Wielding the double-edged sword of complementary therapies
Give your patients the confidence to tell you everything
Your patients are probably using herbs, supplements, hypnosis, and other forms of alternative therapies. That isn’t a secret. And it shouldn’t be a surprise to you that an estimated half of all Americans are using therapies outside the mainstream of Western medicine.
They spent $34.4 billion in 1997, the latest year for which figures are available, and they made 629 million visits to alternative practitioners, according to researchers at the University of Texas in Houston.
If those figures surprise you, you may be even more surprised to know that 40% of those who use such treatments don’t tell their doctors and health care professionals. You may be one of them.
Why the secrecy? The answers are many:
• fear of being ridiculed by their physicians for succumbing to "quackery"
• the belief that physicians will meet their questions about esoteric therapies with a blank stare;
• distrust of the medical establishment;
• genuine lack of understanding that the therapies they are using can have powerful medicinal effects and interact with other medications in a positive or negative way.
Patients with chronic diseases are more likely to use alternative therapies because mainstream medicine sometimes has little to offer to change the long and often painful course of their illnesses.
"Alternative therapies have experienced a revival over the past decade, fueled in part by the public’s desire to participate in their own health care and a perception that the medical profession has failed to find a cure for cancer, despite almost three decades of war on cancer," says Mary Ann Richardson, DrPH. Richardson is the program officer of the National Institutes of Health’s National Center for Complementary and Alternative Medi-cine (NCCAM) in Bethesda, MD.
Physicians need to know
She was lead author of a study on the use of alternative therapies among cancer patients that she conducted at the University of Texas MD Anderson Cancer Center in Houston.1
Richardson says the information available about alternative therapies is outdated and limited and predicts that as incidences of cancer, diabetes, heart disease, and other chronic conditions increase and survival times lengthen, more patients will seek information and will access complementary therapies.
Furthermore, the increasingly common use of alternative therapies without physicians’ knowledge "may be affecting evaluations of conventional therapies [for cancer], since two-thirds of vitamin and herb users also were receiving chemotherapy, radiotherapy, and surgery," she says.
Richardson found that 83.3% of the cancer patients surveyed in Texas had used at least one alternative approach out of seven categories studied. Those categories included:
1. special diets, including vegetarian, vegan, and macrobiotic diets;
2. psychotherapy with a psychiatrist, social worker, psychologist, or support group;
3. movement techniques and physical therapy, including exercise, yoga, tai chi or chi gong, chiropractic or osteopathic manipulation, and massage;
4. mind-body therapies, including imagery or visualization, hypnosis, meditation, biofeedback, energy healing or therapeutic touch, journaling, and music therapy;
5. spiritual practices, including prayer for self and prayer/spiritual healing by others;
6. vitamins and herbs, including melatonin, essiac, mistletoe, laetrile, shark or bovine cartilage, homeopathy, and ayurvedic and folk remedies;
7. other approaches, including immuno-augmentative treatment, 714-X, bioelectromagnetic therapy, and acupuncture.
Spiritual approach most popular
Spiritual practices were used by the largest numbers — more than 80% — of the cancer patients studied. Richardson found that 62.6% used vitamins and herbs, and 72% were likely to use more than one alternative therapy. She speculates that "the high prevalence of multiple therapy use across the disease continuum suggests that complementary and alternative medicine represents an invisible phenomenon in mainstream medicine."
The typical patient who uses alternative medicine in the United States is white, female, age 30 to 50, with above average income and education, and living in the western or northeastern regions of the country.
Richardson found those who were fully or partly insured were 1.7 times more likely to engage in alternative practices, and breast cancer patients were 1.9 times more likely to participate than those presenting at all other clinics combined.
Combining spiritual with conventional
Yet those who use alternative approaches are not likely to abandon conventional cancer care, Richardson found. Almost all (91%) of the patients who used spiritual practices combined them with conventional treatment, but only 76.6% of vitamin and drug users and 66.9% of patients who used movement and physical therapy combined those practices with conventional treatment.
A University of Texas in Austin study shows similar results for patients not suffering from any specific disease, although 10% said they had side effects from the herbs they were taking. As many as 95%, however, did not discuss the supplement use with their physicians.2
Richardson’s study included a question about why the patient was using alternative therapy, and the responses were interesting. Answers included the following:
• Patients had a desire to be hopeful — 73%.
• Patients said the approaches were nontoxic — 48.9%.
• They wanted more control in the decisions about their medical care — 43.8%.
• They expected their approaches to improve their quality of life — 76.7%.
• Patients believed the therapies would boost their immune system — 71.1%.
• They wanted to prolong life — 62.5%.
• They used the methods to relieve symptoms — 44%.
• They expected the therapies would cure their disease — 37.5%.
Since she recently took her position at NCCAM, Richardson says she is dedicated to increasing the knowledge base "so we can develop reliable sources of evidence we can pass on to patients."
"Furthermore," she wrote in an article published in the July issue of the Journal of Clinical Oncology, "expanded research initiatives are needed to determine the safety and efficacy of drug and herb or vitamin interactions." (See supplement on herb-drug interactions, inserted in this issue.)
NCCAM is currently conducting research on a handful of the most commonly used herbs.
"Patients should be reassured that physicians are becoming more aware of these issues," says Katherine Gundling, MD, director of medical education at the University of California-Davis.
"Even compared to five years ago, doctors now know much more about complementary therapies patients are using and how they can have a significant impact on their patients’ care," she points out.
Gundling says that many physicians are "trying hard" to learn about these therapies because the larger picture is so important to patient care.
"Patients need to consider that any alternative or complementary therapies they are using should be part of their overall medical care," she says.
A case in point: It is routine when taking a patient history to ask what medications the patient may be taking. But many patients do not consider supplements, herbs, and vitamins to be medications, so they don’t tell health care professionals about their usage.
"Physicians should ask directly," suggests Gundling. "If you make it routine to ask exactly what supplements they are taking, you’ll probably get all the information you are looking for.
"Patients need to be humbled by some of the medical properties of the remedies they are using. These are not magical pills that only do good things," she adds.
"The concept of natural’ substances, implies that since it was natural, it must be safe," says Cynthia Payne, MS, RD, dietitian and educator at the Joslin Diabetes Center in Boston.
Payne points out that poison ivy and snake venom are natural products, too, but they can have severe physiological effects.
She also mentions that some kidney transplant patients, for example, may want to take substances such as echinacea to prevent infections. However, because of its effect on enhancing the immune system, echinacea may reverse the effect of immunosuppressants designed to prevent rejection of the transplanted kidneys.
"We should be relaxed, watch our body language, and listen to patients," she says. "If they feel safe, they will tell you a great deal more."
Payne says she has found that caregivers who exercise patience will be able to uncover symptoms the patient had not previously mentioned as the reason for taking the supplement.
"Health care professionals who praise their patients for self-care and self-education will help obtain trust as well as help the patient communicate better," Payne says. "No patient should make the journey alone."
Shifting viewpoints
Success will be a matter of shifting both the patient’s and the physician’s viewpoints on the issue of alternative therapies, says Gundling. Yes, some doctors may ridicule the use of alternative therapies, but those physicians are becoming increasingly rare, she says.
It’s important to arm yourself with the best information available, says Gundling. "If a patient with diabetes asks you about using ginseng to help lower blood sugar, he has a right to expect an informed answer." (For more on ginseng and diabetes, see Complementary Therapies in Chronic Care, July 2000, p. 11.)
"You have to adopt a neutral stance," advises Barry Smiler, MD, a staff anesthesiologist at Sarasota (FL) Memorial Hospital. "So many of us have read the negative literature about alternative and complementary therapies that we forget they have many benefits as well."
For example, the anticoagulant effects of ginkgo biloba may be very helpful to patients with heart disease, among many other benefits, but they can be disastrous for patients undergoing surgery.
Smiler has seen two patients, both of whom were taking high doses of ginkgo, who had severe and unexpected bleeding during surgery. Ginkgo and other anticoagulants may be particularly dangerous if they are combined with drugs that have similar actions, such as aspirin or warfarin.
"We now have a very thorough pre-surgical discussion with patients so we can get all the information possible," he says.
"We sit down with them one on one, face to face, if possible. We let them know that they will be receiving several drugs during surgery, so they need to let us know all the supplements and other medications they are taking so we can prevent dangerous interactions," explains Smiler.
It requires an attitudinal change on the part of the health care team, says Smiler. "It’s duck soup once the patients realize we are not going to ridicule them."
Since the expanded interaction, says Smiler, there have been no herb-drug interaction problems during surgery. "And we tell patients to stop taking ginkgo two weeks before surgery," he adds.
References
1. Richardson MA. Complementary/alternative medicine use in a comprehensive cancer center and the implications for oncology. J Clin Oncol 2000; 13:2,505-2,514.
2. Bennet J, et al. Use of herbal remedies by patients in a health maintenance organization. J Am Pharmacol Assoc 2000; 40(3):353-358.
Related reading
• Blumenthal, Goldberg, Bruckmann. Herbal Medicine: Expanded Commission E Monographs. Newton, MA: Integrative Medicine Communications; 2000.
• Cupp. Toxicology and Clinical Pharmacology of Herbal Products. Totowa, NJ: Humana Press; 2000.
• PDR for Herbal Medicines. Montvale, NJ: Medical Economics Co.; 1998.
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