December 18, 1998

By Richard Karel

It's only fitting that when it comes to alternative medicine, George Lundberg, M.D., editor of the Journal of the American Medical Association (JAMA), has a mantra. Lundberg's mantra, that "there is no alternative medicine; there is only scientifically proven, evidence-based medicine supported by solid data, or unproven medicine, for which scientific evidence is lacking," was the theme of a November 10 press briefing sponsored by the AMA at the National Press Club in Washington, D.C.

A functional definition of alternative medicine was offered by panelist David Eisenberg, M.D. as "interventions neither taught widely in medical schools nor generally available in U.S. hospitals. . . ." Eisenberg is an assistant professor of medicine and director of the Center for Alternative Medicine Research and Education at Beth Israel Deaconess Medical Center, which is affiliated with Harvard Medical School.

The AMA press briefing was coordinated with the publication of special theme issues of JAMA (November 11) and the AMA Archives (November 9) that presented more than 80 articles on alternative medicine. For psychiatrists and other physicians increasingly faced with sorting out the value or risk of various alternative therapies, the 80-plus articles provide another resource with which to evaluate the meaning and role of these therapies.

According to a survey published in the November 11 JAMA, Americans are flocking to alternative therapies and their practitioners at unprecedented rates, with four out of 10 Americans reporting some use of alternative therapies in 1997, and visits to alternative practitioners up by nearly 50 percent since 1990. Total visits to alternative practitioners in 1997 exceeded the number of visits to U.S. primary care physicians, and Americans paid more than $21 billion for services provided by alternative practitioners. More than 70 percent of patients did not inform their physicians of their use of alternative therapies.

Although the trend is not confined to any segment of society, the survey found that more women than men use alternatives, while fewer African Americans than whites do so. Those with annual incomes over $50,000 account for 48 percent of those using alternatives. Total prevalence of alternative use among the adult U.S. population rose from 34 percent in 1990 to 42 percent in 1997, while total visits to alternative practitioners increased from 427 million visits in 1990 to 629 million in 1997.

Nearly half the total increase in visits was accounted for by visits to chiropractors and massage therapists. The majority (58 percent) of people paid for their alternatives out of pocket. An estimated 15 million of those who reported taking prescription drugs reported concurrent use of at least one herbal product, high-dose vitamin, or both, putting them at possible risk of drug-herb interactions, according to the JAMA survey.

"Make no mistake-some alternative therapies and herbal remedies are quackery," remarked Yank Coble, Jr., M.D., of the AMA Board of Trustees. "As we look at today's research, one thing is clear: most alternative therapies are unproven, ineffective, and risky, yet some may be the scientifically tested therapies of tomorrow. The key is to know the difference. Only good research gives us that knowledge." He noted that the "gold standard" of medical research is the double-blind, placebo-controlled, clinical trial.

The AMA briefing focused on four alternative therapies that were subjected to controlled trials. Two of the trials repudiated the therapies tested, while two upheld the therapies as useful. But the complexity of running controlled trials for alternative therapies was clearly demonstrated by one of the therapies found successful, moxibustion for correction of breech presentation in pregnancy. Moxibustion is the burning of preparations containing the herb artemisia vulgaris (known in Japanese as moxa) at acupuncture points to induce therapeutic effects.

Although the therapy was proven effective, the trial for the therapy was not blinded and involved no placebo treatment, leaving many questions unanswered. The trial was conducted by Francesco Cardini, M.D., a private practitioner from Verona, Italy, and Huang Weixin, M.D., from the Jiangxi Women's Hospital in Nanchang, China. The trial involved 260 participants from the outpatient departments of two hospitals in Jiangxi Province. All participants had fetuses in the breech position. Half the participants were given moxibustion, while the control group received routine care but no moxibustion. Seventy-five percent of fetuses in the group treated with moxibustion changed to a head-first position compared with 48 percent of those in the control group.

The researchers dismissed the need for blindness and placebo, writing that "since the main results of the trial are of a qualitative type and were measured objectively (ultrasound), we believe that the lack of blindness and a placebo does not undermine the validity of the results."

Among the unanswered questions were whether burning of another herb at the same acupuncture point would have been effective and whether the burning of the same or another herb at a different or randomly selected point would have been effective. Hence, despite the impressive results of the study, it remains unclear whether success was dependent upon the burning of a specific herb at a specific point. Further, scientists have yet to fully fathom how placebos work, and it is possible that within the cultural context of Chinese medicine the belief in moxibustion could initiate a change in fetal position. The author's dismissal of the need for placebo because objective measures showed a change in fetal position was not convincing; placebo therapies have been known to cause the disappearance of cancerous tumors, as verified by objective measures.

In another trial of chiropractic spinal manipulation for tension headache, the efficacy of chiropractic manipulation was repudiated, with positive results attributed to soft tissue therapy, specifically, massage to the upper back muscles, a therapeutic technique commonly employed by chiropractors in conjunction with manipulation. The trial was designed to delineate any confounding variables that might erroneously have led to the conclusion that spinal manipulation caused the improvement in tension headache, a standard to which the moxibustion trial was not held.

Two herbal therapies were evaluated, using rigorous, randomized, double-blind, placebo-controlled studies. One study found that an extract of the herb garcinia cambogia was no more effective than placebo in promoting weight loss. Another study found that a standardized preparation of 20 herbs used in accordance with Chinese herbal medical practice was significantly more effective than placebo in alleviating symptoms of irritable bowel syndrome.

A study reported in the November 9 Archives of Internal Medicine found that acupuncture was no more effective than placebo in reducing nicotine withdrawal symptoms. Another article in the same issue focused on the potential for drug-herb interactions, noting that some commonly used herbs, including St. John's wort and valerian, could interfere with or potentiate the action of commonly prescribed drugs. St. John's wort, for example, can cause photosensitivity and hence might potentiate the photosensitivity caused by the antibiotic tetracycline and other drugs. Concomitant use with a selective serotonin reuptake inhibitor may cause a serotonergic syndrome, something that has been anecdotally reported. Valerian, commonly used as a sedative, prolongs barbiturate-induced sleep and is thus contraindicated for use with barbiturates.

Regarding the potential to bring the scientific method to bear in the evaluation and potential integration of alternative therapies, Lundberg recalled the famous quote that "East is East and West is West and never the twain shall meet. Today" he added, "they shall meet. It is the beginning of the beginning of the acceptance of some form of alternative medicine into the mainstream of medicine in the United States."