Essentials of Complementary and Alternative Medicine (June 1999)

Q
UALITY OF
 P
RODUCTS
The “natural” products used by CAM practitioners are largely unmonitored and their quality uncontrolled. These products are available on the market as “dietary 
supplements” and may be contaminated or vary tremendously in content, quality, and safety (
86
, 
87
). Garlic, for example, demonstrated to have cholesterol lowering 
effects for many years (
17
), may not produce such effects if processed in certain ways (
88
). Thus, even if one product is proven safe and effective, other similar 
products on the market may have quite different effects that preclude consistent dosing. Fifteen million Americans are taking high-dose vitamins or herbs along with 
prescription drugs, thus risking adverse effects from unknown interactions (
2
) (see Part II, 
Chapter 6
, 
Chapter 7
, and 
Chapter 8
).
Q
UALITY OF
 S
CIENCE
There is often no scientific foundation for a particular CAM practice–whether according to Western biomedicine or even to an alternative scientific world view (e.g., 
Ayurveda, traditional Chinese medicine). Most CAM systems have been around largely unchanged for hundreds or thousands of years. Many of these tenets 
originated from the teachings of a charismatic leader–tenets that have not been advanced with new observations, hypothesis-driven testing, innovation, and 
peer-review. Claiming that their practices are too “individual” or “holistic” to study scientifically, many CAM practitioners hide behind anecdotal, case-series, or 
outcomes research (
89
). To accept such views is to falsely label conventional medicine as “nonholistic” and to reject the hard fought gains made in the use of basic 
biological knowledge, randomized controlled clinical trials, and evidence-based medicine for health care decision making (
90
) (see 
Chapter 4
 and 
Chapter 5
).
The Potential Benefits of Integration
Among the potential benefits of integration, several in particular are especially valuable. The emergence of a truly integrated medicine promises to shift medicine's 
emphasis to the total healing process, to reduce unnecessary side effects, and to reduce the costs of care.
E
MPHASIS ON
 H
EALING
Most CAM systems carefully attend to the illness and suffering that accompanies all disease. Patients are often more satisfied with their interactions with unorthodox 
than orthodox medical practitioners (
35
). Patients require understanding, meaning, and self-care methods for managing their condition. Empowerment, participation in 
the healing process, time, and personal attention are essential elements of all medical care, yet these elements are easily lost in the subspecialization, technology, 
and economics of modern medicine. By increasingly being integrated into mainstream medical practice, CAM promises to restore to medicine a more focused 
emphasis on the healing process.
R
EDUCTION IN
 S
IDE
 E
FFECTS
In the eighteenth century, unconventional medical practices increased in popularity in part because they eschewed the use of severe treatments such as bloodletting, 
purging, and use of toxic metals–all staples of conventional medicine at one time (
91
). The popularity of CAM in this century is also driven by the perception that 
conventional treatments are too harsh to use for chronic and non-life-threatening diseases (
30
, 
31
). Iatrogenic disease from conventional medicine is a major cause of 
death and hospitalization in the United States (
43
). Although some CAM practices may introduce toxicity, many of them offer reduced potential for adverse effects 
when properly delivered (
45
). Unconventional medicine may help us “gentle” our approach by focusing on the patient's inherent capacity for self-healing (
84
).
R
EDUCTION IN
 C
OSTS
The skyrocketing costs of conventional medicine also drive the search for medical alternatives. Savings from managed care are now maximized, and health care costs 
are predicted to double within the next 10 years (
47
). If low-cost interventions, such as life style changes, diet and supplement therapy, and behavioral medicine, can 
be delivered as substitutes for high-cost drugs and technological interventions, true cost reductions and reductions in morbidity may be achieved (
48
).
Science and Healing
Today we have discovered more scientific ways of deciding how to counter and oppose disease causes, but very little research has been done on the support and 
induction of healing processes. This has made the interference/opposition approach (see 
Figure 1
) much more useful than in the past, and is one of the reasons for 
the tremendous rise in the use of these kinds of therapies around the world. Technology has provided another impetus for this growth. Biotechnology allows for finer 
dissection of disease causes and for development of scientific methods to manipulate these causes. The usefulness of this approach, however, is limited to those 
diseases in which there are only a few causes and they have been clearly identified. For illnesses of multifactorial or unknown causation (as in most chronic 
diseases), this approach is not very useful for producing long-term healing. Unfortunately, application of the scientific method to the study of the induction and hygiene 
approaches is still in its early stages. As investigation of conventional practices (e.g., physical therapy, dietary therapy, and immunization) and of CAM systems (e.g., 
acupuncture, homeopathy, and manipulation) increases, a science of healing may emerge.
WHAT PHYSICIANS NEED TO KNOW ABOUT CAM
For physicians to be able to help their patients choose the most rapid, safest, and most effective long-term solutions for treating disease and alleviating suffering, 
certain basic knowledge and skills are needed. Understanding the fundamental assumptions of etiology and treatment of medical systems–both conventional and 
unconventional–is crucial. When specific causes are known and effective methods for intervention exist, approaches that can interfere with those causes are key to 
successful treatment. When specific causes are unknown or complex contributory influences are dominant in a disease, approaches that support health and induce 
healing become primary. Sometimes a combination of approaches is needed, whereby causes are blocked and healing mechanisms are stimulated and supported. An 
optimal practice makes flexible use of what best fits the clinical situation.
To respond appropriately, physicians and other health care practitioners must be able to obtain information about the history of self-treatment by their patients and 
must communicate to them the results of the best current research evidence. Practitioners need a variety of skills: communicating with patients, documenting patient 
encounters with alternative therapies, evaluating and applying modern principles of scientific evidence and medical ethics, and understanding the current quality and 
liability status of CAM medical treatments. Finally, practitioners should become familiar with the basic principles of treatment for specific CAM systems as well as the 
current evidence of benefit or harm from these systems. This information is required for the careful and thoughtful management of patients, many of whom have 
already visited alternative practitioners. This basic knowledge of common CAM practices will be an indispensable component of medical information in the twenty-first 
century.
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I
NTRODUCTION
: E
VALUATING THE
 S
AFETY OF
 C
OMPLEMENTARY AND
 A
LTERNATIVE
 P
RODUCTS AND
 P
RACTICES
Essentials of Complementary and Alternative Medicine
I
NTRODUCTION
: E
VALUATING THE
 S
AFETY OF
 C
OMPLEMENTARY AND
 A
LTERNATIVE
 P
RODUCTS AND
 P
RACTICES
 
Wayne B. Jonas and Edzard Ernst
Broad Scope
The Relative Nature of “Safety”
The Relative Safety of “Natural”