Complementary and alternative medicine

Chapter Eight THE ”CAM” MOVEMENT c0 HARLEY SCHWADRON “Tell them about your psoriasis, Betty. Maybe they can cure it.” There cannot be two kinds ofmedicine-conventional and alternative. There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work. Once a treatment has been tested rigorously, it no longer matters whether it was considered alternative at the outset. If it is found to be reasonably safe and effective, it will be accepted. But assertions, speculation, and testimonials do not substitute for evidence. MARCIA ANGELL, M.D. JEROME KAssIRER, M.D.1 The more mysterious, ancient, traditional, spiritual and holistic an explanation is, the more powerful and attractive it seems to be. The fact that vitalism is unscientific and posits the existence of an ethereal force beyond the powers of science to detect, may in itself be attractive to those who can’t live with the realities of the material world, are unable to deal with a negative or uncertain diagnosis or prognosis, those who fear science and to those who are unable to understand it. PETER H. CANTER, PH.D.2 The reason we should defer to experts is not that the experts know everything. Of course they don’t. It’s just that they know more than non-experts do. It’s not that science has all the answers. It doesn’t. It’s just that astrologers, shamans, and natural healers have none of them. 3 DAVID FRUM 132 Part Two Health-Care Approaches Key Concepts KEEP THESE POINTS IN MIND AS You STUDY Tms CHAPTER • “Complementary and alternative medicine” is an ambiguous marketing term rather than a sharply defined set of practices. Thus general statements about its popularity or effectiveness should be interpreted very cautiously. • The vast majority of methods referred to as “alternative” lack a scientifically plausible rationale. • Calling a method “complementary” does not mean that adding it to an effective method will improve the outcome. • Many proponents of unscientific “alternatives” hold sincere beliefs that their methods are effective or worth trying. • Under the rules of science, the burden of proof falls on those who make the claims. Few “CAM” proponents test their claims or even keep track of their results, and many don’t feel that the rules of science are applicable to them. • “Alternative” proponents are campaigning to abolish consumer protection laws that require products and services to be proven effective before they are marketed. T he phrase “complementary and alternative medicine” (“CAM”) is a euphemistic label for practices most of which are unsubstantiated and lack a scientifically plausible rationale. “CAM” is also a social movement that involves businesses, media outlets, academic institutions, health professionals, government agencies, self-proclaimed healers, celebrities, authors, bloggers, spiritualists, legislators, and crusading consumer groups. The National Institutes of Health Center for Complementary and Alternative Medicine (NCCAM)4 defines “CAM” as: A group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. Complementary medicine is used together with conventional medicine, and alternative medicine is used in place of conventional medicine. The above statement implies that “CAM” methods actually complement or serve as sensible alternatives to standard methods. However, the “CAM” marketplace is dominated by products and services that do neither. The dictionary definition of the noun “alternative” is a choice between mutually exclusive possibilities. Until the late 1980s, in standard medical usage, it referred to choices among effective treatments. In some cases they were equally effective (for example, the use of radiation or surgery for certain cancers); in others the expected outcome differed, but there were reasonable tradeoffs between risks and benefits. Today, however, the word “alternative” is applied to a multitude of approaches that would be more accurately classified as irrational, ineffective, or quack. Dictionaries define the adjective “complementary” as completing or combining to enhance or emphasize each other’s qualities. Thus, referring to something as “complementary medicine” implies that it completes or enhances what standard medicine does not do by itself. However, just because something is called complementary does not mean it is effective. If a treatment doesn’t add to the patient’s outcome, it doesn’t complement; it just adds to the cost. 5 Despite their misleading nature, the terms “alternative,” “complementary,” and “CAM” have become institutionalized in our culture. This book uses quotation marks to remind readers that these terms are inherently misleading. Although many of the source materials and opinions cited in this chapter originated long ago, they remain relevant to the current marketplace. Enough is known about many “CAM” practices to evaluate their worth. Some may be appropriately used as part of the art of patient care or as self-care. Relaxation techniques and massage are examples. But practices linked to belief systems that reject science itself have no place in responsible medicine. A complete listing of “CAM” methods would be a monumental task, if not an impossible one. This chapter focuses on methods that have been widely publicized. Other chapters cover additional practices related to mental health, dental care, chiropractic, nutrition, weight control, cardiovascular disease, cancer, and aging. CLASSIFICATION The NCCAM classifies “CAM therapies” into five “domains”: (1) whole medical systems, (2) mind-body medicine, (3) biologically based practices that use natural substances, (4) manipulative and body-based practices, and (5) energy medicine, which includes unusual uses of measurable electromagnetic fields as well as methods intended to influence “biofields ,” the existence of which have not been demonstrated.4 Chapter Eight The “CAM” Movement Whether something should be considered “alternative” depends not only on the method itself but also on how it is used and what claims are made for it. Spinal manipulation, for example, may be useful in properly selected cases of low-back pain. But manipulating the spine once a month for “preventive maintenance” or to promote general health- as many chiropractors recommend- has no plausible rationale. Relaxation techniques have a limited but acceptable role in the treatment of anxiety states. But meditation for the purpose of “balancing” one’s “life energy” is another matter. Consideration of herbal products is even more complicated (see Chapter 11). The vast number of available “CAM” products include some that have proven usefulness, some that are toxic, and many that have no plausible medical use. Critics are concerned that “alternative” methods are promoted as equally useful or better than standard methods even though they are not. It makes more sense to classify alternatives as genuine, experimental, or questionable.6 Under this system, genuine alternatives are comparable methods that have met science-based criteria for safety and effectiveness; experimental alternatives are unproven but have a plausible rationale and are undergoing responsible investigation; and questionable “alternatives” are groundless and lack a scientifically plausible rationale. Classifying proven therapies as “alternative” is advantageous to proponents who suggest that if some work, the rest deserve equal consideration and respect. Practitioners of “integrative” medicine claim to synthesize standard and alternative methods, using the best of both. However, no published data indicate the quality Historical Perspective Folk (Traditional) Medicine Webster’s New Collegiate Dictionary defines folk medicine as “traditional medicine as practiced non-professionally by people isolated from modem medical services and involving especially the use of vegetable [plant-derived] remedies on an empirical basis.” Traditional medicine is largely primitive medicine, which assumes that supernatural forces are responsible for both the cause and cure of disease. Even herbal remedies may be said to harbor either good or evil spirits, so that believers can explain failures or successes in supernatural terms. Curanderas, popular among Mexican-Americans, are regarded as specialists in the folk medicine of their people. The conditions they treat include ma[ ojo (“evil eye”), ma[ aire (“bad air” due to evil spirits or other forces believed to inhabit the air), bilis (anger), susto (fright), and diseases of “hot and cold imbalance.” Their ministrations include prayers, religious objects, herbs, and dietary measures. Powwow, centered in rural Pennsylvania, combines prayer and laying on of hands. They may touch an afflicted part lightly, rub the surrounding area vigorously, or pass their hands over the entire body while praying either quietly or aloud. Some practitioners sell charms, spells, potions, and other paraphernalia. Some prescribe and sell herbs and teas. Root doctors, found mainly in southeastern states, are consulted by people who believe they have been “hexed” or have had unduly bad luck. The “doctor” listens to their story and either prepares a token, charm, powder, or other special object (“root”) that can help them fulfill their wishes or undo the hex. Voodoo, a religion indigenous to Haiti, is also practiced in southern Louisiana and elsewhere in the United 133 States where Haitians have migrated. Derived from ancestor worship, it invokes spirits to explain and influence the course of events. It includes an elaborate system of folk medical practices. Voodoo “queens” and “doctors” also sell charms, magical powders, and amulets promised to help cure illness and grant other desires . Folk medicine, even when known to be toxic, is not generally considered quackery so long as it is not done for financial gain. Thus self-treatment, family home treatment, neighborly medical advice, and the noncommercial activities of folk healers should not be labeled as quackery. State laws against practicing medicine without a license are rarely enforced against folk healers. However, folk medicine and quackery are closely connected because folk medicine often provides a basis for commercial exploitation. For example, herbs long gathered for personal use have been packaged and promoted by modem entrepreneurs, and practitioners who once served their neighbors voluntarily or for gratuities may market themselves outside their traditional communities. Folk beliefs may influence the ability or willingness of a patient to cooperate with or respond to scientific treatment. Some science-based programs have enlisted folk healers to help gain the trust of people who have little knowledge of medical care. De Smet7 has noted that some folk remedies have therapeutic benefits, some may provide psychosocial benefits, and others (such as azarc6n powder, rattlesnake meat, and certain herbal teas) can produce serious adverse reactions. Young 8 has noted that scientific medicine discards inferior therapies as science advances, but folk medicine and quackery continue to use these as long as a demand persists. 134 Part Two Health-Care Approaches of such care or the extent to which they burden patients with medically useless methods. Typically these practitioners employ a “heads-I-win, tails-you-lose” strategy in which they claim credit for any improvement experienced by the patient and blame standard treatments for any negative effects. This may undermine the patient’s confidence in standard care, reducing compliance or causing the patient to abandon it altogether.9 The “integrated” concept has been further criticized by Arnold Relrnan, MD., former editor of The New England Journal of Medicine 10 : There are not two kinds of medicine, one conventional and the other unconventional, that can be practiced jointly in a new kind of “integrative medicine.” Nor .. . are there two kinds of thinking, or two ways to find out which treatments work and which do not. In the best kind of medical practice, all proposed treatments must be tested objectively. In the end, there will only be treatments that pass that test and those that do not, those that are proven worthwhile and those that are not, POPULARITY Prevalence reports depend on the modalities that are included and the methods used to collect the data. Although this limits their usefulness in discerning trends, taken together, they indicate that many of the methods described in this chapter are widely used. A 1993 report by David Eisenberg, M .D .11 claimed that one out of three Americans was using unconventional care. However, this figure was inflated by counting exercise, relaxation, self-help groups, and commercial weight-loss clinics as “alternative,” even though they involve practices that are medically accepted. 12 A 1999 report of practitioner use concluded that 6.5% of Americans used both unconventional and conventional practitioners, 1.8% used only unconventional services, 59.5% used only conventional care, and 32.2% used neither. 13 The most comprehensive report on “CAM” use among Americans was based on data on more than 23,000 adults and 9000 children gathered during the 2007 National Health Interview Survey (NHIS). The report noted that the methods most commonly used by adults age 18 or older during the previous 12 months were nonvitamin, nonrnineral natural products (17 .7% ), deep breathing exercises (12.7%), meditation (9.4%), chiropractic or osteopathic manipulation (7 .5%), massage (8 .3%), and yoga (6 .1 %) . The most commonly used modalities by children were nonvitamin, nonmineral natural products (3 .9%), chiropractic or osteopathic manipulation (2.8%), deep breathing exercises (2.2%), yoga (2.1 %), and homeopathic treatment (1.3%). Prayer- related practices, which are more common than any of these, were not included in this survey. 14 Another NHIS report15 estimated that in 2007, adults in the United States spent $33 .9 billion out of pocket on visits to CAM practitioners and purchases of CAM products, classes, and materials and about 38 million adults made an estimated 354 million visits to the practitioners. Hyman 16 has noted that popularity is not a reliable yardstick of effectiveness: Every system- be it based on the position of the stars, the pattern oflines in the hand, the shape of the face or skull, the fall of the cards or the dice, the accidents of nature,orthe intuitions of a “psychic”-claims its quota of satisfied customers. It is often suggested that people seek “alternatives” because doctors are brusque, and that if doctors were more attentive, their patients would not look elsewhere. It is true that doctors sometimes pay insufficient attention to the emotional needs of their patients. But some people’s needs exceed what scientific health care can provide. A Canadian study of children attending an outpatient clinic found that word of mouth, fear of drug side effects, and persistence of a medical problem were more significant than dissatisfaction with conventional medicine in influencing their parents’ decision to seek “alternative” care.17 A New Zealand study of 148 cancer patients using ” alternative” approaches found that most were satisfied with conventional medicine and used alternative therapy only as a supplement.18 Furnham and Smith19 have suggested that “CAM” users may fall into three groups: “principalists,” who believe in “CAM,” people who are primarily frustrated with mainstream care, and “opportunists” who shop around. A study based on NHIS data found that among those who used only “alternative medicine” for treatment purposes, about half said they “thought it would be interesting to try,” about 20% each said they believed that standard treatments would not work, and about 20% said they were too expensive.20 Misleading publicity also plays an important role in fostering popularity. Few media outlets place “alternative” methods in proper perspective; most reports feature the claims of proponents and testimonials from satisfied customers. The National Center for Homeopathy, which rates reports that mention homeopathy, has concluded that since 1999, only 12% of more than 1000 mentions of homeopathy were negative. Critical analyses of acupuncture, ayurveda, chelation therapy, chiropractic, macrobiotics, and naturopathy are even scarcer. Figure 8-1 shows an ad that promotes a “CAM” newsletter by exaggerating problems within our mainstream health care system. Chapter Eight The “CAM” Movement COMMON THEMES Public interest in “alternative medicine” is part of a general societal trend toward rejection of science as a method of determining truths.21 In line with this philosophy, “alternative” proponents assert that scientific medicine is but one of a vast array of health-care options worth considering. Ernst22 has countered that “Anatomy, physiology, and pathology are not ‘ Western medical systems.’ They are generalizable truths that apply to all humans.” Vitalism Many “alternative” approaches are rooted in vitalism, the concept that bodily functions are due to a vital principle or “life force” distinct from the physical forces explainable by the laws of physics and chemistry. Nonscientific health systems based on this philosophy maintain that diseases should be treated by “stimulating the body’s ability to heal itself’ rather than by “treating symptoms.” Homeopaths, for example, claim that illness is due to a disturbance of the body’s “vital force,” which they can correct with special remedies, whereas acupuncturists claim that disease is due to imbalance in the flow yours–d0\·en limE-S more lhan Wl’ra On To Youl …And You’re Not Going To Get Away With It Anymore! Drug Companies • and the FDA Conspire Against Your Health! Good nutr it ion and purir dnors, n1u fi~·.i1t•1l llwir 11roduc·ts aml 11111 tht-1111)11I 11f husi• OC’SS. Drug Companies • Bribe Doctors To Push Tl1eir Drugs! clit> from hf>roin, cL.;;. Useless Surgeries Kill Thousands Each Year! ‘.\la.stcctomi(‘S were used for over 100 )’Cars before anyone a MlKly 10 Stt if lhcy we re “did t•ff~1..iw ( lhf>y wnen’t). D0t.·tors gr1 frC’
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