Uncertainty and Placebos Galore: Complementary and Alternative Medicine

What is medicine? Perhaps you first visualize images of digital prescriptions at the doctor’s office or bottles of pharmacy medications. Maybe you think of physicians in their white coats or surgeons in their blue scrubs — ultimately, it’s likely that you associate the term “medicine” with conventional Western medicine.


In the U.S., we are predominantly exposed to Western medicine. However, another form of medicine — complementary and alternative medicine (CAM) — exists under the radar. Complementary medicine is defined as the usage of unconventional medicine in conjunction with mainstream medicine. On the other hand, alternative medicine is defined as the usage of unconventional medicine to replace mainstream medicine [1]. CAM approaches medicine by viewing patients holistically. While CAM proposes that mental, social, physical and spiritual health are interconnected, Western medicine views the body in separate parts [2]. As physicians of traditional Western medicine focus on compartmentalized body systems in order to treat a patient, CAM emphasizes natural treatment methods that aim to manipulate the general “energy fields'' of the body. These methods encompass herbal medicine, chiropractic medicine, traditional Chinese medicine, Ayurvedic medicine, and more [3]. While CAM is rarely talked about in mainstream medicine, it influences both the U.S. healthcare system and its consumers.


The CAM industry has held a steady presence in the U.S. healthcare system for many years. The most recent National Health Interview Survey estimated that in 2007, 35.5% of adults used some form of CAM in the U.S. and 33.2% in 2012 [4]. Its considerable usage in the U.S. can also be evidenced by how the general public spends a sizable amount of money on CAM-based products. In 2016, Americans were said to spend around $30.1 billion on CAM procedures; $14.7 billion of that went to CAM practitioner visits such as acupuncturists, naturopaths and hypnotists, while $12.8 billion went to natural product supplements [5]. These costs are all out-of-pocket, indicating that there is significant demand for CAM products. The CAM industry is not nearly as widely discussed as dominant conventional Western medicine, but it is crucial to address its implications on general public health. Despite high demand, the scientific legitimacy behind various CAM products remains dangerously unclear, possibly due to the lack of scientifically sound experimental trials for these products. Some studies may not have control groups for the “placebo effect,” which can result in a false positive when determining the efficacy of a drug. Some studies may not be randomized, and some may have too small a sample pool to come to reliable conclusions [6]. As such, it is incredibly difficult to find reliable evidence for various CAM treatments, and current scientific literature often reflects inconclusive evidence for treatment efficacy. For instance, therapies such as yoga and meditation have generally been deemed safe by scientific consensus, despite a lack of clarity regarding efficacy in alleviating depression or anxiety [7, 8]. The effects of acupuncture are conflicting; a 2007 Cochrane systematic review was conducted on 32 papers, and only two were found to support the efficacy of acupuncture for nausea and headaches [9]. Another 2010 Cochrane review noted small benefits of acupuncture on osteoarthritis, yet clarified that the benefits could very possibly be due to a placebo effect [10]. Additionally, St. John’s Wort is an herbal remedy that is categorized as a dietary supplement by the FDA — it is thought to treat depression and other mental disorders, but some trials have failed to observe its effect over placebo [11].


Being that CAM treatments often consist of dietary supplements and methods that target a patient’s “spiritual energy,” the very nature of CAM makes it susceptible to the placebo effect. CAM’s naturalistic approach to medicine may appeal to the public with its “healing effect,” which feels more accessible than a doctor’s office and hospital setting. It is imperative to approach with caution, however, as the lack of sound scientific information supporting CAM therapies can make their efficacy unclear to consumers. In one particular instance, Hyland’s, the nation’s largest homeopathic business, sold teething tablets for toddlers, claiming “safe, effective, and natural health solutions.” These teething tablets were discovered to contain an herb called “deadly nightshade,” and caused more than 370 children to experience horrific respiratory effects over a period of 10 years [12]. The manufacturers claimed that the toxic belladonna compound would help reduce the pain associated with teething, although its effects were unclear. The tablets were not strictly regulated by the FDA and were considered as over-the-counter medications. This resulted in dire consequences for the toddlers, such as seizures and infant deaths.


Although the topic rarely appears when we initiate conversations about medicine, it is important for us to be aware of the potential consequences of promoting CAM to consumers. The field of complementary and alternative medicine is one that is shrouded by both uncertainty and hope, and a tricky source of controversy among patients, researchers, and physicians alike. From the challenges of controlling for placebo in CAM trials to the subsequent obscure literature that exists to support CAM treatment, one should approach these “natural, organic remedies” with caution.


References:

1. Complementary, Alternative, or Integrative Health: What’s In a Name? (n.d.). NCCIH. https://www.nccih.nih.gov/health/complementaryalternative-or-integrative-health-whats-in-a-name

2. Types of Complementary and Alternative Medicine. (n.d.). Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/wellness-andprevention/types-of-complementary-andalternative-medicine

3. Complementary and Alternative Medicine for Cancer Patients. (2018, December 7). Centers for Disease Control and Prevention. https://www.cdc.gov/cancer/survivors/patients/complementaryalternative-medicine.htm

4. CDC. (2015, February). Trends in the Use of Complementary Health Approaches Among Adults: United States, 2002–2012 (No. 79). https://www.cdc.gov/nchs/data/nhsr/nhsr079.pdf

5. Bakalar, N. (2016, June 28). The Alternative Medical Bill: $30.2 Billion. The New York Times. https://www.nytimes.com/2016/06/28/health/alternativecomplementary-medicine-costs.html

6. Why Are Complementary and Alternative Therapies Harder to Evaluate? (n.d.). American Cancer Society. https://www.cancer.org/treatment/treatments-and-sideeffects/complementary-and-alternative-me dicine/complementaryand-alternative-methods-and-cancer/why-cam-is-hard-toevaluate.html

7. Cramer, H., Ward, L., Saper, R., Fishbein, D., Dobos, G., & Lauche, R. (2015). The Safety of Yoga: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. American journal of epidemiology, 182(4), 281–293. https://doi.org/10.1093/aje/kwv071

8. Cramer, H., Ostermann, T., & Dobos, G. (2018). Injuries and other adverse events associated with yoga practice: A systematic review of epidemiological studies. Journal of science and medicine in sport, 21(2), 147–154. https://doi.org/10.1016/j.jsams.2017.08.026

9. Ernst E. (2009). Acupuncture: what does the most reliable evidence tell us?. Journal of pain and symptom management, 37(4), 709–714. https://doi.org/10.1016/j.jpainsymman.2008.04.009

10. Manheimer, E., Cheng, K., Linde, K., Lao, L., Yoo, J., Wieland, S., van der Windt, D. A., Berman, B. M., & Bouter, L. M. (2010). Acupuncture for peripheral joint osteoarthritis. Cochrane Database of Systematic Reviews, https://doi.org/10.1002/14651858.cd001977.pub2

11. Rapaport, M. H., Nierenberg, A. A., Howland, R., Dording, C., Schettler, P. J., & Mischoulon, D. (2011). The treatment of minor depression with St. John's Wort or citalopram: failure to show benefit over placebo. Journal of psychiatric research, 45(7), 931–941. https://doi.org/10.1016/j.jpsychires.2011.05.001

12. Segal, G. (2018, April 18). Homeopathic remedies harmed hundreds of babies, families say. STAT. https://www.statnews.com/2017/02/21/hylands-homeopathicteething-fda/

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