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Safety, communication issues slowing internists' use of alternative medicine

From the June 1999 ACP-ASIM Observer, copyright 1999 by the American College of Physicians-American Society of Internal Medicine.

By Edward Martin

NEW ORLEANS—During a tense moment at an Annual Session conference on alternative medicine, the critical issues raised by patients who go outside of mainstream medicine for care came down to one internist and one of his patients.

Mark I. Hainer, ACP-ASIM Associate, chief internal medicine resident at the University of Hawaii in Honolulu, explained that a patient with cancer discovered an Internet site that promoted hydrazine sulfate, a chemical used in rocket fuel, as a way to control cancer pain and improve appetite. The substance eventually caused the patient's liver to fail.

"My patient died, and when someone dies, you learn a big lesson," Dr. Hainer told a hushed audience. "With our reliance on high-technology, low-touch medicine and the 12-minute office visit, is alternative medicine really our own fault?"

David M. Eisenberg, MD, a Harvard Medical School expert on alternative medicine who led the workshop, said that the story illustrates the challenges—and the dangers—that alternative therapies bring to medicine. "We all share concerns about patients coming to us with shopping bags of remedies," he noted. "But having said that, we need to create another place for them to go. If every hospital in the country had a few respected physicians where patients could go for advice and consultation about alternative medicine, they might not rely on Internet sites."

Dr. Eisenberg said that while physicians may have a strong reaction to the idea of alternative medicine, they can no longer view it as an enemy. Instead, he explained, they must view alternative medicine as a reality in today's practice environment. He cited figures indicating that U.S. consumers spent roughly $30 billion out-of-pocket on alternative medicine last year and made about 640 million visits to alternative practitioners, figures that roughly parallel mainstream medicine.

Wayne Jonas, MD, director of the National Center for Complementary and Alternative Medicine, a new $50 million budget center run by the National Institutes of Health, said that the popularity of alternative medicine is only going to grow. Dr. Jonas believes, for example, that an aging population seeking relief from chronic conditions will accelerate demand for CAM, as the field has become known. Already, 42% of Americans use alternative medicines, an increase of 25% since 1990. Patients are largely college educated and affluent, and physicians themselves are heavy users of alternative products.

According to Dr. Jonas, patients are increasingly willing to pay for alternative therapies. A recent survey found that a third of Americans strongly want alternative medicine options in their health plans and that the same percentage would consider paying for them. Insurers such as Oxford Health Plans Inc. in New England have embraced the trend and now offer alternative medicine options in their coverage, allowing patients to bypass primary care physicians and go directly to chiropractors and other types of alternative providers.

"As we in the baby boom generation grow older, we're going to observe an increasing demand for health plans and Medicare to pay for alternative therapies," Dr. Eisenberg said. "Some of my colleagues say this is a fad. It's anything but. This is just the beginning."

Red flags

While such statistics may indicate consumer confidence in nonconventional therapies, internists remain concerned about alternative medicine on a number of levels. During a week of Annual Session workshops and lectures, the most prevalent concern voiced by internists was safety.

Product labels may say "natural," but in the largely unregulated world of alternative medicines, products can include ingredients that internists would never dream of prescribing for their patients. They include arsenic, mercury and cadmium, said Keith Block, MD, an Illinois oncologist who uses some nontraditional treatments.

Dr. Block is both supportive and skeptical of alternative medicine. In his practice, he has seen nutritional supplements and biotherapy increase the median survival time for selected prostate cancer patients from 36 to 56 months. He also noted that some Chinese herbs appear useful in cancer treatment.

"But that's not what most of us see when a patient walks in the door from Chinatown with them," he said. "There are issues not just with contamination, but herbs laced with conventional prescription drugs such as testosterone."

Dr. Block also cited studies that show that many products advertised as St. John's Wort contain relatively little hypericin, the chemical believed to alleviate depression. Another study of 400 ginseng products showed one in four contained no ginseng at all.

Lack of standardization, he said, poses serious problems for patients interested in using these products and for their internists who feel uncomfortable dispensing advice. "If you buy an alternative medicine in a drugstore, you've got no idea what you're getting," cautioned Dr. Jonas.

Experts at Annual Session said that the content of herbal medications is not the only safety consideration. A number of speakers also warned of potential interactions of herbal medicines with prescription drugs. The herbal therapy Kava, for example, can exaggerate the effect of medications that affect the central nervous system. Other speakers noted that generally safe herbals like feverfew, garlic, ginger and ginseng may alter bleeding time. And valerian, which is widely marketed as an herbal relaxant, can cause excessive sedation when used with barbiturates.

Communication gap

As several speakers pointed out, an even bigger threat comes from patients' reluctance to talk about their use of alternative therapies with their physicians. Dr. Jonas cited research indicating that fewer than one patient in three tells his internist he uses alternative medicine or treatments, even for the condition the physician is treating.

"That means 15 million Americans use supplements along with prescriptions, so the potential for adverse drug interactions is great," said Dr. Jonas. "Surveys show 74% of patients use herbal medications and alternative treatments to complement conventional care." His advice? "Internists have to get rid of the doctrine, 'Don't ask, don't tell.'"

How can physicians bridge that gap? In one session, when Dr. Eisenberg asked how many internists receive patient requests for advice on alternative procedures, there were awkward chuckles as half the hands in the audience rose. "How do you react?" he asked. "Let me guess. You're probably thinking to yourself, 'Scotty, beam me up!' 'Oh God, don't ask me that!' 'You aren't serious, are you?'"

To better understand patient requests for alternative therapies, Raymond H. Murray, FACP, moderator of a panel on nutrition and complementary medicine and professor of medicine emeritus at Michigan State University, said that internists need to consider patients' motivation. Dr. Murray, who is considered a pioneer in alternative and complementary medicine, said that patients often turn to holistic care after conventional measures fail. He also noted that many patients fear the side effects of conventional medicine.

Dr. Jonas agreed, noting that certain myths about the type of patient who embraces alternative medicine don't seem to be true. That patient "is generally not anti-science or motivated by cost," he said, noting that most combine nontraditional therapies with more conventional ones.

Instead of expressing skepticism about alternative therapies, several speakers suggested that internists develop strategies to coax information from patients about the alternative treatments they're using, if only to monitor and prevent dangerous measures such as use of hydrazine sulfate to mitigate cancer symptoms. "You don't have to give up evidence-based medicine to engage in these conversations," said Dr. Eisenberg.

'Eat this root'

While herbal remedies may seem unconventional to U.S. physicians, plant-based medicines remain the foundation of pharmacology for more than 80% of the world's population. According to Norman Farnsworth, PhD, director of the College of Pharmacy at the University of Illinois, synthetics did not begin to squeeze herbs and other alternative remedies into the background in industrialized nations until the 1940s.

Dr. Farnsworth, a member of the Presidential Commission on Dietary Supplements, which is expected to release new regulations for the labeling and marketing of herbal products this fall, was among several experts who pointed out that scientific data are beginning to support the clinical value and safety of some herbal products. "Ginseng had been used in China for 3,000 years and they aren't dying like flies over there," he said. "They must be doing something right."

He noted that saw palmetto, common in the Southeast, has been demonstrated effective in treating benign prostatic hyperplasia, with fewer side effects than prescription drugs. A particular extract from ginkgo may act as a neuroprotective agent to preserve or enhance mental function in Alzheimer's patients.

In addition, Duke University scientists recently received a $4.5 million grant to study St. John's Wort, whose compounds of hypericin, pseudohypericin and hyperforin appear to be useful in treating depression and anxiety disorders.

Despite such emerging data, internists are still left wondering how they can evaluate a possible herbal remedy or alternative treatment. Dr. Farnsworth suggested looking for a U.S. or German manufacturer that has been in business a decade or longer; the label should specify that the product is standardized; and it should be a single herb product, rather than a mixture. He also said that pregnant patients should be advised to avoid herbal products.

Internists at the Annual Session presentations had other concerns, including liability. Although liability issues remain ill-defined, initial studies show fewer and typically less serious claims against chiropractors, massage therapists and acupuncturists than against physicians, panelists said.

Speakers also predicted that some of these concerns will gradually subside. Some said that the herbal market will become standardized as evidence shows which nontraditional remedies are effective adjuncts to traditional treatment and as large drug manufacturers like Bayer Corp. enter the herbal market. With two-thirds of medical schools now including some instruction in alternative therapies, increasing numbers of physicians are expected to discuss alternative medicine with their patients.

For now, however, the movement is still propelled by the medical consumer. "It will either expand until widely accepted by internists or it will blow up in everybody's face," Dr. Farnsworth predicted. "A rash of deaths from some unscrupulous company with a lousy product could kill the whole thing overnight, although I really don't think that's likely."

In his lecture, he outlined pharmacological evolution, starting when man learned plants could cure. "Here, eat this root" was an early prescription. Then came cycles of medical mysticism, a return to science-based medicine and, in the 1940s, synthetic drugs. Antibiotics became widely available, but in the 1990s, resistant viral strains appeared.

"Now we're in 1999," he concluded. "Here, eat this root."

Edward Martin is a freelance writer in Charlotte, N.C.

Potential problems with 'natural' therapies

While herbal remedies are often touted as "natural" alternatives, they have side effects and can interact with prescription drugs. Here, from a variety of Annual Session presentations, is a list of commonly used herbal substances and their known side effects:

Echinacea. Used to treat colds and flu. Potential adverse effects for patients with HIV, multiple sclerosis and tuberculosis. Possible interaction with hepatoxic drugs such as anabolic steroids.

Garlic. Used for cardiovascular health. Adverse effects include odor, possible stains on clothing and increased bleeding times in patients prescribed warfarin sodium.

Ginkgo biloba. Used for cerebrovascular and circulatory health. Possible side effects include gastrointestinal discomfort and skin reactions. Small potential for increased bleeding times and spontaneous hemorrhage.

Asian ginseng. Used to boost physical endurance. Possible side effects include the potential to increase hypertension in large dosages and altered bleeding times. Should be avoided concomitantly with warfarin sodium, estrogens or corticosteroids.

Hawthorn. Used to treat mild coronary insufficiency. No side effects known, but because of seriousness of heart disease, should be used only under physician supervision.

Kava. Used to treat anxiety, insomnia and stress. May affect judgment and motor reflexes and increase effects of alcohol and barbiturates. Long-term use can induce dermatosis, producing yellow skin and motion impairment.

St. John's Wort. Used to treat mild to moderate depression, seasonal affective disorder and anxiety. May interact with monoamine oxidase inhibitors and other antidepressants. Unknown effects for pregnant and lactating women.

Saw palmetto. Used to treat benign prostatic hyperplasia. May cause gastric discomfort.

Goldenseal. Used as an antimicrobial. May cause gastrointestinal disturbances, possible uterine contractions. Effects on hypertension largely unstudied.

Slippery elm. Used to treat sore throat. No known side effects.

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