Wham, bam, thank you CAM

I got a phone call the other day from a man asking whether I did “alternative” medicine. When I told him that I wasn't in regular practice, he asked for a referral to someone who could provide this type of care. It made me think.

Complementary and alternative medicine (CAM) comprises a diverse group of treatments, ranging from symptomatic interventions to be used in conjunction with traditional therapies—therapeutic touch or meditation—to unique treatments meant to replace conventional chemotherapy or surgery. CAM includes complex and longstanding fields of study, such as acupuncture, ayurvedic medicine, and homoeopathy, but can also be as straightforward as taking a specific dietary supplement to lower blood pressure or blood lipid concentrations.

Americans love CAM. Over a third of them report having used some form of CAM therapy in the previous 12 months, and the use is increasing every year. Leading CAM therapies include natural products (supplements and herbals medicines and so on), meditation, chiropractic, and massage. Symptoms most commonly treated with CAM therapies include musculoskeletal, respiratory, and psychological symptoms.

It's a huge business: Americans spend at least $50bn (£25bn; €36bn) a year on CAM therapies. An increasing amount of this care is covered by US health insurance schemes, although generally this applies only to the more accepted CAM treatments, such as acupuncture and chiropractic. About a third to a half of all spending on CAM is paid out of patients' pockets, more than we pay directly for hospitalisations.

Despite all this many Americans don't like to talk to their doctors about the CAM treatments they are using. Only about a third to a half of patients who use CAM report discussing this with their doctor. Their reasons vary from thinking that doctors will not be supportive to saying that it is not important for doctors to know. That's a potential problem, given the documented interactions between some natural products and conventional drugs. Surveys in the US find that doctors rarely ask about use of CAM products, even though they admit they need to know more about them.

With all of this activity, it would be nice to know which CAM treatments work and which don't. A number of Cochrane reviews have looked at CAM treatments, and the US Agency for Healthcare Research and Quality has commissioned around 20 evidence reports—systematic reviews—on CAM therapies. The UK's National Institute for Health and Clinical Excellence (NICE) has explicitly avoided assessing CAM, however, despite calls for it to do so (BMJ 2007;334:506 doi: 10.1136/bmj.39122.512211.BE and BMJ 2007:334:507 doi: 10.1136/bmj.39122.551250.BE).

In addition, in response to a mandate from Congress, the US National Institutes of Health created the National Center for Complementary and Alternative Medicine in 1999. Its mission is to support rigorous research into CAM and to disseminate its results. This research ranges from large randomised controlled trials of CAM products to basic science research to elucidate physiological explanations for CAM therapies such as acupuncture and ayurvedic medicine. The centre has spent hundreds of millions of dollars investigating CAM products and treatments.

So why don't we know more than we do about what works and what doesn't? Part of the explanation is the huge number and heterogeneity of CAM interventions. Only a small number of the most promising treatments have so far been rigorously tested. Part of the problem is the nature of CAM treatments: they can be hard to quantify and hard to specify, and often they don't lend themselves to standard research techniques such as placebo controlled trials.

Furthermore, once research is done, it is often hard to assess its quality. Paul Shekelle and colleagues have written about the difficulties of systematically reviewing CAM studies (Annals of Internal Medicine 2005;142:1042-7). The challenges include publication, expectation, and other biases; difficulty in locating the literature; treatment variability; variability in use of placebo or sham treatment; and dealing with rare but serious adverse events.

Critics say that CAM doesn't deserve a place at the table—that enough time has passed and enough research has been done to show whether any of these interventions are safe and effective. The fact that unequivocal success stories are few indicates only that the treatments are placebo and expectation effects masquerading as medicine, they say. And yet so many people use them and seem to derive benefit, it seems a shame to lump them all together and throw them out.

I think a sensible approach is, firstly, for doctors to inquire of patients what non-traditional treatments they are using, both for conditions that the doctor knows about and is treating and for others that have not been dealt with. This will at least allow discussion and investigation of possible adverse interactions. Secondly, doctors should discuss truly complementary symptomatic CAM treatments—for chronic pain, allergies, or the like—so that their scientific basis can be investigated and understood by the patient and the doctor, if possible. Thirdly, for alternative treatments for serious or life threatening diseases such as cancer, doctors should assess the scientific evidence for the treatment and try to understand the range of benefit the patient expects to receive from it.

Although the US seems to lag behind the United Kingdom, we all need to pay more attention to the CAM treatments that our patients are seeking out and are willing to pay for and to the evidence behind their effectiveness.

So many people use alternative treatments and seem to derive benefit, it seems a shame to lump them all together and throw them out