Complementary and alternative medicine: What’s working and what’s ahead

By Heather Boerner, independent journalist

Naturopathic Physician Jane Guiltinan, clinical professor at the Bastyr Center for Natural Health and member of the board of Trustees at Harborview Medical Center in Seattle, had been talking for just a minute when a question came from the standing-room-only crowd:

"Is it really accurate to call you a physician?" blurted the man. "You can't prescribe or do surgery, can you?"

For the record, Guiltinan said, her license from the state of Washington gives her authority to prescribe most medications and to do small in-office procedures such as wart and skin tag removal. But it was a telling question at the Health Journalism 2009 panel "Complementary and Alternative Medicine: What's working and what's ahead," where naturopathic and Western medical doctors met journalistic skeptics and true believers to discuss the science and scams that mix in the growing alternative medicine market.

To help journalists wade through the growing body of hype that's not yet matched by replicated clinical trials, the three panelists advised journalists to cover naturopathic trends using respected sources and vet naturopathic doctors through licensing agencies.

Complementary and alternative medicine (CAM) is an umbrella term for four distinct forms of non-medical health maintenance:

• Alternative medical systems, such as homeopathy, naturopathy, traditional Chinese medicine and the Indian practice of ayurveda
• Mind-body interventions, such as meditation, prayer, biofeedback and hypnosis
• Biologically based therapies, such as herbs, supplements and aromatherapy
• Manipulative and body-based methods, such as acupuncture and chiropractic care

There's a good chance many of your readers are already using some form of CAM therapy: Among U.S. adults, 62 percent report using some form of CAM- and 41 percent are using two or more CAM therapies, according to a 2004 report to the Centers for Disease Control. Many of those are people, including children, with chronic conditions for which there are few Western medical solutions, said Anjana Kundu, M.B., B.S., a Western medical practitioner and licensed acupuncturist at Seattle Children's. According to a 2003 study, 45 percent of pediatric patients in one emergency room reported using some CAM therapies.

"You would think kids wouldn't use CAM because many therapies haven't been proven," she said. "But what we're actually finding is that for pediatric patients at our pain centers, the reports of CAM therapies were pretty high. Generally, this is because CAM has few side effects and the family and patients feel very empowered by them."

But because many of these treatments, which also include exercise such as tai chi, qi gong and yoga, have so little evidence-based research, Guiltinan advised reporters to check out claims by business people with the big databases for this kind of research: The National Center for Complementary and Alternative Medicine at the National Institutes of Health; the Cochrane Database; PubMed's Alternative Medicine Review; and Natural Medicines comprehensive databases Naturaldatabase.com and naturalstandard.com are reputable sources for research.

If you find a naturopathic doctor who might be a good source, check him out through state licensing agencies. Seven North American schools offer doctorates in naturopathic medicine, requiring 4,100 hours of training – 2,000 of them clinical – and 12 states license naturopathic doctors. To find out if a source you're considering using is legit, check with the North American Board of Naturopathic Examiners. Still, the snake-oil salesmen are out there.

"They call themselves naturopathic doctors, but have, for $2,000 online, gotten a diploma," said Guiltinan. "These doctors cannot practice in states with licensing rules – and when we go to those states to get licensing and regulations, these folks are not happy."

The good news is there's growing evidence – though still in small-cohort studies – that some CAM therapies are effective. Guiltinan was involved in studies on the effect of herbals, such as black cohosh and soy for menopause symptoms. The results have been mixed and showed no effect in the study she conducted. But among the most vetted is acupuncture for back pain, said Dan Cherkin, Ph.D., and researcher at the Seattle-based Group Health Center for Health Studies.

For the 10 percent to 20 percent of those with back pain who report that it's persistent and chronic, few therapies work, whether Western or alternative, he said. But in a recently published study, Cherkin found acupuncture to be "clearly better than usual care."

In fact, due to emerging evidence over the past decade, CAM therapies have gained respect as reasonable treatments to try for chronic back pain. Today, four of the eight interventions for chronic low back pain recommended by a recent evidence-based practice guideline for physicians were CAM therapies, he said: acupuncture, spinal manipulation including chiropractic care, massage and yoga.

"This represents a major change in thinking about the role of CAM therapies for back pain," he said.

One audience member, Alan Cassels, a drug policy researcher a the University of Victoria and coauthor of "Selling Sickness: How the World's Biggest Pharmaceutical Companies are Turning Us All Into Patients," insisted the evidence base behind alternative therapies shouldn't have to be held to the same standards as Western medicine because they don't have the same potential for risk or benefit as pharmaceuticals. He pointed to the very small cohort used by Dr. James Lind in the 18th century to discover that citrus cured scurvy: Only 12 patients were included but the intervention worked.

"[CAM practitioners] are not doing themselves a lot of favors when they call the evidence base for these therapies small," he said. "There is tons of evidence of the effectiveness of alternative therapies. Sure, you don't have 5,000 patients for your studies – but you don't need them either. And if you're talking about placebo effect, the placebo effect from these therapies is very important and can probably be achieved with greater safety, certainly compared to trying to achieve the placebo effect with Vioxx or something."

But panelists disagreed.

"We have to present the results as they are," Kundu said. "Soy was effective in some, it wasn't in others. Three were positive, four were negative and if we were to do a systemic review, it would be inconclusive. The bigger issue is whether we can reproduce research. That's what's meaningful: If we can do it over and over again."

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Heather Boerner is an independent journalist based in San Francisco. She attended Health Journalism 2009 as an AHCJ-California Health Journalism Fellow.