Complementary and alternative medicine

The emphasis on this page is on the scientific, legal and practitioner issues. For an overview of the philosophical and cultural dimensions, see also Alternative medicine (theories).

Alternative medicine is a set of therapies that are considered whole systems of healthcare that operate outside the realm of mainstream healthcare in the Western world — literally, they consider themselves alternatives to mainstream medicine. Complementary medicine is comprised of those systems, or parts of systems, that are used in conjunction with the mainstream. Since some techniques may be found both in whole and complementary systems, it is convenient to speak of complementary and alternative medicine (CAM) as one broad field. Many of these systems predate modern scientific methods and some, particularly the eastern therapies, stem from well before the time of Hippocrates. Some of these practices include acupuncture, homeopathy, herbal medicine, spiritual therapies, chiropractic, and prayer. Integrative medicine deals with the optimal combination of mainstream and complementary medicine.

Conventional, biologically-based medicine is not inherently critical of CAM, as some alternatives show as much efficacy as conventional methods, certainly for specific indications. Physicians do express concerns over whole systems whose patients have not first been evaluated by medically trained physicians for fear that this might delay proper treatment for conditions that are not sufficiently assessed. They also suggest that therapists may either not identify dangerous conditions that are treatable by conventional medicine, such that the patient does not have the information to decide to give informed consent to alternative treatment alone. Another aspect of that concern is that some conditions can respond to mainstream medical treatment early in the process, but delay of diagnosis could put the patient in a situation where the conventional treatment would no longer be effective.

As the term integrative medicine comes into wider use, its advocates consider it

the very best of conventional medicine and cutting-edge diagnosis and treatment, with appropriate complementary therapies. Whenever possible, it favors the use of low-tech, low-cost interventions. All factors that affect health, wellness, and disease are considered, including the psychosocial and spiritual dimensions of a person's life. It brings patients and caregivers into a partnership to achieve the patient's optimal health and healing."

Integrative medicine does assume that all techniques used, mainstream or complementary, will be evidence-based, and with full information sharing to avoid dangerous interactions or missed diagnoses. As in the Johns Hopkins example, the terminology can get confusing, when an integrative center speaks of "alternative programs", which are not synonymous with "alternative medicine".

Lack of integration

All too often,patients today see both conventional and CAM practitioners, with the patient perhaps not mentioning one type of therapist to the other. In integrative medicine, there is active consultation among the various practitioners and the patient. Integrative medicine also includes nurses, whose training emphasizes managing chronic diseases (e.g., compliance with monitoring and medicine), encouraging healthy lifestyles, and providing continuity.

Integrative medicine reduces some of the concerns that physicians have with patients who self-refer to practitioners of what are indeed complementary techniques, but which might interact with other treatments if all the prescribers are not aware of everything being done. Indeed, one of the challenges of many primary care physicians is simply to find out all the drugs their patients are taking, prescribed by different physician specialists who do not share information.

While some conventional physicians will reject any complementary method for which they do not know the exact mode of action, integrative medicine assumes teams of mainstream and complementary (but not whole system) practitioners. For example, it is quite common for pain medicine specialists to use complementary methods.

Simply to serve as an example that evidence-based methods can deal with complementary techniques, a 1997 NIH Consensus Conference on Acupuncture found evidence for its use for the nausea of cancer chemotherapy, NIH does put a caveat on all of its consensus statements that are more than five years old:

This statement is more than five years old and is provided solely for historical purposes. Due to the cumulative nature of medical research, new knowledge has inevitably accumulated in this subject area in the time since the statement was initially prepared. Thus some of the material is likely to be out of date, and at worst simply wrong.

Classification of CAM

An editorial about alternative practices in the New England Journal of Medicine comments that "Many are well known, others are exotic and mysterious, and some are dangerous." To begin a discussion, it is necessary to define the scope of the problem. The table below is derived from one created by the U.S. National Center for Complementary and Alternative Medicine.

Major field and Description	Subfield	Subfield
Whole Medical Systems comprise complete systems of theory and practice. Often, these systems have evolved apart from and earlier than the conventional medical approach used in the United States. These are usually alternative rather than complementary.	Western systems include homeopathy and naturopathy	Non-western systems include classical traditional Chinese medicine and ayurveda
Mind-Body Medicine uses a variety of techniques designed to enhance the mind's capacity to affect bodily function and symptoms. Some of the "still considered CAM" techniques are more and more accepted.	Accepted as mainstream (not strictly CAM) include patient support groups and cognitive-behavioral therapy	Still considered CAM include meditation, visualization, and relaxation (physiology) techniques; eye motion desensitization reprocessing; spiritual therapies, mental healing, and creative outlets such as art therapy, music therapy and dance
Biologically based practices in CAM use substances found in nature, such as medicinal herbs (i.e., phytotherapy), diet therapy, pharmacologic doses of vitamins, essential oils, and dietary supplements. An example of an unproven method is using shark cartilage to treat cancer.
Manipulative and Body-Based Practices involve the controlled use of force against parts of the body, or maneuvers that move body parts out of their usual range of motion. These may be used as whole systems or as complementary methods. They include osteopathic manipulation, massage therapy, chiropractic, reflexology, and methods involving movement or posture instruction.
Energy Medicine breaks into therapies that use forces that are, and are not, detectable with conventional scientific instrumentation.	Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields, such as pulsed fields, magnetic fields, or alternating-current or direct-current fields.	Biofield therapies are intended to affect energy fields that purportedly surround and penetrate the human body. These include qi gong (part of traditional Chinese medicine), reiki, and therapeutic touch

Cost Effectiveness

Complementary and alternative therapies are often claimed to be more cost-effective than conventional therapies, but this evalualation is inextricably bound up with disputes about efficacy. Between July, 1999 and June 2005, five complementary therapies – anthroposophical medicine, homeopathy, neural therapy, phytotherapy and traditional Chinese herbal therapy – were included on a trial basis among services covered by the compulsory health insurance scheme in Switzerland. In June 2005, the Swiss interior ministry decided to withdraw these alternative medicines from compulsory heath insurance on grounds of poor cost-effectiveness following a report of their Complementary Medicine Evaluation Programme (PEK). The decision was influenced by pre-publication sight of the study on which a Lancet article critical of homeopathy which was accompanied by an editorial entitled “The end of homeopathy”. In its summary, the PEK report stated:

”Practitioners of complementary medicine can be distinguished from physicians providing conventional healthcare with regard to the nature, location and technical resources of their practice. The patients they treat tend to be younger, female and better educated. These patients tend to have a favourable attitude towards complementary medicine and to exhibit chronic and more severe forms of disease. Technical diagnostic procedures are performed more rarely, and patients’ wishes are taken into account more frequently in the choice of treatment. On average, the consultation lasts markedly longer than in conventional care. Patients are more satisfied with the care provided in practices offering complementary medicine. Side effects are reported by markedly fewer patients than with conventional care – with the exception of phytotherapy. With complementary medicine, the total annual costs are markedly lower than the average for conventional care. Overall, however, complementary practitioners treat fewer patients, and more frequently younger and female patients. Adjusted for these factors, the total patient- related costs do not differ significantly from those for conventional care. The cost structure is characterized by a greater weighting for consultation costs and a lower weighting for drug costs.”

Attitudes of conventional medicine to CAM

An editorial in Archives of Internal Medicine argues that alternative medicine should not be "condemned out of hand," but that traditional medicine ashould pproach alternative therapy based on five principles: 1. Maintain an open-minded attitude about all potentially new therapeutic interventions that include those commonly referred to as alternative.

2. Encourage carefully performed and appropriately controlled studies of these new therapies.

3. Do not ignore or ridicule the potential of the placebo effect to produce marked therapeutic benefit.

4. Do not accept all new therapies as efficacious on first acquaintance. Practitioners of quack medicine continue to abound as in all earlier times. Claims of therapeutic efficacy should be rationally examined and tested.

5. Avoid hubristic and arrogant attitudes toward alternative medical practices because one might be embarrassed by the subsequent demonstrations of their clinical efficacy.

The following statements, recommended by the Council on Scientific Affairs, were adopted by the AMA House of Delegates as AMA policy at the 1997 AMA Annual Meeting.

• "There is little evidence to confirm the safety or efficacy of most alternative therapies. Much of the information currently known about these therapies makes it clear that many have not been shown to be efficacious. Well-designed, stringently controlled research should be done to evaluate the efficacy of alternative therapies.
• Physicians should routinely inquire about the use of alternative or unconventional therapy by their patients, and educate themselves and their patients about the state of scientific knowledge with regard to alternative therapy that may be used or contemplated.
• Patients who choose alternative therapies should be educated as to the hazards that might result from postponing or stopping conventional medical treatment.
• Courses offered by medical schools on alternative medicine should present the scientific view of unconventional theories, treatments, and practice as well as the potential therapeutic utility, safety, and efficacy of these modalities."