Complementary and Alternative Medicine

Alternative medicine describes practices used in place of conventional medical treatments. Complementary medicine describes alternative medicine used in conjunction with conventional medicine. The term complementary and alternative medicine (CAM) is an umbrella term for both branches. Alternative medicine includes practices that incorporate spiritual, metaphysical, or religious underpinnings; non-European medical traditions, or newly developed approaches to healing. There are almost 500 such systems.

The National Center for Complementary and Alternative Medicine defines complementary and alternative medicine as "a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine". It also defines integrative medicine as " [combining] mainstream medical therapies and CAM therapies for which there is some high-quality scientific evidence of safety and effectiveness".

Proponents of evidence-based medicine regard the distinction between conventional and alternative medicine as moot, preferring "good medicine" (with provable efficacy) and "bad medicine" (without it). "Bad medicine" is any treatment where the efficacy and safety of which has not been verified through peer-reviewed, double blind placebo controlled studies, regarded as the "gold standard" for determining the efficacy of a compound. It is thus possible for a method to change categories in either direction, based on increased knowledge of its effectiveness or lack thereof.

Alternative Definition
The terms "alternative medicine", "complementary medicine" and "CAM" are generally understood in terms of their relationship to mainstream medicine, as described above. Richard Dawkins, Professor of the Public Understanding of Science at Oxford, argues for a different definition of alternative medicine, based not on sphere of usage but on evidence: "alternative medicine is defined as that set of practices which cannot be tested, refuse to be tested, or consistently fail tests. If a healing technique is demonstrated to have curative properties in properly controlled double-blind trials, it ceases to be alternative. It simply...becomes medicine." He also states that "There is no alternative medicine. There is only medicine that works and medicine that doesn't work."

Well-known proponents of evidence-based medicine who study CAM, such as the Cochrane Collaboration and Edzard Ernst, Professor of Complementary Medicine at the University of Exeter, have retained CAM's generally-accepted definition and do not define CAM as Dawkins does. In their view, there can be "good CAM" or "bad CAM" based on evidentiary support.

Problems in definition
The main problem that most scientists have with this terminology is that the CAM definition is not sufficiently culturally senstive, since what is "alternative" and/or "complementary" towards a pre-existing medical tradition/school can be very different in different cultures of the world.So, what in the West is considered "alternative" medicine may elsewhere be considered "traditional" medicine - for example Chinese medicine and Ayurveda. Paradoxically, industrial "pharmaceuticals" could also be seen as CAMs within the context of traditional medicine/traditional healers in Africa or even among Traditional Chinese Medicine.

Other continental European scientific communities -- with even a much longer history in traditional medicine or herbal medicine (such us Germany or France)-- do not know this term, neither do they use it.

Moreover, the list of what is considered to be CAM can change continually, as those therapies that are proven to be safe and effective become adopted into conventional health care and as new approaches to health care emerge. (eg Acupuncture, mindfulness

CAM should not be confued with integrative medicine. Ralph Snyderman and Andrew Weil state "integrative medicine is not synonymous with complementary and alternative medicine (CAM). It has a far larger meaning and mission in that it calls for restoration of the focus of medicine on health and healing and emphasizes the centrality of the patient-physician relationship".

==Classification of CAMs According to the NIH (National Institutes of Health): 1. complementary medicine is used together with conventional medicine. An example of a complementary therapy is using aromatherapy to help lessen a patient's discomfort following surgery; 2. alternative medicine is used in place of conventional medicine. An example of an alternative therapy is using a special diet to treat cancer instead of undergoing surgery, radiation, or chemotherapy that has been recommended by a conventional doctor. A less extreme example would be choosing an echinacea medicine from a naturopath, for hayfever, rather than an NSAID pharmaceutical or conventional doctor recommendation/prescription.

NCCAM classifies CAM therapies into five categories, or domains:

1. Alternative Medical Systems

Alternative medical systems are built upon complete systems of theory and practice. Often, these systems have evolved apart from and earlier than the conventional medical approach used in the United States. Examples of alternative medical systems that have developed in Western cultures include homeopathic medicine and naturopathic medicine. Examples of systems that have developed in non-Western cultures include traditional Chinese medicine and Ayurveda.

2. Mind-Body Interventions

Mind-body medicine uses a variety of techniques designed to enhance the mind's capacity to affect bodily function and symptoms. Some techniques that were considered CAM in the past have become mainstream (for example, patient support groups and cognitive-behavioral therapy). Other mind-body techniques are still considered CAM, including meditation, prayer, mental healing, and therapies that use creative outlets such as art, music, or dance.

3. Biologically Based Therapies

Biologically based therapies in CAM use substances found in nature, such as herbs, foods, and vitamins. Some examples include dietary supplements,3 herbal products, and the use of other so-called natural but as yet scientifically unproven therapies (for example, using shark cartilage to treat cancer).

4. Manipulative and Body-Based Methods

Manipulative and body-based methods in CAM are based on manipulation and/or movement of one or more parts of the body. Some examples include chiropractic or osteopathic manipulation, and massage. See Bodywork

5. Energy Therapies

Energy therapies involve the use of energy fields. They are of two types:

Biofield therapies are intended to affect energy fields that purportedly surround and penetrate the human body. The existence of such fields has not yet been scientifically proven. Some forms of energy therapy manipulate biofields by applying pressure and/or manipulating the body by placing the hands in, or through, these fields. Examples include qi gong, Reiki, and Therapeutic Touch.

Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields, such as pulsed fields, magnetic fields, or alternating-current or direct-current fields.

CAM is often erroneously confused in Western countries with traditional medicine.

Regulation
Jurisdiction differs concerning which branches of alternative medicine are legal, which are regulated, and which (if any) are provided by a government-controlled health service or reimbursed by a private health medical insurance company.

A number of alternative medicine advocates disagree with the restrictions of government agencies that approve medical treatments (such as the American Food and Drug Administration) and the agencies' adherence to experimental evaluation methods. They claim that this impedes those seeking to bring useful and effective treatments and approaches to the public, and protest that their contributions and discoveries are unfairly dismissed, overlooked or suppressed. Alternative medicine providers often argue that health fraud should be dealt with appropriately when it occurs.

In India, which is the home of several alternative systems of medicines, Ayurveda, Siddha, Unani, and Homeopathy are licenced by the government. Naturopathy will also be licensed soon because several Universities now offer bachelors degrees in it. Other activities connected with AM/CM, such as Panchakarma and massage therapy related to Ayurveda are also licenced by the government now.

Contemporary use of alternative medicine
Edzard Ernst wrote in the Medical Journal of Australia that "about half the general population in developed countries use complementary and alternative medicine (CAM)" (Ernst 2003). A survey (Barnes et al 2004) released in May 2004 by the National Center for Complementary and Alternative Medicine, part of the National Institutes of Health in the United States, found that in 2002, 36% of Americans used some form of alternative therapy in the past 12 months &mdash; a category that included yoga, meditation, herbal treatments and the Atkins diet. If prayer was counted as an alternative therapy, the figure rose to 62.1%. Another study by Astin et al (1998) suggests a similar figure of 40%. A British telephone survey by the BBC of 1209 adults in 1998 shows that around 20% of adults in Britain had used alternative medicine in the past 12 months (Ernst & White 1999)

The use of alternative medicine appears to be increasing. Eisenburg et al carried out a study in 1998 which showed that use of alternative medicine had risen from 33.8% in 1990 to 42.1% in 1997. In the United Kingdom, a 2000 report ordered by the House of Lords suggested that "limited data seem to support the idea that CAM use in the United Kingdom is high and is increasing".

Medical education
Increasing numbers of medical colleges have begun offering courses in alternative medicine. For example, the University of Arizona College of Medicine offers a program in Integrative Medicine under the leadership of Dr. Andrew Weil which trains physicians in various branches of alternative medicine which "neither rejects conventional medicine, nor embraces alternative practices uncritically." In three separate research surveys that surveyed the 125 medical schools offering an MD degree, the 19 medical schools offering a DO degree, and 585 schools of nursing in the United States: 60 percent of U.S. medical schools offering an MD degree teach CAM, 95% of Osteopathic medical school teach CAM, and 84.8% of US schools of nursing teach CAM. (Wetzel et al 1998, Saxon et al 2004, Fenton & Morris 2003)

In the UK, no medical schools offer courses that teach the clinical practice of alternative medicine. However, alternative medicine is taught in several schools as part of the curriculum. Teaching is based mostly on theory and understanding alternative medicine, with emphasis on being able to communicate with alternative medicine specialists. To obtain competence in practicing clinical alternative medicine, qualifications must be obtained from individual medical societies. The student must have graduated and be a qualified doctor. The British Medical Acupuncture Society, which offers medical acupuncture certificates to doctors, is one such example, as is the College of Naturopathic Medicine UK and Ireland.

Public popularity
The NCCAM surveyed the American public on complementary and alternative medicine use in 2002. According to the survey :
 * 36 percent of U.S. adults age 18 years and over use some form of complementary and alternative medicine (CAM).
 * When prayer specifically for health reasons is included in the definition of CAM, the number of adults using some form of CAM in 2002 rose to 62 percent.
 * The majority of individuals (54.9%) used CAM in conjunction with conventional medicine.
 * Most people use CAM to treat and/or prevent musculoskeletal conditions or other conditions associated with chronic or recurring pain.
 * "The fact that only 14.8% of adults sought care from a licensed or certified CAM practitioner suggests that most individuals who use CAM" prefer to treat themselves."
 * "Women were more likely than men to use CAM. The largest sex differential is seen in the use of mind-body therapies including prayer specifically for health reasons".
 * "Except for the groups of therapies that included prayer specifically for health reasons, use of CAM increased as education levels increased".
 * The most common CAM therapies used in the USA in 2002 were prayer (45.2%), herbalism (18.9%), breathing meditation (11.6%), meditation (7.6%), chiropractic medicine (7.5%), yoga (5.1%), body work (5.0%), diet-based therapy (3.5%), progressive relaxation (3.0%), mega-vitamin therapy (2.8%) and Visualization (2.1%)

Support for alternative medicine
Advocates of alternative medicine hold that alternative therapies often provide the public with services not available from conventional medicine. This argument covers a range of areas, such as patient empowerment, alternative methods of pain management, treatment methods that support the biopsychosocial model of health, stress reduction services, other preventive health services that are not typically a part of conventional medicine, and of course complementary medicine's palliative care which is practiced by such world renowned cancer centers such as Memorial Sloan-Kettering (see Vickers 2004).

Efficacy
Advocates of alternative medicine hold that the various alternative treatment methods are effective in treating a wide range of major and minor medical conditions, and contend that recently published research (such as Michalsen 2003, Gonsalkorale 2003, and Berga 2003) proves the effectiveness of specific alternative treatments. They assert that a PubMed search revealed over 370,000 research papers classified as alternative medicine published in Medline-recognized journals since 1966 in the National Library of Medicine database (such as Kleijnen 1991, Linde 1997, Michalsen 2003, Gonsalkorale 2003, and Berga 2003).

Advocates of alternative medicine hold that alternative medicine may provide health benefits through patient empowerment, by offering more choices to the public, including treatments that are simply not available in conventional medicine:


 * "Most Americans who consult alternative providers would probably jump at the chance to consult a physician who is well trained in scientifically based medicine and who is also open-minded and knowledgeable about the body's innate mechanisms of healing, the role of lifestyle factors in influencing health, and the appropriate uses of dietary supplements, herbs, and other forms of treatment, from osteopathic manipulation to Chinese and Ayurvedic medicine. In other words, they want competent help in navigating the confusing maze of therapeutic options that are available today, especially in those cases in which conventional approaches are relatively ineffective or harmful." (Snyderman, Weil 2002)

Although advocates of alternative medicine acknowledge that the placebo effect may play a role in the benefits that some receive from alternative therapies, they point out that this does not diminish their validity. Researchers who judge treatments using the scientific method are concerned by this viewpoint, since, according to standard controlled studies, it is an acknowledgement of the inefficacy of alternative treatments.

Danger reduced when used as a complement to conventional medicine
A major objection to alternative medicine is that it may be done in place of conventional medical treatments. As long as alternative treatments are used alongside standard conventional medical treatments, most medical doctors find most forms of complementary medicine acceptable (Vickers 2004). Consistent with previous studies, the CDC recently reported that the majority of individuals in the United States (i.e., 54.9%) used CAM in conjunction with conventional medicine. (CDC Advance Data Report #343, 2002)

Patients should however always inform their medical doctor they are using alternative medicine. Some patients do not tell their medical doctors since they fear it will hurt their patient-doctor relationship. However some alternative treatments may interact with orthodox medical treatments.

The issue of alternative medicine interfering with conventional medical practices is minimized when it is only turned to after the conventional medicine path has been exhausted. Many patients believe alternative medicine can help in coping with chronic illnesses for which conventional medicine offers no cure and only management. It is becoming more common for a patient's own MD to suggest alternatives when they cannot offer a treatment.

Criticism of alternative medicine
Due to the wide range of therapies that are considered to be "alternative medicine" few criticisms apply across the board. For more information about a particular therapy or branch of alternative medicine, including specific criticism, please refer to the following link: List of branches of alternative medicine.

Criticisms directed at specific branches of alternative medicine range from the fairly minor (conventional treament is believed to be more effective in a particular area) to incompatibility with the known laws of physics (for example, in homeopathy).

Critics argue that alternative medicine practitioners may not have an accredited medical degree or be licensed physicians or general practitioners. This cannot always be considered a serious criticism, because unless a new system of medicine becomes established, it does not receive accreditation of any kind, except by its own professional organizations. This is the route homeopathy, ayurveda, siddha, unani, and naturopathy had to follow in those countries where it is now offered by accredited institutions.

Proponents of the various forms of alternative medicine reject criticism as being founded in prejudice, financial self-interest, or ignorance. Refutations of criticism sometimes take the form of an appeal to nature.

Lack of proper testing
Although proponents of alternative medicine often cite the large number of studies which have been performed, critics point out the fact that there are no statistics on exactly how many of these studies were controlled, double-blind peer-reviewed experiments or how many produced results supporting alternative medicine or parts thereof. They contend that many forms of alternative medicine are rejected by conventional medicine because the efficacy of the treatments has not been demonstrated through double-blind randomized controlled trials. Some skeptics of alternative practices point out that a person may attribute symptomatic relief to an otherwise ineffective therapy due to the natural recovery from or the cyclical nature of an illness (the regression fallacy), the placebo effect, or the possibility that the person never originally had a true illness.

Problems with known tests and studies
Critics contend that observer bias and poor study design invalidate the results of many studies carried out by alternative medicine promoters.

A review of the effectiveness of certain alternative medicine techniques for cancer treatment (Vickers 2004), while finding that most of these treatments are not merely "unproven" but are proven not to work, notes that several studies have found evidence that the psychosocial treatment of patients by psychologists is linked to survival advantages (although it comments that these results are not consistently replicated). The same review, while specifically noting that "complementary therapies for cancer-related symptoms were not part of this review", cites studies indicating that several complementary therapies can provide benefits by, for example, reducing pain and improving the mood of patients.

Some argue that less research is carried out on alternative medicine because many alternative medicine techniques cannot be patented, and hence there is little financial incentive to study them. Drug research, by contrast, can be very lucrative, which has resulted in funding of trials by pharmaceutical companies. Many people, including conventional and alternative medical practitioners, contend that this funding has led to corruption of the scientific process for approval of drug usage, and that ghostwritten work has appeared in major peer-reviewed medical journals. (Flanagin et al. 1998, Larkin 1999). Increasing the funding for research of alternative medicine techniques was the purpose of the National Center for Complementary and Alternative Medicine. NCCAM and its predecessor, the Office of Alternative Medicine, have spent more than $200 million on such research since 1991. The German Federal Institute for Drugs and Medical Devices Commission E has studied many herbal remedies for efficacy. 

Safety
Critics contend that "dubious therapies can cause death, serious injury, unnecessary suffering, and disfigurement" and that some people have been hurt or killed directly from the various practices or indirectly by failed diagnoses or the subsequent avoidance of conventional medicine which they believe is truly efficacious.

Alternative medicine critics agree with its proponents that people should be free to choose whatever method of healthcare they want, but stipulate that people must be informed as to the safety and efficacy of whatever method they choose. People who choose alternative medicine may think they are choosing a safe, effective medicine, while they may only be getting quack remedies. Grapefruit seed extract is an example of quackery when multiple studies demonstrate its universal antimicrobial effect is due to synthetic antimicrobial contamination.

Delay in seeking conventional medical treatment
They state that those who have had success with one alternative therapy for a minor ailment may be convinced of its efficacy and persuaded to extrapolate that success to some other alternative therapy for a more serious, possibly life-threatening illness. For this reason, they contend that therapies that rely on the placebo effect to define success are very dangerous.

Danger can be increased when used as a complement to conventional medicine
A Norwegian multicentre study examined the association between the use of alternative medicines (AM) and cancer survival. 515 patients using standard medical care for cancer were followed for eight years. 22% of those patients used AM concurrently with their standard care.

The study revealed that death rates were 30% higher in AM users than in those who did not use AM: "The use of AM seems to predict a shorter survival from cancer."

Associate Professor Alastair MacLennan of the Department of Obstetrics and Gynaecology in Adelaide University, Australia reports that a patient of his almost bled to death on the operating table. She had failed to mention she had been taking "natural" potions to "build up her strength" for the operation - one of them turned out to be a powerful anticoagulant which nearly caused her death.

Danger from undesired side-effects
Conventional treatments are thoroughly checked for undesired side-effects, whereas alternative treatments are normally not. Any alternative treatment that has a biological or psychological impact may also have potentially dangerous biological or psychological side-effects. Attempts to refute this sometimes use the appeal to nature fallacy, i.e. "that what is natural cannot be harmful".

Danger related to self-medication
Similar problems as those related to self-medication also apply to parts of alternative medicine. For example, an alternative medicine may instantly make problems better, but actually worsen problems in the long run. The result may be addiction and deteriorating health.

Issues of regulation
Critics contend that some branches of alternative medicine are often not properly regulated in some countries to identify who practices or know what training or expertise they may possess. Critics argue that the governmental regulation of any particular alternative therapy does necessitate that the therapy is effective.

Evidence-based medicine
Evidence-based medicine (EBM) applies the scientific method to medical practice, and aims for the ideal that healthcare professionals should make "conscientious, explicit, and judicious use of current best evidence" in their everyday practice.

Prof. Edzard Ernst is a notable proponent of applying EBM to CAM.

Integrative medicine
Integrative medicine is a branch of alternative medicine which limits itself to methods with strong scientific evidence of efficacy and safety. The main proponent of integrative medicine is Andrew T. Weil M.D., who founded the Program in Integrative Medicine at the University of Arizona in 1994 based on a phrase coined by Elson Haas, MD.

Responsible alternative health product providers who have had medical studies conducted on their products often publish these studies online. Even so, it is wise to ask for a list of the ingredients used in the products you are considering purchasing.

Dictionary definitions

 * Complementary medicine

World Health Organization publication

 * WHO Global Atlas of Traditional, Complementary and Alternative Medicine

Journals dedicated to alternative medicine research

 * Alternative therapies in health and medicine. Aliso Viejo, CA : InnoVision Communications, c1995- NLM ID: 9502013
 * Alternative medicine review : a journal of clinical therapeutic. Sandpoint, Idaho : Thorne Research, Inc., c1996- NLM ID: 9705340
 * BMC complementary and alternative medicine. London : BioMed Central, 2001- NLM ID: 101088661
 * Complementary therapies in medicine. Edinburgh ; New York : Churchill Livingstone, c1993- NLM ID: 9308777
 * Evidence based complementary and alternative medicine
 * Evidence Based journal of Integrative medicine
 * Journal of Integrative medicine.
 * The journal of alternative and complementary medicine : research on paradigm, practice, and policy. New York, NY : Mary Ann Liebert, Inc., c1995- NLM ID: 9508124
 * Journal of alternative & complementary medicine. London : Argus Health Publications, c1989- NLM ID: 9883124
 * Journal for Alternative and Complementary Medicine
 * Scientific Review of Alternative Medicine (SRAM)

Other works that discuss alternative medicine

 * Ninivaggi, F. J., An Elementary Textbook of Ayurveda: Medicine with a Six Thousand Year Old Tradition, International Universities/Psychosocial Press, Madison, CT, 2001.
 * Diamond, J. Snake Oil and Other Preoccupations, 2001, ISBN 0-09-942833-4, foreword by Richard Dawkins reprinted in Dawkins, R., A Devil's Chaplain, 2003, ISBN 0-7538-1750-0.
 * Rosenfeld, Anna, Where Do Americans Go for Healthcare?", Case Western Reserve University, Cleveland, Ohio, USA.
 * Planer, Felix E. 1988 Superstition, Revised ed. Buffalo, New York: Prometheus Books
 * Hand, Wayland D. 1980 "Folk Magical Medicine and Symbolism in the West", in Magical Medicine, Berkeley: University of California Press, pp. 305-319.
 * Phillips Stevens Jr. Nov./Dec. 2001 "Magical Thinking in Complementary and Alternative Medicine", Skeptical Inquirer Magazine, Nov.Dec 2001
 * Illich, Ivan. Limits to Medicine. Medical Nemesis: The expropriation of Health. Penguin Books, 1976.
 * Dillard, James and Terra Ziporyn. Alternative Medicine for Dummies.  Foster City, CA:  IDG Books Worldwide, Inc., 1998.
 * Pert, Candace B., Molecules of Emotion: Why You Feel the Way You Feel, Scribners, 1997, ISBN 0-684-84634-9
 * Trudeau, Kevin, More Natural "Cures" Revealed, Alliance Publishing Group, 2006,  ISBN 0-9755995-4-2.
 * Wisneski, Leonard A. and Lucy Anderson, The Scientific Basis of Integrative Medicine, CRC Press, 2005. ISBN 0-8493-2081-X.

Criticism

 * A Different Way to Heal? - Scientific American Frontiers Web
 * What is Complementary and Alternative Medicine? - By Steven Novella MD
 * Skepdic Article on Alternative Medicine
 * NCAHF Resource Documents - Includes a list of alternative medicine modalities with links to articles relating to them
 * Index of Questionable Treatments - Includes a list of alternative medicine modalities and links to articles relating to them
 * Who Gets to Validate Alternative Medicine - PBS article