Complementary and alternative medicine (CAM) includes a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine.¹ Complementary medicine is generally regarded as a complementary treatment that is used alongside conventional medicine whereas alternative medicine is regarded as a treatment used in place of conventional medicine.¹

CAM may be practised by those with a medical qualification, as is often the case with acupuncture or homeopathy. They may also be practised by those with another relevant qualification such as physiotherapy, as may be the case with manipulation. However, patients should be alerted to practitioners who have no specific training or registration in CAM.

A good reason for registration of all CAM practitioners is to ascertain that they are appropriately trained and that they also comply with certain ethical standards and undergo some form of peer review and continued professional development.

There has been considerable interest in CAM with a House of Lords Select Committee Report in November 2000² and a subcommittee of the Royal College of Physicians set up to examine certain aspects. They reported in Clinical Medicine in 2003.³

The House of Lords Select Committee was very keen that there should be professional standards, registration and accountability in all aspects of CAM.² The acupuncture profession will be statutorily regulated by 2010.⁴ Osteopathy is regulated by the General Osteopathic Council. Chiropractic is regulated by the General Chiropractic Council.

Popularity of complementary and alternative medicine

In the UK, research published in 2001 showed that 47% of people have used CAM at some time in their lives and 10% use some form of CAM each year.⁵ Users tend to be older and female. Over 90% is purchased outside of the NHS. At least 10% of hospital physicians are also thought to use CAM as part of their clinical practice.⁶ A survey conducted in 2001 estimated that one in two practices in England now offer their patients some access to CAM.⁷

A report in the Lancet in 2007 stated that about 13,000 patients are treated at the five homeopathic hospitals in the UK each year. 14.5% of the population say that they trust homeopathy and £38 million is spent on homeopathy each year in the UK.⁸ Of the various forms of CAM, acupuncture is amongst the most popular. Approximately 3 million people undergo acupuncture treatment in the UK each year.⁹

Examples of complementary and alternative medicine practices

There are a great many approaches that may be classified as CAM. There are also activities such as yoga and tai chi and various diets where health benefits are claimed and some may regard them as CAM.

Separate articles discuss:

• Acupuncture
• Homeopathy
• Back Manipulation (Osteopathy and Chiropractic)
• Aromatherapy
• Reflexology

Other examples of CAM include:

• Herbal remedies
• Hypnosis
• Diets including the 'macrobiotic diet'
• Chelation therapy
• Faith healing

Herbal remedies

The medicinal properties of herbs have been exploited for many centuries. The druids and the Ancient Egyptians are amongst the best known exponents of herbal medicine. Nicholas Culpeper's work in the 17th century was seminal. Bearing in mind the origins of such drugs as digoxin, aspirin, quinine and penicillin, it would be surprising if other plants or micro-organisms did not also offer therapeutic potential. However, it would also be surprising if they did not have adverse effects. If digoxin had been discovered recently, it may not have received a product licence, as the ratio of toxic to therapeutic dose is too low.

The concern is that many herbal remedies that are for sale have not been thoroughly tested for efficacy, toxicity, drug interactions and teratogenicity. In addition there are often problems of variation in potency between batches, and correct doses are not carefully established.

The problem with herbal remedies is that they may well have pharmacological properties. As such, they can be expected to have some of the same problems as licensed drugs, including adverse effects. Ideally, before any herbal remedy is allowed to be marketed, there are a number of questions that should be answered, as for conventional medicines:

• Is potency reliable or is there marked variation between batches?
• Is it effective? This needs double-blind randomised controlled trials of appropriate sizes.
• What is the appropriate dose?
• What is the toxic dose?
• What is the adverse effect profile?
• What interactions are there with other drugs that may commonly be used simultaneously?
• Is it teratogenic? If that question cannot be answered, there must be warnings about pregnancy.

The Medicines and Healthcare products Regulatory Agency (MHRA) is the government agency which is responsible for ensuring that medicines and medical devices work, and are acceptably safe.¹⁰ They say that the current weak regulation of herbal remedies in the UK has led to specific safety concerns.¹⁰ There are three regulatory routes by which a herbal remedy can reach consumers:¹⁰

1. As unlicensed herbal remedies - there are no specific standards of safety and quality and so standards can vary widely. They are not required to be sold with product information for consumers to use them safely, such as safety warnings and contra-indications. This situation is not ideal and by April 2011 all manufactured herbal medicines will be required to have either a traditional herbal registration or a product licence (see below).
2. As registered traditional herbal medicines - the Traditional Herbal Medicines Registration Scheme (THMRS) began on 30th October 2005. Products have to meet specific standards of safety and quality. They have to be accompanied by agreed indications, based on traditional usage, and systematic patient information allowing the safe use of the product. There is a nine-digit registration number starting with the letters 'THR' on the container or packaging.
3. As licensed herbal medicines - some herbal medicines in the UK hold a product licence or marketing authorisation, as any other medicine. Such medicines are required to demonstrate safety, quality and efficacy and be accompanied by information for safe usage. There is a nine-number product licence (PL) number on the container or packaging, prefixed by the letters 'PL'.

The MHRA website also provides a list of herbal ingredients which are prohibited or restricted in medicines.

There is a separate article on St John's Wort, which is one of the best researched of all the various herbal remedies.

Hypnosis

Hypnosis may be practised by medically qualified people, clinical psychologists or those without healthcare qualifications. Hypnosis must be used with skill and care, as adverse events, including the implantation of false memories, may occur. The British Society of Clinical Hypnosis can help in finding a registered practitioner.¹¹ Both competence and ethics are essential.

Conditions amenable to treatment include:

• Smoking cessation
• Nail biting
• Weight control
• Healthy eating
• Sports performance
• Exam nerves
• Irrational fears and phobias
• Stress management
• Compulsive behaviour
• Anxiety and panic attacks
• Stress-related stomach and digestive problems
• Childbirth
• Some skin problems
• Pain control
• Stress-related high blood pressure
• Self-confidence
• Compulsions and compulsive behaviour
• Some sexual problems

There have been a number of systematic reviews, including Cochrane reviews of the various topics.

Diets

There is no doubt that diet is very important and that it can have a profound influence on arterial disease and cancer. However, there is concern over 'fad' and 'trendy' diets of unproven value that may be inadequate in terms of effective nutrition, especially in children.

The aim of the macrobiotic diet is to avoid foods containing toxins. It is a completely vegan diet and no dairy products or meats are allowed. Macrobiotic diets have become popular with people who have cancer who believe that it can help them fight their cancer and lead to a cure.¹² However, there is no scientific evidence to prove that a macrobiotic diet can treat or cure cancer or any other disease.¹²

Some research shows that macrobiotic diets may improve health in some people as long as they are not followed to an extreme.¹² This may be because of an increase in fruit and vegetable intake and a reduction in fat, sugar and salt intake. However, a 'normal' diet can also allow this. There is concern that for some people, following a macrobiotic diet can have serious, harmful effects such as nutrient deficiencies and weight loss.¹² They are also very expensive.

Chelation therapy

Chelation therapy is the use of chelating agents - usually the man-made amino acid ethylene diamine tetra-acetic acid (EDTA) - to remove heavy metals from the body. It is of proven value in Wilson's disease, haemochromatosis and heavy metal poisoning (including lead and mercury). However, it has also been promoted by some for the treatment of other disorders, including arterial disease, Alzheimer's disease and autism.

The basis for its use in arterial disease is the belief that it also chelates calcium, one of the components of atherosclerotic plaques. The American Heart Association has spoken out against the use of chelation therapy in arterial disease. It has concluded that the benefits claimed for this form of therapy aren't scientifically proven, and so they therefore do not recommend its use.¹³

Faith healing

Faith healing is not new. It is well documented in both the Old Testament (Second Book of Kings, chapter 5) and New Testament (Gospel of Luke, chapter 8, verses 26 to 56) of the Bible, along with the observation that it is only effective where there is absolute faith. There are still charismatic preachers who carry out 'faith' healing in which people come to the front and publicly discard the wheelchairs that they have allegedly depended upon for many years.

Many churches, including traditionally reserved sections of the Church of England, have taken to 'healing services' but they are not to be confused with the hysteria of the charismatic performances. They do not try to portray their role as a substitute for medical care but more as an adjunct. However, much as we may try to be holistic, patients may have spiritual needs that are not within our remit. This is where religious organisations can help. They may be beneficial in helping the person to live in peace with his disease, and perhaps we should not always equate 'healing' with 'cure'.

Reasons for using complementary and alternative medicine

It is important to try to understand someone's motivation for using CAM. There may be many reasons that they may choose it. Talk to patients and find out what they are doing and why.

For example, many people have the belief that CAM techniques are 'natural' when compared to conventional medicine. There is an implication that 'natural' means invariably effective and invariably safe. However, as discussed above in the 'Herbal remedies' section, considering the array of toxins in nature, anything that is natural is not invariably safe. Interestingly, there are well documented cases of 'herbal remedies' for childhood eczema that have been found to contain potent topical corticosteroids.^14,15

Another reason why patients may choose CAM is that they receive more time, empathy and emotional support from an alternative therapist. There may also be a spiritual component that they like. However, this shouldn't be confused with efficacy of a treatment. They may feel that their own doctor has little time or understanding for their problems. This is one reason why an holistic approach is important for all doctors.

Patients may also turn to CAM when they feel that conventional medicine has 'let them down'. For example, people with eczema, psoriasis or irritable bowel syndrome may wish to take control of their disease where they feel that conventional medicine has failed to cure them. Therapies that encourage relaxation may be useful in these conditions. If a patient is taking the usual medication for irritable bowel syndrome but also having some aromatherapy, this may well be beneficial and is unlikely to do harm.

On the other hand, there may be cases where patients may be put at risk when using CAM. For example, if parents have decided that their children should have homeopathic vaccines. Explain to them that these vaccines do not induce an antibody response against the diseases and that the Faculty of Homeopathy says that all children should have conventional vaccines.

Conclusion

Professor Ernst from Exeter University is seen by many in the CAM community as being antagonistic to their cause. This he denies. He says that he is trying to validate CAM by putting it on the same evidence base as conventional medicine.

There is some evidence that CAM may work for certain conditions but ,for many conditions for which it is currently used, the evidence is of poor quality and it is impossible to draw a firm conclusion about its effectiveness. However, we must remember that this is not the same as evidence of lack of efficacy. More research is needed in this area.

CAM does appeal to patients. We, as doctors, should help our patients to make informed decisions about their healthcare. We must provide them with the evidence about CAM to aid their empowerment and decision-making process.