Complementary and Alternative Medicine: Examining the Evidence
Am Fam Physician. 2003 Jan 1;67(1):36-38.
The surge of interest in complementary and alternative medicine (CAM) over the past decade is apparent from the increased use of these products by patients,1 the inception of the National Center for Complementary and Alternative Medicine (NCCAM), and the increase in physician education and research focused on these products. Multiple studies2–4 have documented that 21 to 50 percent of patients making office visits to family physicians have used or are currently using alternative therapies. The most commonly used therapies among the patients in these studies were herbal remedies and supplements, chiropractic techniques, and massage therapy.2–4 The studies2–4 also found that close to one half of patients failed to discuss their use of CAM therapies with their physicians.
The Dietary Supplement Health and Education Act of 1994 (DSHEA) currently directs the regulatory guidelines for herbal medications and other supplements. Under the DSHEA's broad definition of dietary supplements, these products can be marketed without proven safety or efficacy studies as long as the manufacturers do not make specific medical claims. The act mandates the inclusion of a disclaimer by the U.S. Food and Drug Administration (FDA) on the product label stating that the supplement has not been evaluated by the FDA and is not intended to diagnose, treat, cure, or prevent any disease.5 However, it does permit a description of the effects the product may have on a “structure or function” of the body.
Unlike the FDA, the German Commission E6 independently checks the bibliographic data of herbal products used in Germany with the goals of establishing “reasonable certainty” of their safety and efficacy and of publishing monographs; however, critics argue that even this evaluation process is not meticulous enough. Thus, the lack of an international gold standard and of formal regulatory oversight in the United States forces physicians to be proactive in researching which herbal medications and alternative therapies are safe and efficacious. A study7 conducted in 2002 reinforces this concept by showing that 84 percent of physicians (n = 302 physicians) think that they need to learn more about CAM to adequately communicate with their patients.
Given the prevalence of the use of CAM by patients and the medical community's desire to learn more to aid in communication and treatment, we have created a new article series in American Family Physician, entitled “Complementary and Alternative Medicine.” The Kligler article8 on echinacea in this issue of AFP is the first of the series. It succinctly outlines echinacea's current uses and evidence, followed by the adverse effects and interactions. Presently, many of the studies evaluating echinacea and other herbal remedies and supplements are limited by small subject populations, lack of rigorous control methods, studies of heterogenous products, concerns about manufacturers' influence, or lack of availability in English. Fortunately, NCCAM is conducting several randomized controlled trials on CAM therapies, including three on echinacea.
The intent of this new AFP series is to summarize and label the evidence behind various alternative therapies, starting with the most frequently prescribed and well-researched herbal remedies and supplements. Ultimately, we hope to generate a resource guide that clinicians could use at the point of care. Currently, an abundance of information on CAM exists in textbooks, journals, newsletters, and Web sites. The purpose of the series is not to replace the existing information or to encourage physicians to prescribe CAM therapies, but rather to extract the most important data in the literature and present it as concisely as possible.
Most of the articles will be short summaries accompanied by simple tables that could be used in the following ways: as a starting point for learning about a particular remedy, with solid references for further reading; as a quick reference for drug interactions or common side effects during a patient visit; and as a reference for physicians to note which products have undergone the most rigorous clinical trials.
It is hoped that, as the search for knowledge about CAM therapies continues, the drive for good research to investigate safety and efficacy will follow. We strive for a time when patients no longer hesitate to reveal the modalities they use, because they know their physicians are prepared to help them make educated decisions about therapy.
Sumi M. Sexton, M.D., is an assistant editor for American Family Physicianand an assistant professor at Georgetown University School of Medicine, Washington, D.C.
Address correspondence to Sumi M. Sexton, M.D., Department of Family Medicine, Georgetown University Medical Center, 212 Kober-Cogan Hall, 3800 Reservoir Rd., NW, Washington, DC 20007 (e-mail: firstname.lastname@example.org). Reprints are not available from the author.
1. Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, et al. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA. 1998;280:1569–75.
2. Elder NC, Gillcrist A, Minz R. Use of alternative health care by family practice patients. Arch Fam Med. 1997;6:181–4.
3. Del Mundo WF, Shepherd WC, Marose TD. Use of alternative medicine by patients in a rural family practice clinic. Fam Med. 2002;34:206–12.
4. Palinkas LA, Kabongo ML. The use of complementary and alternative medicine by primary care patients. A SURF*NET study. J Fam Pract. 2000;49:1121–30.
5. Bauer BA. Herbal therapy: what a clinician needs to know to counsel patients effectively. Mayo Clin Proc. 2000;75:835–41.
6. Blumenthal M, et al., eds. The complete German Commission E monographs: therapeutic guide to herbal medicines. Austin, Tex.: American Botanical Council, 1998.
7. Corbin Winslow L, Shapiro H. Physicians want education about complementary and alternative medicine to enhance communication with their patients. Arch Intern Med. 2002;162:1176–81.
8. Kligler B. Echinacea. Am Fam Physician. 2003;67:77–80.
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