Return to Sender! Some CAM Ruminations

Returning to the roost: Pliny says I think I CAM...

Me and my big mouth suggesting an exercise where we have to take an opposite point of view on a topic from where we would normally find ourselves. I am hosed since others have already accepted the challenge and been quite true to its intent so here goes.
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Complementary and Alternative Medicine (CAM) is a broad-ranged group of beliefs, professions, cultural models and philosophies that generally fall into one of five recognized categories:

1. Whole Medical Systems (naturopathy, Chinese medicine, etc.),
2. Mind-Body medicine (prayer, meditation, etc.),
3. Biologically-based practices (herbalism, vitamins, antioxidants, etc.),
4. Manipulative or Body-based practices (osteopathy, chiropracy), and
   
5. Energy Medicine (Reki, touch, magnets, etc.)
   

Generally these practices fall outside of the range of options used by (and recognized by) most Western trained clinicians.

Obviously the full range of CAM options is beyond the scope of a single discussion so for now I am going to limit my comments to herbal remedies. In a later post I will talk about what CAM practices can teach western clinicians about caring for the sick. First, some general operating principles that I use in studing these claims.

Why limit the discussions of CAM to scientific practices? Many would take issue but this is a reasonable approach due to the reality of the medical market place. Medicine is held to a high standard in our society and the stated ideal for the healthcare system is the use of scientifically vetted best practices. Payment and professional liability are determined in this way for physicians so it seems both logical and fair that any complements to medicine be judged the same way particularly when we are considering paying for these services at the societal level. How can we have a double standard for those who provide healthcare services? To hold physicians to a higher level than that applied to chiropractors for example would be unfair and a tacit acknowledgment that the two professions were not comparable in clinical utility. Some defenders of CAM imply that using science as a benchmark is unfair but what other standard is reasonable? Why should medicine be held to an objective standard when others are not? Others may point out that there is more to healthcare than objective outcomes. While true, this in no way eliminates the need for objective measurement of outcomes of any therapies in addition to consideration of subjective patient experience.

Many adherents of CAM point out that some previously discounted alternates have reached more mainstream acceptance (group counseling and meditation for example) suggesting that many of today's fringe beliefs may yet be vindicated. Perhaps, but this kind of thinking ignores the considerable differences between today's medical science and that of even 50 years ago. Medical science of today incorporates a far greater understanding of biochemistry, molecular biology and physiology that makes it less and less likely that huge gaps in basic science understanding will be discovered. With the ability of naturalistic models to account for the so much of the range of observed phenomena it becomes less likely that any mysterious lifeforces or novel forms of energy will be discovered. If they exist in the gaps of our knowledge they are becoming tiny indeed.

Based upon purely scientific criteria for success the overwhelming majority of CAM practices fail to demonstrate clinical efficacy in controlled trials. Controlled trials are imperfect but they remain our best method for identifying true effects that can be reproduced in future patients. Fortunately for the practitioners of such, the public doesn't seem to mind and billions of dollars are spent each year on CAM. Even ignoring the danger of delaying or interfering with proven and effective treatment through the use of these practices, some are down right dangerous in themselves. Spinal manipulation for example has been proven to result in neck injuries and damage to the carotid arteries resulting in stroke in some patients, without a single study demonstrating its clinical utility.

Professor Sprout to the Rescue!

Herbal remedies are an area of CAM which has been proven to have clinically demonstrable effects - though not always the desired ones. There is no doubt that naturally occurring chemicals in plants, etc. have physiologic effects and this is in fact the wellspring from which the modern field of pharmacology arose. Penicillin, digitalis, atropine, all these substances and many others were discovered from the chemical analysis of folk and herbal remedies. No one one disputes that fact and others probably are out there waiting to be discovered.

What is often ignored by the herbal remedy community is HOW these discoveries were usually made - through the study of toxicology - i.e. the study of poisoned people. Certainly true of digitalis and atropine (belladonna anyone?) That as they say is the rub. Below are some cautions suggested to those who use herbal remedies.

The problem with herbal remedies is not that they don't do something. The problems are these:

1. Herbal remedies contain multiple active ingredients
2. The pharmacological effects of these preparations aren't always the advertised outcome
   
3. Herbal remedies are unregulated
4. Herbal remedies interact with other medications
   

Multiple agents in the preparations

As said before; herbal remedies do have biologic effects. But many preparations include more than one biologically active ingredient. Why is this concerning? Imagine the following. In your medicine cabinet there is a drug that may help you. Instead of finding it and taking the one drug, you just grab a handful of many of the drugs in the cabinet including the one of interest. Would you be surprised if the effect was somewhat different from what you hoped? Probably not. But that in essence is what happens with unregulated herbal remedies. There are a lot of things in herbal preparations that may be active beyond what it's being taken for. (Many of the people who rant about the dangers of vaccinations turn right around and down a handful of unregulated pharmoactive agents without a second thought. )

The pharmacological effects of these preparations aren't always the advertised outcome

Related to the above, but with the additional concern that people often incorrectly perceive that taking herbal preparations is not taking a medication. They are. Drugs of any kind - herbal or from Glaxo affect a wide range of the body's processes. And because they are unregulated these undesirable effects may be recognized only after many people have been harmed.

Herbal remedies interact with other medications

Some agents in common herbal remedies interfere with aspirin or coumadin, for example, used to either treat blood clots or reduce the risk of stroke or heart attack. Some increase the anticoagulant effect of the drugs (increasing the risk of bleeding) and some reduce it (counteracting the desired effect). Often the ingredient that has this effect is not the primary agent in the preparation.

Lack of regulation

The FDA can be a pain, of that there is no doubt. Pain or not, regulation of medications is what separates a medication from snake oil. Controlled trials of drugs often (nothing is perfect) discover hidden effects before they reach the market. It adds to cost, its adds to delays but it improves safety. When taking unregulated medications (which have not been shown to have any of their claimed effects via clinical trials) you are taking a risk. certainly one that you should share with your care givers so that they are aware of the drug's presence. You are agreeing to participate in an unregulated trial of a drug when you buy them.

Why trials are so important beyond simple safety.

Science is a very unforgiving discipline. It cares nothing for our pet theories or for what sounds reasonable. It only deals with demonstrable facts. Take the antioxidant issue. Oxygen free radicals exist, are a byproduct of metabolism, and are very reactive (White Blood Cells use them as one of their ways to kill bacteria, for example). Substantial investments in enzyme infrastructure exist to combat the effects of O2 free radicals. It makes logical sense that getting rid of these guys is a good thing. It is not entirely crazy to theorize that they are involved in some of the processes of aging from a purely chemical perspective. But just because it sounds reasonable doesn't make it true. (There in lies much of America's problem ;) and much of why CAM is so popular). Only through controlled trials of antioxidants can we learn whether our common sense musings have any basis in demonstrable science. You can of course gobble blueberries until you look like violet from Willy Wonka, but it may not be helping you. Just a thought.

Many of these agents may be useful. But for safety's sake they should be isolated and studied individually in controlled trials. Herbal remedies may be beneficial but this must be confirmed through the same kinds of testing as we use for antibiotics. My advise is avoid drugs as much as you can and take only those that specifically address a well described clinical need be they herbal or not.