What's the alternative?

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What's the alternative?http://www.australiandoctor.com.au/in-depth/work-wise/what-s-the-alternative

Adelaide GP Dr Oliver doesn’t differentiate between conventional medicine and complementary and alternative medicine.

“It’s a meaningless and artificial divide,” he says. “As far as I’m concerned they’re all just medicines, and the recommendations I make to my patients about them are based on the same key principles.”

He says those principles can be summarised by the questions: “Is the medicine in the best interests of the patient?” and “Is it safe and effective as determined by the conventional scientific evidence?”

“So, if a patient says she’s taking paracetamol to treat some of the symptoms of a viral cold, I will tell her I agree with what she is doing

because we have reasonable evidence about the safety and efficacy of paracetamol used for this purpose. But if she asks me for antibiotics, I’ll explain the reasons why they’re not recommended for her condition,”

Dr says.

“Or if she’s taking something that she describes as a complementary medicine for which there is a paucity of evidence about safety and efficacy, I engage with her to find out the reasons she’s taking it and then provide her with the relevant information.

“It may be she has a misunderstanding about other treatments for which we do have reasonable evidence of efficacy and safety or she says, ‘I know three other people who took it and they felt better’. I explain what that all means in terms of the evidence and provide my recommended options.

“Then I leave it with her to decide what to do.”

A fiery debate has erupted recently over teaching complementary and alternative medicine at universities in Australia. Initiated by a recent

petition organised by the Friends of Science in Medicine.

With over 400 signatures from doctors, medical researchers and scientists, the debate reignited questions about the use of alternative medicines by medical practitioners in clinical practice.

The easy part is when an alternative medicine is shown to be safe and effective, such as St ’s wort for the treatment of major depression,

which has strong evidence according to a 2008 Cochrane review.1

But what happens when the evidence is absent or weak? Some say a CAM shouldn’t be recommended — yet not all of general practice itself has strong evidence of safety and efficacy.

In 2008, the UK Government conducted a study looking at where GPs found

answers to their clinical questions. It revealed that only 11% of their

questions were answered by the findings of existing systematic reviews,

meta-analyses and randomised controlled trials.

Sixteen per cent of their clinical queries couldn’t be answered at all because of a lack of evidence.2

The same principle and approach that allows GPs to recommend conventional medical treatments where the evidence is absent or weak should be applied to CAMs, says Professor Kerryn Phelps, Adjunct Professor at the University of Sydney’s faculty of medicine and co-author of General Practice: The Integrative Approach.

“It simply requires an assessment of the underlying reasoning and aims of the CAM and applying common sense as a guide,” says Professor Phelps,

who as a former AMA federal president established an advisory committee

on complementary medicine that developed the AMA’s first position statement on the topic.

“For example, with some therapies the risk is so minimal — such as massage therapy, tai chi, camomile tea and lavender in the bath — that you can feel safe to recommend it to your patients."

Professor Komesaroff, director of the Monash Centre for Ethics in Medicine and Society in Melbourne, agrees that an alternative medicine may be recommended, even when there is a lack of strong evidence of safety and efficacy, as long as a general assessment of the CAM indicates that it is safe.

“For instance, the fact that a herbal medicine has received TGA listing

indicates a wide margin of safety and provides some comfort,” he says.

“Traditional and anecdotal evidence, such as having a long history of widespread use in the community, provide an additional layer of comfort.”

Weighing the rational

Not everyone agrees with this approach. Some in the primary care community say the rationale underlying a treatment should be given significant weight when deciding whether to recommend it.

Professor Malcolm , professor of medical ethics at the University

of Queensland and a former Brisbane GP, is one. “For a number of decades the use of high dosage steroids for idiopathic Bell’s palsy was common practice, but it lacked evidence. It is only in recent years that

a high level of evidence was produced that supported its usage,” he says.3

"Yet at least the reasoning that Bell’s palsy was associated with inflammation of the nerve, and steroids reduced the inflammation, made sense.

“In contrast, the reasoning for chiropractic treatment for asthma based

on nerve supply to the airways does not have good support, and in fact our understanding of asthma is that it involves airway inflammation and bronchoconstriction.”

Emeritus Professor of Medicine at the University of NSW Dwyer uses

the term “pseudoscience” to describe many complementary and alternative

medicines.

“They are an affront to our knowledge and understanding of the anatomy,

physiology, pathology and therapeutic approaches to the human body. They include homeopathy, reflexology, iridology, energy medicine and a traditional approach to chiropractic that is based on innate intelligence of the spinal cord,” says Professor Dwyer, one of the spokespeople for the Friends of Science in Medicine.

“Alternatively other CAMs, such as herbal medicine, aspects of Traditional Chinese Medicine and musculoskeletal aspects of chiropractic

have more of a basis in science.”

However, ethicist Professor Komesaroff says we shouldn’t be entirely dismissive of CAMs in the belief there is only one, single criterion of truth.

“Chinese medicine, for example, has a deep tradition of knowledge that may have some truth and validity,” he says.

“We need to engage with these other ways of looking at the world that may provide new insights and different ways of looking at nature. To reject them is short-sighted.

“We should welcome all ideas that challenge our own ideas so that we can make progress.”

Occasionally, conventional medicine gets it wrong. Recall the example in the 1980s, of the widespread rejection of the theory that Helicobacter pylori infection

was the major cause of peptic ulcers because of the belief that bacteria couldn’t survive in such an acidic environment.

But Professor Dwyer says while being open-minded is important, it shouldn’t be used as an excuse to give carte blanche to all CAMs.

“Yes, there is a need to be open-minded, because science is always searching for answers. So if there are good observations and anecdotal evidence of efficacy, then this should be followed up with strong scientific research,” he says.

“This is exactly what was done with H. pylori.”

So does being open-minded stretch to recommending a CAM for reasons outside the conventional scientific evidence of efficacy?

“In the large majority of cases it is the patient who initiates the use

of a CAM and studies show that their reasons are often not purely related to evidence of efficacy or of low cost,” Professor Komesaroff says.

“A study of HIV patients that I co-authored, for instance, found that most of the patients, who used conventional medicines — so clearly they weren’t against them — used CAMs for reasons such as treating the side effects of conventional medicines, non-medical goals — such as mind and body balance, and spirituality — and wanting to regain control of their health when subjected to feelings of disempowerment,” he says.

These are all legitimate reasons and shouldn’t be derided because of a lack of conventional scientific evidence, Professor Komesaroff suggests.

“The doctor should engage with the patient to understand why the patient is using a CAM and then support these reasons if they are appropriate and safe,” he says. “For example, if it is to regain control

of health, there is no reason why a patient shouldn’t take multivitamins and minerals.”

Apple CEO Steve Jobs delayed surgery for nine months to treat a tumour with alternative remedies. He died in October, 2011.

However, Professor says even if there are other reasons, a doctor is duty-bound in the best interests of the patient to explain the

evidence on safety and efficacy, and point out the options other than the CAM, before leaving it to the patient to make their own decision.

“Just leaving it to the patient without an explanation amounts to recommending a placebo, which doctors should do their utmost to avoid, because in effect you are not getting the patient’s informed consent. And once you make an exception, you’ll be at risk of losing your grip on

this principle,” he says.

There is also the risk of taking advantage of vulnerable people, Professor Dwyer says.

“People who are vulnerable can suspend their judgement, particularly patients with conditions such as cancer and HIV and chronic health problems. CAMs can waste their time and money and in worst-case scenarios it can lead to harm, such as with Steve Jobs [Apple CEO] who rejected conventional medicine for the treatment of his pancreatic cancer until it was too late,” he says.

Professor Phelps thinks there are double standards applied to thinking about complementary and alternative medicines and this causes harm in itself.

“With adverse drug reaction reporting, around 97% are for pharmaceuticals and 3% for CAMs. Then there are all the drugs that had negative results covered up before going to market and causing harm before withdrawal in recent decades, such as Vioxx,” she says.

“When a patient gets a rash on his chest after taking a CAM, some doctors raise their hands in the air in dismay and rail against quackery, but when a conventional drug kills patients they mutter ‘For a

drug to be effective, it comes with mortality risk’.”

Professor Phelps says the way forward is an integrative approach.

“Conventional medicine is undoubtedly highly effective for acute conditions, but with chronic conditions, which are the vast majority of patients seen in general practice, there is far more of an overlap in what GPs already do than they often realise,” she says.

“For example, with osteoarthritis treatment for older-aged patients, the first line of treatments should include a combination of gentle exercises, flexibility training, lifestyle management, weight loss, stress management, fish oil and glucosamine.”

Despite such calls for integration, divisions over the use of CAMs in clinical practice appear likely to remain until the gaps in the evidence

are filled. If that day comes, not only will it be easier for doctors to make recommendations in clinical practice, but terms such as conventional, complementary and alternative medicine may become redundant.

References

1. Cochrane Database Systematic Review 2008; 4:CD000448.

2. Health Information and Libraries Journal 2011; 28:285-93.

3. Cochrane Database Systematic Review 2010; 3:CD001942.

Meryl Dorey,SpokespersonThe Australian Vaccination Network, Inc.Investigate before you vaccinateEditor,Living Wisdom MagazineFamily, Health, EnvironmentPO Box 177BANGALOW NSW 2479AUSTRALIAhttp://www.avn.org.auhttp://www.living-wisdom.comPhone: 02 6687 1699 FAX 02 6687 2032skype: ivmmagFreedom is not merely the opportunity to do as one pleases; neither is it merely the opportunity to choose between set alternatives. Freedom is, first of all, the chance to formulate the available choices, to argue over them -- and then, the opportunity to choose. - C. MillsThe authority of any governing institution must stop at its citizen's skin. - Gloria SteinemWe rely on the help and support of our members and subscribers to continue offering our services freely and without prejudice.Please consider helping us by joining the AVN as a member. Go to http://www.avn.org.au to become a member or donate to support our work.We also sell books, videos and DVDs on vaccination and other health issues. Go to http://shop.avn.org.au/ for more details.