays and absences of conventional science based medicine has resulted in deaths where they are ineffective.[24][25] Some voluntary health agencies focused upon health fraud, misinformation, and quackery as public health problems, have been highly critical of alternative medicine generally or more specifically.[26]

Terminology

"Alternative medicine" refers to any practice that is put forward as having the healing effects of medicine, but is not based on evidence gathered with the scientific method,[3] when used independently or in place of medicine based on science.[9][27][28][29] Alternative medical systems can only exist when there is a identifiable, regularized and authoritative medical orthodoxy, such as arose in the west during the nineteenth-century, to which they can function or act as an alternative.[30]

"Complementary medicine" refers to use of alternative medicine alongside conventional science based medicine, in the belief that it increases the effectiveness.[9][27][28] An example of “complementary medicine” is use of the alternative medicine called acupuncture (sticking needles in the body to influence the flow of a supernatural energy), along with using medicine based on science, in the belief that the alternative medicine increases the effectiveness of the medicine based only on science, which does not address problems with the flow of the supernatural energy. The alternative medicine is thus believed to “complement” medicine that is based on science.[9]

"CAM" is an abbreviation for "complementary and alternative medicine".

The term "Integrative medicine" ("integrated medicine") is used in two different ways. One use refers to a belief that medicine based on science can be "integrated" with practices that are not. Another use refers only to a combination of alternative medical treatments with conventional science based treatments that have some scientific proof of efficacy, in which case it is identical with CAM.[18] Some well known advocates of integrative medicine claim that it also addresses alleged problems with medicine based on science, which are not addressed by CAM. For example, Ralph Snyderman and Andrew Weil state that "integrative medicine is not synonymous with complementary and alternative medicine. It has a far larger meaning and mission in that it calls for restoration of the focus of medicine on health and healing and emphasizes the centrality of the patient-physician relationship."[31]

“Whole medical systems” is used in two different ways.

  • One refers to a spiritual belief, that “spiritual wholeness” is the root of physiological and physical well-being.[32] Ayurveda, Chinese medicine, Homeopathy and Naturopathy are cited as examples[2]
  • Another use is that of the National Institute of Health's National Center for Complementary and Alternative Medicine (NCCAM), to differentiate widely comprehensive systems of practice, from specific components of the system, or from practices that claim to heal only a limited kind of specific medical conditions. An example is Ayurvedic medicine (a traditional medicine of India based in part on religious beliefs and in part on traditional use of herbs), which includes many practices and claims to treat many conditions, as compared to a specific herbal remedy within the Ayurvedic medicine system.[33]

Alternative medicine often relies on using loose language to give the appearance of effectiveness or to suggest that a dichotomy exists when it does not. One example of this is the use of "Western medicine" and "Eastern medicine" to suggest that the difference is not between evidence based medicine and treatments which don't work, but a cultural difference between the asiatic east and the European west.[34]

Characterization

There is no clear and consistent definition for either alternative or complementary medicine.[23]: 17 

Self-characterization

The US National Center for Complementary and Alternative Medicine (NCCAM) defines CAM as "a group of diverse medical and healthcare systems, practices, and products, that are not currently part of conventional medicine”, in a context where conventional medicine is that which is scientifically proven.[9] This definition of CAM is widely known and used and is inclusive of many different types of therapies and products.[35][36]

The Danish Knowledge and Research Center for Alternative Medicine an independent institution under the Danish Ministry of the Interior and Health (Danish abbreviation: ViFAB) uses the term “alternative medicine” for:

  • Treatments performed by therapists that are not authorized healthcare professionals
  • Treatments performed by authorized healthcare professionals, but those based on methods otherwise used mainly outside the healthcare system. People without a healthcare authorisation must be able to perform the treatments.

Institutions

The World Health Organization defines complementary and alternative medicine as a broad set of health care practices that are not part of that country's own tradition and are not integrated into the dominant health care system.[12]

In a consensus report released in 2005, entitled Complementary and Alternative Medicine in the United States, the Institute of Medicine (IOM) defined complementary and alternative medicine (CAM) as the non-dominant approach to medicine in a given culture and historical period.[11] A similar definition has been adopted by the Cochrane Collaboration,[10][37] and official government bodies such as the UK Department of Health.[38] The Cochrane Collaboration Complementary Medicine Field finds that what is considered complementary or alternative practices in one country may be considered conventional medical practices in another. Their definition is, therefore, general: "complementary medicine includes all such practices and ideas that are outside the domain of conventional medicine in several countries and defined by its users as preventing or treating illness, or promoting health and well-being."[37] As an example biofeedback is commonly used within the Physical Medicine & Rehabilitation community but is considered alternative within the medical community as a whole. While some herbal therapies are mainstream in Europe, but are alternative in the United States.[39]

Proponents of evidence-based medicine, such as the Cochrane Collaboration, use the term alternative medicine but agree that all treatments, whether "mainstream" or "alternative", ought to be held to the standards of the scientific method.[40]

The United States' National Science Foundation has defined alternative medicine as "all treatments that have not been proven effective using scientific methods."[3]

Scientists

Numerous mainstream scientists and physicians have commented on and criticised alternative medicine.

A clinical review published in the British Medical Journal defined complementary and alternative medicine as " group of therapeutic and diagnostic disciplines that exist largely outside the institutions where conventional health care is taught and provided."[10]

There is a debate among medical researchers over whether any therapy may be properly classified as 'alternative medicine'. Some claim that there is only medicine that has been adequately tested and that which has not.[41] They feel that healthcare practices should be classified based solely on scientific evidence. If a treatment has been rigorously tested and found safe and effective, traditional medicine will adopt it regardless of whether it was considered "alternative" to begin with.[41] It is thus possible for a method to change categories (proven vs. unproven), based on increased knowledge of its effectiveness or lack thereof. Prominent supporters of this position include George D. Lundberg, former editor of the Journal of the American Medical Association (JAMA).[42]

David M. Eisenberg, an integrative medicine researcher,[43] defines it as "medical interventions not taught widely at US medical schools or generally available at US. hospitals,"[44] NCCAM states that formerly unproven remedies may be incorporated into conventional medicine if they are shown to be safe and effective.[9] Barrie R. Cassileth, a researcher of complementary and alternative medicine, has summed up the situation as "not all mainstream physicians are pleased with CAM, with current efforts to integrate CAM into mainstream medicine, or with a separate NIH research entity for "alternative" medicine.[41][45]

Stephen Barrett, founder and operator of Quackwatch, argues that practices labeled "alternative" should be reclassified as either genuine, experimental, or questionable. Here he defines genuine as being methods that have sound evidence for safety and effectiveness, experimental as being unproven but with a plausible rationale for effectiveness, and questionable as groundless without a scientifically plausible rationale. He has concerns that just because some "alternatives" have merit, there is the impression that the rest deserve equal consideration and respect even though most are worthless.[46] He says that there is a policy at the NIH of never saying something doesn't work only that a different version or dose might give different results.[47]

Edzard Ernst, professor of complementary medicine, characterizes the evidence for many alternative techniques as weak, nonexistent, or negative, but states that evidence exists for others, in particular certain herbs and acupuncture.[48] Ernst has concluded that 95% of the alternative treatments he and his team have studied, including acupuncture, herbal medicine, homeopathy, and reflexology, are, according to The Economist, "statistically indistinguishable from placebo treatments."[49]

Richard Dawkins, an evolutionary biologist, defines alternative medicine as a "set of practices that cannot be tested, refuse to be tested, or consistently fail tests."[50] He also states that "there is no alternative medicine. There is only medicine that works and medicine that doesn't work."[51] He says that if a technique is demonstrated effective in properly performed trials, it ceases to be alternative and simply becomes medicine.[52]

A letter by four Nobel Laureates and other prominent scientists deplored the lack of critical thinking and scientific rigor in National Institutes of Health supported alternative medicine research.[53] In 2009 a group of scientists made a proposal to shut down the National Center for Complementary and Alternative Medicine. They argued that the vast majority of studies were based on unconventional understandings of physiology and disease and have shown little or no effect. Further, they argue that the field's more-plausible interventions such as diet, relaxation, yoga and botanical remedies can be studied just as well in other parts of NIH, where they would need to compete with conventional research projects.[54]

These concerns are supported by negative results in almost all studies conducted over ten years at a cost of $2.5 billion by the NCCAM.[55] R. Barker Bausell, a research methods expert and author of "Snake Oil Science" states that "it's become politically correct to investigate nonsense."[47] There are concerns that just having NIH support is being used to give unfounded "legitimacy to treatments that are not legitimate."[54]

Wallace Sampson, an editor of Scientific Review of Alternative Medicine and a Stanford University professor of medicine write that CAM is the "propagation of the absurd" based on the example that alternative and complementary have been substituted for quackery, dubious and implausible and concerns that CAM tolerates contradiction without thorough reason and experiment.[56]

The Washington Post reports that a growing number of traditionally trained physicians practice integrative medicine, which it defines as "conventional medical care that incorporates strategies such as acupuncture, reiki and herbal remedies."[57]

An editorial in the Economist characterized alternative medicine as mostly "quackery" and described the vast majority as offering nothing more than the placebo effect. It suggested that, "Virtually all alternative medicine is bunk; but the placebo effect is rather interesting."[58]

Classifications

NCCAM has developed one of the most widely used classification systems for the branches of complementary and alternative medicine.[9][23] It classifies complementary and alternative therapies into five major groups, which have some overlap.[9]

  1. Whole medical systems: cut across more than one of the other groups; examples include Traditional Chinese medicine, Naturopathy, Homeopathy, and Ayurveda
  2. Mind-body medicine: takes a holistic approach to health that explores the interconnection between the mind, body, and spirit. It works under the premise that the mind can affect "bodily functions and symptoms"
  3. Biology-based practices: use substances found in nature such as herbs, foods, vitamins, and other natural substances
  4. Manipulative and body-based practices: feature manipulation or movement of body parts, such as is done in chiropractic and osteopathic manipulation
  5. Energy medicine: is a domain that deals with putative and verifiable energy fields:
    • Biofield therapies are intended to influence energy fields that, it is purported, surround and penetrate the body. No empirical evidence has been found to support the existence of the putative energy fields on which these therapies are predicated.
    • Bioelectromagnetic-based therapies use verifiable electromagnetic fields, such as pulsed fields, alternating-current, or direct-current fields in an unconventional manner.

Usage

Further information: List of branches of alternative medicine
Age-adjusted percent of adults who have used complementary and alternative medicine: United States, 2002[59]

A 2011 multi-National systematic review concluded that about 40% of cancer patients use some form of complementary and alternative medicine.[60] Alternative medicine varies from country to country. Jurisdictions where alternative medical practices are sufficiently widespread may license and regulate them. Edzard Ernst has said that in Austria and Germany complementary and alternative medicine is mainly in the hands of physicians,[16] while some estimates suggest that at least half of American alternative practitioners are physicians.[61] In Germany herbs are tightly regulated: half are prescribed by doctors and covered by health insurance based on their Commission E legislation.[62]

Many people utilize mainstream medicine for diagnosis and basic information, while turning to alternatives for therapy or health-enhancing measures. Studies indicate that alternative approaches are often used in conjunction with conventional medicine.[59] This is referred to by NCCAM as integrative (or integrated) medicine because it "combines treatments from conventional medicine and CAM for which there is some high-quality evidence of safety and effectiveness."[9] According to Andrew T. Weil M.D., a leading proponent of integrative medicine, the principles of integrative medicine include: appropriate use of conventional and CAM methods; patient participation; promotion of health as well as treatment of disease; and a preference for natural, minimally-invasive methods.[63]

A 1997 survey found that 13.7% of respondents in the United States had sought the services of both a medical doctor and an alternative medicine practitioner. The same survey found that 96% of respondents who sought the services of an alternative medicine practitioner also sought the services of a medical doctor in the past 12 months. Medical doctors are often unaware of their patient's use of alternative medical treatments as only 38.5% of the patients alternative therapies were discussed with their medical doctor.[64]

Edzard Ernst, Professor of Complementary Medicine at the University of Exeter, wrote in the Medical Journal of Australia that "about half the general population in developed countries use complementary and alternative medicine (CAM)."[65] Survey results released in May 2004 by the National Center for Complementary and Alternative Medicine, part of the United States National Institutes of Health, found that in 2002 62.1% of adults in the country had used some form of CAM in the past 12 months and 75% across lifespan (though these figure drop to 36.0% and 50% if prayer specifically for health reasons is excluded); this study included yoga, meditation, herbal treatments and the Atkins diet as CAM.[59][66] Another study suggests a similar figure of 40%.[67]

A British telephone survey by the BBC of 1209 adults in 1998 shows that around 20% of adults in Britain had used alternative medicine in the past 12 months.[68] Ernst has been active politically on this issue as well, publicly requesting that Prince Charles recall two guides to alternative medicine published by the Foundation for Integrated Health, on the grounds that "[t]hey both contain numerous misleading and inaccurate claims concerning the supposed benefits of alternative medicine" and that "[t]he nation cannot be served by promoting ineffective and sometimes dangerous alternative treatments."[69] In general, he believes that CAM can and should be subjected to scientific testing.[40][48][70]

The use of alternative medicine in developed countries appears to be increasing. A 1998 study showed that the use of alternative medicine had risen from 33.8% in 1990 to 42.1% in 1997.[64] In the United Kingdom, a 2000 report ordered by the House of Lords suggested that "...limited data seem to support the idea that CAM use in the United Kingdom is high and is increasing."[71] In developing nations, access to essential medicines is severely restricted by lack of resources and poverty. Traditional remedies, often closely resembling or forming the basis for alternative remedies, may comprise primary healthcare or be integrated into the healthcare system. In Africa, traditional medicine is used for 80% of primary healthcare, and in developing nations as a whole over one-third of the population lack access to essential medicines.[72]

Advocates of alternative medicine hold that the various alternative treatment methods are effective in treating a wide range of major and minor medical conditions, and that recently published research (such as Michalsen, 2003,[73] Gonsalkorale 2003,[74] and Berga 2003)[75] proves the effectiveness of specific alternative treatments. They assert that a PubMed search revealed over 370,000 research papers classified as alternative medicine published in Medline-recognized journals since 1966 in the National Library of Medicine database. See also Kleijnen 1991,[76] and Linde 1997.[77]

Complementary therapies are often used in palliative care or by practitioners attempting to manage chronic pain in patients. Complementary medicine is considered more acceptable in the interdisciplinary approach used in palliative care than in other areas of medicine. "From its early experiences of care for the dying, palliative care took for granted the necessity of placing patient values and lifestyle habits at the core of any design and delivery of quality care at the end of life. If the patient desired complementary therapies, and as long as such treatments provided additional support and did not endanger the patient, they were considered acceptable."[78] The non-pharmacologic interventions of complementary medicine can employ mind-body interventions designed to "reduce pain and concomitant mood disturbance and increase quality of life."[79]

Physicians who practice complementary medicine usually discuss and advise patients as to available complementary therapies. Patients often express interest in mind-body complementary therapies because they offer a non-drug approach to treating some health conditions.[80] Some mind-body techniques, such as cognitive-behavioral therapy, were once considered complementary medicine, but are now a part of conventional medicine in the United States.[81] "Complementary medicine treatments used for pain include: acupuncture, low-level laser therapy, meditation, aroma therapy, Chinese medicine, dance therapy, music therapy, massage, herbalism, therapeutic touch, yoga, osteopathy, chiropractic, naturopathy, and homeopathy."[82]

In defining complementary medicine in the UK, the House of Lords Select Committee determined that the following therapies were the most often used to complement conventional medicine:[83] Alexander technique, Aromatherapy, Bach and other flower remedies, Body work therapies including massage, Counselling stress therapies, hypnotherapy, Meditation, Reflexology, Shiatsu, Maharishi Ayurvedic medicine, Nutritional medicine, and Yoga.

United States

A botánica, such as this one, caters to the Latino community and sells folk medicine alongside statues of saints, candles decorated with prayers, and other items.

A 2002 survey of US adults 18 years and older conducted by the National Center for Health Statistics (CDC) and the National Center for Complementary and Alternative Medicine indicated:[59]

  • 74.6% had used some form of complementary and alternative medicine (CAM).
  • 62.1% had done so within the preceding twelve months.
  • When prayer specifically for health reasons is excluded, these figures fall to 49.8% and 36.0%, respectively.
  • 45.2% had in the last twelve months used prayer for health reasons, either through praying for their own health or through others praying for them.
  • 54.9% used CAM in conjunction with conventional medicine.
  • 14.8% "sought care from a licensed or certified" practitioner, suggesting that "most individuals who use CAM prefer to treat themselves."
  • The Dietary Supplement Industry is expected to be $250 Billion by 2016 worldwide
  • Most people used CAM to treat and/or prevent musculoskeletal conditions or other conditions associated with chronic or recurring pain.
  • "Women were more likely than men to use CAM. The largest sex differential is seen in the use of mind-body therapies including prayer specifically for health reasons".
  • "Except for the groups of therapies that included prayer specifically for health reasons, use of CAM increased as education levels increased".
  • The most common CAM therapies used in the US in 2002 were prayer (45.2%), herbalism (18.9%), breathing meditation (11.6%), meditation (7.6%), chiropractic medicine (7.5%), yoga (5.1%), body work (5.0%), diet-based therapy (3.5%), progressive relaxation (3.0%), mega-vitamin therapy (2.8%) and Visualization (2.1%)

In 2004, a survey of nearly 1,400 U.S. hospitals found that more than one in four offered alternative and complementary therapies such as acupuncture, homeopathy, and massage therapy.[84]

A 2008 survey of US hospitals by Health Forum, a subsidiary of the American Hospital Association, found that more than 37 percent of responding hospitals indicated they offer one or more alternative medicine therapies, up from 26.5 percent in 2005. Additionally, hospitals in the southern Atlantic states were most likely to include CAM, followed by east north central states and those in the middle Atlantic. More than 70% of the hospitals offering CAM were in urban areas.[85]

In 2011 the Millennium Cohort Study (United States) found that 39% of the then currently enrolled 44,287 cohort members reported using at least one CAM therapy.[86]

The National Science Foundation has also conducted surveys of the popularity of alternative medicine. After describing the negative impact science fiction in the media has on public attitudes and understandings of pseudoscience, and defining alternative medicine as all treatments that have not been proven effective using scientific methods, as well as mentioning the concerns of individual scientists, organizations, and members of the science policymaking community, it commented that "nevertheless, the popularity of alternative medicine appears to be increasing."[3]

In the state of Texas, physicians may be partially protected from charges of unprofessional conduct or failure to practice medicine in an acceptable manner, and thus from disciplinary action, when they prescribe alternative medicine in a complementary manner, if board specific practice requirements are satisfied and the therapies utilized do not present "a safety risk for the patient that is unreasonably greater than the conventional treatment for the patient's medical condition."[87]

Denmark

45.2% of the Danish population aged 16 or above had in 2005 used alternative medicine at some point in life. 22.5% had used alternative medicine within the previous year.[88]

The most popular types of therapies within the previous year (2005) are:

  • Massage, osteopathy or other manipulative techniques (13.2 percent)
  • Reflexology (6.1 percent)
  • Acupuncture (5.4 percent)

More results of statistical surveys on alternative medicine in Denmark is available on ViFABs (Knowledge and Research Center for Alternative Medicines) home page, see the pages on Statistics: http://www.vifab.dk/uk/alternative+medicine/statistics

Use among medical students

68% of the medical students in Denmark were in 2008 using or had used alternative therapy.[89] The most commonly used types of alternative medicine were:

Education

In the United States, increasing numbers of medical colleges have started offering courses in alternative and complementary medicine. A 1998 study reported "There is tremendous heterogeneity and diversity in content, format, and requirements among courses in complementary and alternative medicine at US medical schools". Common topics included chiropractic, acupuncture, homeopathy, herbal therapies, and mind-body techniques. In three separate research surveys that surveyed 729 schools (125 medical schools offering a Doctor of Medicine degree (M.D.), 25 medical schools offering a Doctor of Osteopathic Medicine degree (D.O.), and 585 schools offering a nursing degree), 60% of the medical schools, 95% of osteopathic medical schools and 84.8% of the nursing schools teach some form of CAM.[90][91][92] The University of Arizona College of Medicine offers a program in Integrative Medicine under the leadership of Andrew Weil that trains physicians in various branches of alternative medicine that "...neither rejects conventional medicine nor embraces alternative practices uncritically."[93] The Florida Institute for Complementary and Alternative Medicine is the only state accredited school which can confer an Alternative Medicine degree.[citation needed] Accredited Naturopathic colleges and universities are also increasing in number and popularity in Canada and the USA. (See Naturopathic medical school in North America).

A 2001 survey of European universities found that unconventional medicine courses are widely represented at European universities. They cover a wide range of therapies and many of them are used clinically. Research work is underway at several faculties.[94] A 2006 survey showed that 40% of the responding European universities were offering some form of CAM training."[95]

Universities in the United Kingdom have been dropping their degree courses in alternative medicine, and as of 2012, no more degrees will be offered in such courses as homeopathy, naturopathy, and reflexology.[96][97]

Regulation

Because of the uncertain nature of various alternative therapies and the wide variety of claims different practitioners make, alternative medicine has been a source of vigorous debate, even over the definition of alternative medicine.[98][99] Dietary supplements, their ingredients, safety, and claims, are a continual source of controversy.[100] In some cases, political issues, mainstream medicine and alternative medicine all collide, such as in cases where synthetic drugs are legal but the herbal sources of the same active chemical are banned.[101]

In other cases, controversy over mainstream medicine causes questions about the nature of a treatment, such as water fluoridation.[102] Alternative medicine and mainstream medicine debates can also spill over into freedom of religion discussions, such as the right to decline lifesaving treatment for one's children because of religious beliefs.[103] Government regulators continue to attempt to find a regulatory balance.[104]

Jurisdiction differs concerning which branches of alternative medicine are legal, which are regulated, and which (if any) are provided by a government-controlled health service or reimbursed by a private health medical insurance company. The United Nations Committee on Economic, Social and Cultural Rights – article 34 (Specific legal obligations) of the General Comment No. 14 (2000) on The right to the highest attainable standard of health – states that

Furthermore, obligations to respect include a State's obligation to refrain from prohibiting or impeding traditional preventive care, healing practices and medicines, from marketing unsafe drugs and from applying coercive medical treatments, unless on an exceptional basis for the treatment of mental illness or the prevention and control of communicable diseases.

— [105]

Specific implementations of this article are left to member states.

A number of alternative medicine advocates disagree with the restrictions of government agencies that approve medical treatments. In the United States, for example, critics say that the Food and Drug Administration's criteria for experimental evaluation methods impedes those seeking to bring useful and effective treatments and approaches to the public, and that their contributions and discoveries are unfairly dismissed, overlooked or suppressed. Alternative medicine providers recognize that health fraud occurs, and argue that it should be dealt with appropriately when it does, but that these restrictions should not extend to what they view as legitimate healthcare products.

In New Zealand, alternative medicine products are classified as food products, so there are no regulations or safety standards in place.[106]

In Australia, the topic is termed as complementary medicine and the Therapeutic Goods Administration has issued various guidances and standards.[107] Australian regulatory guidelines for complementary medicines (ARGCM) demands that the pesticides, fumigants, toxic metals, microbial toxins, radionuclides, and microbial contaminations present in herbal substances should be monitored, although the guidance does not request for the evidences of these traits.[108] However, for the herbal substances in pharmacopoeial monographes, the detailed information should be supplied to relevant authorities [109]

The production of modern pharmaceuticals is strictly regulated to ensure that medicines contain a standardized quantity of active ingredients and are free from contamination. Alternative medicine products are not subject to the same governmental quality control standards, and consistency between doses can vary. This leads to uncertainty in the chemical content and biological activity of individual doses. This lack of oversight means that alternative health products are vulnerable to adulteration and contamination.[110] This problem is magnified by international commerce, since different countries have different types and degrees of regulation. This can make it difficult for consumers to properly evaluate the risks and qualities of given products.

Denmark [111]: Herbal and dietary supplements is the designation of a range of products, which have in common their status as medicine belonging under the Danish Medicines Act.In the Danish Medicines Act there exist four types of herbal and dietary supplements: Herbal medicinal products,[112] Strong vitamin and mineral preparations,[113] Traditional botanical medicinal products [114] and Homeopathic medicinal products.[115] Some dietary supplements [116] fall within a special category of products, which differ from the above in that they are not authorized medicinal products. Dietary supplements are regulated under the Food Act and are registered by the Danish Veterinary and Food Administration.

Alternative therapists

Denmark has a registration system for alternative therapy practitioners, RAB.[117]

Criticism

The NCCAM budget has been criticized[118] because, despite the duration and intensity of studies to measure the efficacy of alternative medicine, there had been no effective CAM treatments supported by scientific evidence as of 2002 according to the QuackWatch website.[119] Despite this, the National Center for Complementary and Alternative Medicine budget has been on a sharp sustained rise to support complementary medicine. In fact, the whole CAM field has been called by critics the SCAM.[119]

"There really is no such thing as alternative medicine--only medicine that has been proved to work and medicine that has not." Arnold Relman, editor in chief emeritus of The New England Journal of Medicine.[120][full citation needed] Speaking of government funding studies of integrating alternative medicine techniques into the mainstream, Steven Novella, a neurologist at Yale School of Medicine wrote that it "is used to lend an appearance of legitimacy to treatments that are not legitimate." Marcia Angell, former executive editor of The New England Journal of Medicine says, "It's a new name for snake oil."[118]

Speaking of ethics, in November 2011 Edzard Ernst stated that the "level of misinformation about alternative medicine has now reached the point where it has become dangerous and unethical. So far, alternative medicine has remained an ethics-free zone. It is time to change this."[121]

Alternative and evidence-based medicine

Efficacy

Many alternative therapies have been tested and certain CAM interventions do have evidence.[122] In 2003, a project funded by the CDC identified 208 condition-treatment pairs, of which 58% had been studied by at least one randomized controlled trial (RCT), and 23% had been assessed with a meta-analysis.[123] According to a 2005 book by a US Institute of Medicine panel, the number of RCTs focused on CAM has risen dramatically. The book cites Vickers (1998), who found that many of the CAM-related RCTs are in the Cochrane register, but 19% of these trials were not in MEDLINE, and 84% were in conventional medical journals.[23]: 133 

As of 2005, the Cochrane Library had 145 CAM-related Cochrane systematic reviews and 340 non-Cochrane systematic reviews. An analysis of the conclusions of only the 145 Cochrane reviews was done by two readers. In 83% of the cases, the readers agreed. In the 17% in which they disagreed, a third reader agreed with one of the initial readers to set a rating. These studies found that, for CAM, 38.4% concluded positive effect or possibly positive (12.4%) effect, 4.8% concluded no effect, 0.69% concluded harmful effect, and 56.6% concluded insufficient evidence. An assessment of conventional treatments found that 41.3% concluded positive or possibly positive effect, 20% concluded no effect, 8.1% concluded net harmful effects, and 21.3% concluded insufficient evidence. However, the CAM review used the 2004 Cochrane database, while the conventional review used the 1998 Cochrane database.[23]: 135–136 

Lists of the Cochrane Reviews on alternative medicine including summaries of the results sorted by type of therapy (updated monthly) are made available at ViFABs (Knowledge and Research Center for Alternative Medicines) home page, see the lists here: http://www.vifab.dk/uk/cochrane+and+alternative+medicine

Most alternative medical treatments are not patentable, which may lead to less research funding from the private sector. In addition, in most countries, alternative treatments (in contrast to pharmaceuticals) can be marketed without any proof of efficacy—also a disincentive for manufacturers to fund scientific research.[124] Some have proposed adopting a prize system to reward medical research.[125] However, public funding for research exists. Increasing the funding for research on alternative medicine techniques is the purpose of the US National Center for Complementary and Alternative Medicine. NCCAM and its predecessor, the Office of Alternative Medicine, have spent more than $2.5 billion on such research since 1992; this research has largely not demonstrated the efficacy of alternative treatments.[47][126][127]

Some skeptics of alternative practices say that a person may attribute symptomatic relief to an otherwise-ineffective therapy due to the placebo effect, the natural recovery from or the cyclical nature of an illness (the regression fallacy), or the possibility that the person never originally had a true illness.[128]

In the same way as for conventional therapies, drugs, and interventions, it can be difficult to test the efficacy of alternative medicine in clinical trials. In instances where an established, effective, treatment for a condition is already available, the Helsinki Declaration states that withholding such treatment is unethical in most circumstances. Use of standard-of-care treatment in addition to an alternative technique being tested may produce confounded or difficult-to-interpret results.[129]

Cancer researcher Andrew J. Vickers has stated:

Contrary to much popular and scientific writing, many alternative cancer treatments have been investigated in good-quality clinical trials, and they have been shown to be ineffective. In this article, clinical trial data on a number of alternative cancer cures including Livingston-Wheeler, Di Bella Multitherapy, antineoplastons, vitamin C, hydrazine sulfate, Laetrile, and psychotherapy are reviewed. The label "unproven" is inappropriate for such therapies; it is time to assert that many alternative cancer therapies have been "disproven."[130]

Safety

See also: List of herbs with known adverse effects

Adequacy of Regulation and CAM Safety

One of the commonly voiced concerns about complementary alternative medicine (CAM) is the manner in which is regulated. There have been significant developments in how CAMs should be assessed prior to re-sale in the United Kingdom and the European Union (EU) in the last 2 years. Despite this, it has been suggested that current regulatory bodies have been ineffective in preventing deception of patients as many companies have re-labelled their drugs to avoid the new laws.[131] There is no general consensus about how to balance consumer protection (from false claims, toxicity, and advertising) with freedom to choose remedies.

Advocates of CAM suggest that regulation of the industry will adversely affect patients looking for alternative ways to manage their symptoms, even if many of the benefits may represent the placebo affect.[132] Some contend that alternative medicines should not require any more regulation than over-the-counter medicines that can also be toxic in overdose (such as paracetamol).[133]

Interactions with conventional pharmaceuticals

Forms of alternative medicine that are biologically active can be dangerous even when used in conjunction with conventional medicine. Examples include immuno-augmentation therapy, shark cartilage, bioresonance therapy, oxygen and ozone therapies, insulin potentiation therapy. Some herbal remedies can cause dangerous interactions with chemotherapy drugs, radiation therapy, or anesthetics during surgery, among other problems.[134] An anecdotal example of these dangers was reported by Associate Professor Alastair MacLennan of Adelaide University, Australia regarding a patient who almost bled to death on the operating table after neglecting to mention that she had been taking "natural" potions to "build up her strength" before the operation, including a powerful anticoagulant that nearly caused her death.[135]

To ABC Online, MacLennan also gives another possible mechanism:

And lastly [sic] there's the cynicism and disappointment and depression that some patients get from going on from one alternative medicine to the next, and they find after three months the placebo effect wears off, and they're disappointed and they move on to the next one, and they're disappointed and disillusioned, and that can create depression and make the eventual treatment of the patient with anything effective difficult, because you may not get compliance, because they've seen the failure so often in the past.|[136]

Potential side-effects

Conventional treatments are subjected to testing for undesired side-effects, whereas alternative treatments, in general, are not subjected to such testing at all. Any treatment – whether conventional or alternative – that has a biological or psychological effect on a patient may also have potential to possess dangerous biological or psychological side-effects. Attempts to refute this fact with regard to alternative treatments sometimes use the appeal to nature fallacy, i.e., "that which is natural cannot be harmful".

An exception to the normal thinking regarding side-effects is Homeopathy. Since 1938, the U.S. Food and Drug Administration (FDA) has regulated homeopathic products in "several significantly different ways from other drugs."[137] Homeopathic preparations, termed "remedies," are extremely dilute, often far beyond the point where a single molecule of the original active (and possibly toxic) ingredient is likely to remain. They are, thus, considered safe on that count, but "their products are exempt from good manufacturing practice requirements related to expiration dating and from finished product testing for identity and strength," and their alcohol concentration may be much higher than allowed in conventional drugs.[137]

Treatment delay

Those having experienced or perceived success with one alternative therapy for a minor ailment may be convinced of its efficacy and persuaded to extrapolate that success to some other alternative therapy for a more serious, possibly life-threatening illness.[138] For this reason, critics argue that therapies that rely on the placebo effect to define success are very dangerous. According to mental health journalist Scott Lilienfeld in 2002, "unvalidated or scientifically unsupported mental health practices can lead individuals to forgo effective treatments" and refers to this as "opportunity cost". Individuals who spend large amounts of time and money on ineffective treatments may be left with precious little of either, and may forfeit the opportunity to obtain treatments that could be more helpful. In short, even innocuous treatments can indirectly produce negative outcomes.[24]

Between 2001 and 2003, four children died in Australia because their parents chose ineffective naturopathic, homeopathic, or other alternative medicines and diets rather than conventional therapies.[25] In all, they found 17 instances in which children were significantly harmed by a failure to use conventional medicine.

Unconventional cancer "cures"

Perhaps because many forms of cancer are difficult or impossible to cure, there have always been many therapies offered outside of conventional cancer treatment centers and based on theories not found in biomedicine. These alternative cancer cures have often been described as "unproven," suggesting that appropriate clinical trials have not been conducted and that the therapeutic value of the treatment is unknown. However, many alternative cancer treatments have been investigated in good-quality clinical trials, and they have been shown to be ineffective. [139]

Research funding

Although the Dutch government funded CAM research between 1986 and 2003, it formally ended funding in 2006.[140]

Integrative medicine, complementary medicine, fringe medicine

Integrative medicine is the combination of the practices and methods of alternative/complementary medicine with conventional medicine.[141] It may include preventive medicine and patient-centered medicine. It may also include practices not normally referred to as medicine, such as using prayer, meditation, socializing, and recreation as therapies. Its academic proponents sometimes recommend misleading patients by using known placebo treatments in order to achieve a placebo effect.[142] However, a 2010 survey of family physicians found that 56% of respondents said they had used a placebo in clinical practice as well. Eighty-five percent of respondents believed placebos can have both psychological and physical benefits.[143][144] A number of universities and hospitals have departments of integrative medicine.[145][146][147][148][149][150][151]

Criticism of integrative medicine includes about proposing to lie to patients about alternative medicines known to be no more than a placebo in order to achieve a placebo effect, and “diverting research time, money, and other resources from more fruitful lines of investigation in order to pursue a theory that has no basis in biology”.[21][152]

"Quackademic medicine" is a pejorative term used for “integrative medicine”, when considered to be an infiltration of quackery into academic science-based medicine, and was picked up by science-based medicine anti-ACM critics.[21]

History

Fueled by a nationwide survey published in 1993 by David Eisenberg, which revealed that in 1990 approximately 60 million Americans had used one or more complementary or alternative therapies to address health issues.[153] A study published in the November 11, 1998 issue of the Journal of the American Medical Association reported that 42% of Americans had used complementary and alternative therapies, up from 34% in 1990.[154] However, despite the growth in patient demand for complementary medicine, most of the early alternative/complementary medical centers failed.[155]

Appeal

A study published in 1998[67] indicates that a majority of alternative medicine use was in conjunction with standard medical treatments. Approximately 4.4 percent of those studied used alternative medicine as a replacement for conventional medicine. The research found that those having used alternative medicine tended to have higher education or report poorer health status. Dissatisfaction with conventional medicine was not a meaningful factor in the choice, but rather the majority of alternative medicine users appear to be doing so largely because "they find these healthcare alternatives to be more congruent with their own values, beliefs, and philosophical orientations toward health and life." In particular, subjects reported a holistic orientation to health, a transformational experience that changed their worldview, identification with a number of groups committed to environmentalism, feminism, psychology, and/or spirituality and personal growth, or that they were suffering from a variety of common and minor ailments – notable ones being anxiety, back problems, and chronic pain.

Authors have speculated on the socio-cultural and psychological reasons for the appeal of alternative medicines among that minority using them in lieu of conventional medicine. There are several socio-cultural reasons for the interest in these treatments centered on the low level of scientific literacy among the public at large and a concomitant increase in antiscientific attitudes and new age mysticism.[156] Related to this are vigorous marketing[157] of extravagant claims by the alternative medical community combined with inadequate media scrutiny and attacks on critics.[156][158]

There is also an increase in conspiracy theories toward conventional medicine and pharmaceutical companies, mistrust of traditional authority figures, such as the physician, and a dislike of the current delivery methods of scientific biomedicine, all of which have led patients to seek out alternative medicine to treat a variety of ailments.[158] Many patients lack access to contemporary medicine, due to a lack of private or public health insurance, which leads them to seek out lower-cost alternative medicine.[59] Medical doctors are also aggressively marketing alternative medicine to profit from this market.[157]

In addition to the social-cultural underpinnings of the popularity of alternative medicine, there are several psychological issues that are critical to its growth. One of the most critical is the placebo effect, which is a well-established observation in medicine.[159] Related to it are similar psychological effects such as the will to believe,[156] cognitive biases that help maintain self-esteem and promote harmonious social functioning,[156] and the post hoc, ergo propter hoc fallacy.[156]

Patients can also be averse to the painful, unpleasant, and sometimes-dangerous side effects of biomedical treatments. Treatments for severe diseases such as cancer and HIV infection have well-known, significant side-effects. Even low-risk medications such as antibiotics can have potential to cause life-threatening anaphylactic reactions in a very few individuals. Also, many medications may cause minor but bothersome symptoms such as cough or upset stomach. In all of these cases, patients may be seeking out alternative treatments to avoid the adverse effects of conventional treatments.[156][158]

Schofield et al., in a systematic review published in 2011, make ten recommendations which they think may increase the effectiveness of consultations in a conventional (here: oncology) setting, such as "Ask questions about CAM use at critical points in the illness trajectory"; "Respond to the person's emotional state"; and "Provide balanced, evidence-based advice". They suggest that this approach may address "... concerns surrounding CAM use [and] encourage informed decision-making about CAM and ultimately, improve outcomes for patients".[160]

CAM's popularity may be related to other factors which Edzard Ernst mentions in an interview in The Independent:

Why is it so popular, then? Ernst blames the providers, customers and the doctors whose neglect, he says, has created the opening into which alternative therapists have stepped. "People are told lies. There are 40 million websites and 39.9 million tell lies, sometimes outrageous lies. They mislead cancer patients, who are encouraged not only to pay their last penny but to be treated with something that shortens their lives. "At the same time, people are gullible. It needs gullibility for the industry to succeed. It doesn't make me popular with the public, but it's the truth.[161]

In a paper published in October 2010 entitled The public's enthusiasm for complementary and alternative medicine amounts to a critique of mainstream medicine, Ernst describes these views in greater detail and concludes:

[CAM] is popular. An analysis of the reasons why this is so points towards the therapeutic relationship as a key factor. Providers of CAM tend to build better therapeutic relationships than mainstream healthcare professionals. In turn, this implies that much of the popularity of CAM is a poignant criticism of the failure of mainstream healthcare. We should consider it seriously with a view of improving our service to patients.[162]

Academic resources

See also

References

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Further reading

World Health Organization publication

Journals dedicated to alternative medicine research

Criticism

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