How to help patients who use alternative medicine
With alternative therapies booming, you need to identify patients’ nonconventional treatments
By Christine Kuehn Kelly
While the patient appeared to be controlling her diet and taking her diabetes medications, her glucose levels were not improving. When her physician asked if she was doing anything else to treat her diabetes, the patient sheepishly admitted she was taking several herbal remedies.
But that was only part of the story. Because the patient knew that mixing herbs and medications could be dangerous, she opted to use only her herbal treatments and stopped taking her prescribed glipizide. The patient never told anyone because she didn’t want to insult her physician and the medical staff by explaining that she wasn’t following their orders.
Benjamin Kligler, MD, medical director of the Beth Israel Center for Health and Healing in New York, recounted the incident as an increasingly common example of the problems that physicians face when their patients use alternative medicine.
Complementary and alternative medicine, also known as CAM, is booming. And while patients turn to nonconventional therapies to help improve their health, physicians often find themselves in the difficult position of reconciling these therapies with more mainstream approaches.
Making matters worse, many patients don’t discuss their use of alternative therapies with their physicians. Statistics indicate that fewer than half of patients using alternative medicine tell their physicians.
“Patients are using CAM, and doctors need to recognize it,” said Raymond Murray, MACP, professor of medicine emeritus at Michigan State University. “It’s difficult for residents still training in conventional medicine to add complementary and alternative therapies to the amount of material they need to learn, but it’s important, and it must be done.”
Here are some tips on how to identify patients who are using alternative therapies and how to integrate those treatments with conventional medicine.
To identify patients who might be using alternative medicine, it helps to understand who generally finds nontraditional approaches appealing.
Experts say that patients tend to use alternative medicine for a few simple reasons. They often believe alternative therapies are more effective than traditional medical care, they feel their problems are not serious enough to require the care of a physician, or they don’t want to rely on medications and surgery.
Statistics indicate that patients most frequently seek out alternative or complementary therapies for chronic conditions such as back pain, arthritis, depression, headaches and cancer. Americans who use these approaches also tend to be young and well-educated and looking for a more holistic approach to health care.
Even among the general population, though, alternative medicine is thriving. In 1997, for example, more U.S. patients visited alternative practitioners than primary care practitioners, explained David Eisenberg, ACP–ASIM Member, director of the Center for Alternative Medicine Research at Beth Israel Deaconess Medical Center in Boston. A 1998 article in the Journal of the American Medical Association estimated that one million Americans use the services of acupuncturists each year and that 15 million use high-dose vitamins or herbal medicines like ginkgo biloba.
Because relatively few patients talk to physicians about how they are using alternative therapies, experts suggest asking questions about alternative therapies in every history. They say that open-ended, nonjudgmental questions—the keys of good communication—encourage patients to open up and talk about other therapies they are using.
“I get tremendously positive responses from my patients when I ask about CAM,” said Peter Wolsko, MD, an internist who is an NIH fellow in complementary and alternative medicine at the Beth Israel Center for Alternative Medicine Research and Education. “They view me as someone they can relate to.”
After you identify patients who are using alternative therapies, you need to watch for potential interactions with conventional medications. To start, familiarize yourself with the most commonly used botanicals. (See “Popular herbal supplements: benefits and side effects,” this page.)
Experts also suggest paying close attention to herbs that can affect bleeding, such as garlic, ginger, ginseng and feverfew. Patients with multiple medical problems who take many medications and supplements, for example, need to be closely monitored. You should also closely monitor patients with significant liver or kidney disease, as well as heart conditions requiring anticoagulants.
Exactly what should you look for in these patients? The unfortunate truth is that no one knows the downsides of many alternative treatments. While a wealth of information is available for conventional treatments, relatively little reliable scientific information exists for many alternative therapies.
Most alternative medicines are not subject to the same rigorous scientific testing that is required for conventional treatments. Congress exempted the industry from regulations that require pharmaceutical manufacturers to prove that a drug is safe and effective before releasing it on the market.
Studies of St. John’s wort, for example, have shown widely varying amounts of the antidepressant component hypericum in various products. Some studies of ginseng have shown that some products contained no ginseng at all.
Worse yet, some herbs—particularly some imported from China—have been shown to be contaminated with lead and arsenic or other dangerous substances. One importer recalled products that were contaminated with aristolochic acid, a potent carcinogen and nephrotoxin. “It’s hard to find a safe and reliable product,” said Dr. Murray.
Supplements produced by pharmaceutical companies are generally better tested and more efficacious than substances produced by other companies, Dr. Murray said, as are botanicals from Germany. (The German government has an expert committee evaluate the safety and efficacy of herbs sold there.)
Dr. Murray also said that the safest substances typically come from companies that have been in business for a relatively long time. He added that preparations containing only a single herb product are generally safer than products containing multiple substances.
Knowing your limits
With more than 300 types of CAM therapies on the market, no one can be an authority in all. Experts suggest recognizing your limits and referring to colleagues who specialize in a particular field. “It’s difficult to be an expert in all the many fields of CAM,” said Dr. Wolsko.
Because residents do not get much exposure to community-based therapists, he said, asking patients whom they have used for alternative therapies is one way to get in touch with practitioners in your community.
Residents can also get firsthand knowledge. Dr. Wolsko arranged to shadow an acupuncturist during his residency. Other residents opt for their program’s CAM rotations or attend conferences.
Some experts suggest trying complementary or alternative therapy yourself. Many physicians who integrate alternative therapies into their practice say they have tried chiropractic, mind/body techniques or acupuncture to get a better sense of these therapies’ efficacy and safety.
Finally, while experts say it is important to remain open-minded about alternative therapies, they also point out you should make any objections clear to your patients.
“Sometimes the doctor has to say, ‘I’m worried that what you are doing is not in your best interest,’ ” Dr. Murray said. If the patient continues to pursue the disputed therapy, he added, you may need to appropriately withdraw your care.
Christine Kuehn Kelly is a Philadelphia-based freelance writer specializing in health care.
Echinacea. Used to bolster the immune system, especially for colds and the flu. Adverse effects can occur in patients with HIV, lupus, connective tissue diseases, liver disease or multiple sclerosis.
Ephedra (also known as ma huang). Used for weight loss, it can lead to severe cardiac dysrhythmia.
Garlic. Due to antiplatelet and LDL lowering effects, adverse effects can occur in patients on anticoagulants.
Ginkgo biloba. Because of possible cardiovascular and circulatory health effects, adverse effects can occur as a result of decreased platelet aggregation or in patients predisposed to seizure.
Ginseng (American or Asian). Used to increase mental and physical strength and well-being. Adverse effects can occur as a result of anticoagulation and increased blood pressure.
Green tea. Widely used for antioxidant effects and cardiovascular health. Green tea may affect the absorption of asthma medications and stimulants such as atropine, codeine, ephedrine and pseudoephedrine. May also increase blood pressure.
Kava kava. Used to reduce stress, it may affect motor control and judgment, particularly when combined with alcohol.
St. John's wort. Used to treat mild to moderate depression, it may interact with MOA inhibitors and antidepressants. May also cause photosensitivity.
Saw palmetto. Used to treat benign prostatic hyperplasia. Side effects are rare.
Valerian. Used to treat sleep problems, it may increase the effects of medications for insomnia and anxiety, or it may cause a paradoxical reaction.
Alternative and complementary medicine resources
The Special Nutritionals Adverse Event Monitoring System (SN/AEMS) reports adverse events associated with use of a special nutritional products. Go to http://vm.cfsan.fda.gov/~dms/aems.html
PubMed can help you find relevant journal citations. Visit the site at http://www.ncbi.nlm.nih .gov/entrez/query.fcgi?CMD=&DB=PubMed and type “CAM” in the search window.
“PDR for Herbal Medicines” is published by Medical Economics. For more information, go to http://www.pdr.net/.
Herbalgram and other publications on botanicals are available from the National Botanical Council at www.herbalgram.org/education/ind ex.html.
The NIH National Center for Complementary and Alternative Medicine is online at http://nccam.nih.gov/
The UCLA School of Medicine offers a course in acupuncture for physicians, and the University of Arizona School of Medicine offers a program in integrative medicine. More courses are listed at the Rosenthal Center for Alternative & Complementary Medicine at Columbia's Web site at http://cpmcnet.columbia.edu/dept/rosenthal/Residency.html
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