CAM Overview

							EXAMINING THE CLAIMS OF ALTERNATIVE MEDICINE

• DR. LLOYD OPPEL

ALTERNATIVE MEDICINE
•WHAT IS IT? •WHO USES IT? •DOES IT WORK?

WHAT IS IT?

• DEFINITIONS • HISTORY

DEFINITIONS
• UNPROVEN
• GENERALLY UNAVAILABLE IN

HOSPITALS
• NOT USUALLY TAUGHT IN MEDICAL

SCHOOLS

DEFINITIONS

WHY IS IT „ALTERNATIVE‟?
REASONS RANGE FROM….

• NO RIGOROUS PROOF, BUT NOT PREPOSTEROUS (e.g. some herbal remedies)….
TO...

• COMPLETELY UNSUPPORTABLE (e.g. homeopathy)

WHY IS IT ALTERNATIVE?
• ALL TREATMENTS PROVEN EFFECTIVE HAVE BEEN ACCEPTED BY CONVENTIONAL MEDICINE

History
• PRE 1900: CAVEAT EMPTOR
• FLEXNER REPORT

• MEDICINE SHOULD BE SCIENCEBASED

• GROWTH OF MODERN MEDICINE

HISTORY

SCIENCE +MEDICINE=?
• USE NEW DISCOVERIES TO IMPROVE TREATMENTS (openminded) • COOPERATION WITH SCIENCEBASED PROFESSIONS:
– PHARMACISTS – NURSES – PUBLIC HEALTH INITIATIVES

HISTORY

WHERE HAS THIS GOTTEN US??
• IMPROVED LIFE EXPECTANCY:
– LOWER INFANT MORTALITY – IMPROVED CARE OF DISEASES OF MIDDLE AGE – VACCINES

• BETTER TREATMENTS FOR (AS YET) INCURABLE DISEASES

HISTORY

“NEW AGE” =RECYCLED OLD AGE
• • • • • Spiritual Healing Herbal Medicine Magnets Chiropractic Religious and Cultural Beliefs (TCM, auverdic medicine)

HISTORY

• Mackay: Popular Delusions and the Madness of Crowds • Mesmer: “Don‟t listen to reason” • Ben Franklin did a critical appraisal

HISTORY

WHY THE RESURGENCE?
• • • • FEAR OF TECHNOLOGY MISTRUST OF ESTABLISHMENT NEED FOR HOPE DESIRE FOR COMFORTING PHILOSOPHY

HOW COULD SOMETHING INEFFECTIVE BE POPULAR????
• PLACEBO

• ADVERTISING
• “IT‟S ONLY HUMAN”

HISTORY

NEW VARIATIONS
• GROWTH OF „JUNK SCIENCE‟ • PROMOTION IN POPULAR PRESS AND INTERNET • COLLEGE „COURSES‟ • RELAXED REGULATIONS

JUNK SCIENCE
• • • • BEING PUBLISHED ≠ TRUE INDEPENDENT REPLICATION? WHO REVIEWED IT? WHY DON‟T THE SCIENTISTS BELIEVE IT?

JUNK SCIENCE
• DOES IT CONTRADICT WELL KNOWN FACTS? • NO SIDE EFFECTS? • SUNDAY MORNING TV? • DO YOU SELL IT? • IF ALL THIS IS TRUE, WHY ISN‟T IT MAINSTREAM?

REGULATION
• Variable across states and
provinces

• Validity is not a criterion for
regulation

POLITICAL HOT POTATO
• PUBLIC PRESSURE
• GOVERNMENT WANTS TO

CONTROL HEALTH COSTS

EFFORTS TO RATIONALIZE HEALTH SPENDING
• B.C. PHARMACARE BUDGET

• PRACTICE GUIDELINES
• THERAPEUTICS INITIATIVE

PROVINCIAL
• GOVERNMENT DECIDES WHO IS A PROFESSION • NO VALIDITY CRITERIA
• TWO-TIERED MEDICINE?

FEDERAL
• INTENSE LOBBYING BY PROPONENTS • PARLIAMENTARY COMMITTEE • STANDING COMMITTEE • TRANSITION TEAM • EXPERT ADVISORY COMMITTEE • NHP OFFICE

USA
• 1994: DIETARY SUPPLEMENTS HEALTH AND EDUCATION ACT • BUYER BEWARE: FDA “SILENCED” • NOW • NUTRACUETICAL RESEARCH AND EDUCATION ACT... VS… • DIETARY SUPPLEMENT FAIRNESS IN LABELEING AND ADVERTISING ACT

Summary
• Alternative Medicine is without a scientific basis. • Many elements are identical to old movements. • Regulation is not = effectiveness • Comes at the same time as funding pressures mount on health care.

WHO USES IT?

WHO USES IT?

• 73% DURING LIFETIME • 50% IN THE LAST YEAR

FRASER INSTITUTE, 1999

WHAT‟S BEING USED?
• • • • • CHIROPRACTIC - 36% RELAXATION 23% MASSAGE 23% PRAYER 21% HERBAL 17%
(WITHIN THE LAST YEAR)
FRASER INSTITUTE, 1999

USER PROFILE?
• • • • CHRONICALLY ILL WOMEN MORE THAN MEN ?PSYCHOLOGICAL DISTRESS? SOME POST SECONDARY EDUCATION

WHERE DO ILL PEOPLE GO?
6% 14% 35% NEITHER DOCTOR ONLY DOCTOR PLUS ALT. MED 45% ALT. MED. ONLY
FRAS ER INSTITUTE, 1999

HOW MANY VISITS ARE THERE?

EISENBERG 1998

WHO SEES THE MOST PATIENTS?
OF ALL VISITS TO ALTERNATIVE PRACTITIONERS….

HALF
WERE FOR

CHIROPRACTIC OR MASSAGE

WHAT‟S GROWING THE FASTEST?
• • • • • • • HERBAL (380%) MASSAGE SELF-HELP VITAMINS FOLK REMEDIES ENERGY HEALING HOMEOPATHY
EISENBERG, 1998

WHAT DOES IT CO$T?
• CANADA: $1.8 PROVIDERS • CANADA: $2.0

BILLION BILLION - REMEDIES

USA:$27 BILLION
EQUALS OUT-OF-POCKET
EXPENSES FOR ALL DOCTORS IN THE USA

INTERNATIONAL EXPENSE?
• AUSTRALIA1992/3
$621 million (AU) for remedies. $309 million for providers Compare with $360 million for patient drug contributions
MacLennan A, 1996

TO WHAT EXTENT IS IT COVERED BY PRIVATE CARRIERS?
• EISENBERG: MOST VISITS NOT COVERED • SAME AS IN 1990

WHAT MAKES AN INSURER COVER IT?
• Pelletier, 1997, AM J Health Promotion • Interviewed 18 insurers offering CAM • Surveyed seven hospitals offering 3 or more CAM programs • Wanted to know what the criteria were for inclusion

Factors Influencing Coverage

• MARKET DEMAND

Factors Influencing Whether to Increase Coverage
• Proven Effectiveness (#1)
• High Market Demand • Coverage Mandated by State Law • Potential Cost Savings

What was Being Covered?*
• Physical Therapy •Acupuncture

• Osteopathy
• Chiropractic

•Preventive Medicine
•Nutrition Counseling

• Biofeedback
• Psychotherapy

•Massage
•Hypnotherapy

*To any extent under any policy by 9 or more of 18 insurers

Was CAM Coverage “Successful”?
“Although cost-benefit analyses are hotly debated

there are little empirical data brought to bear on whether CAM will indeed decrease costs, or whether coverage of CAM will be an added expense.”
Pelletier, 1997

SWISS EXPERIMENT
Sommer, 1999

• 7500 OF 677,000 SUBSCRIBERS WERE GIVEN FREE CAM COVERAGE • RESULT: NO EFFECT ON SUBJECTIVE STATE OF HEALTH • NO DISCERNABLE EFFECT ON OVERALL SPENDING, BUT CAM USE WAS A POWERFUL PREDICTOR OF TRATMENT COSTS

“BECAUSE THE DEMAND FOR HEALTH CARE (AND PRESUMABLY ALTERNATIVE THERAPIES) IS SENSITIVE TO HOW MUCH PATIENTS MUST PAY OUT OF POCKET,

CURRENT USE IS LIKELY TO UNDERREPRESENT UTILIZATION PATTERNS IF INSURANCE COVERAGE FOR ALTERNATIVE THERAPIES INCREASES IN THE FUTURE.”

EISENBERG D, 1998

“However, until there is clear scientific proof of the efficacy of particular CAM therapies,
Each insurance company is left to decide for itself whether the effectiveness may exceed the costs of covering a particular therapy. Insurers want to know whether or not a particular therapy is cost effective.”
Pelletier, 1997

SUMMARY OF DEMOGRAPHICS
• Explosive growth in this decade • Use associated with chronic/incurable diseases and the “worried well” • More visits than to family doctors • Out of pocket costs top US $27 billion • Cost/benefit for insurers very

DOES IT WORK?

DOES IT WORK?

• CHALLENGES FOR HEALTH CARE MANAGERS

How to allocate resources to where they do the most good. Sort out reliable information.

WHO TO BELIEVE?
• PROPONENTS CITE PAPERS AS WELL AS TESTIMONIALS • AN EXPERT IN ONE FIELD MAY KNOW LITTLE ABOUT ANOTHER • WHAT CONSTITUTES GOOD EVIDENCE?

THERE ARE SOME GROUND RULES
• STANDARD,WIDELY ACCEPTED PRINCIPLES OF EXPERIMENTAL DESIGN
• CRITERIA FOR RATING THE STRENGTH OF EVIDENCE

BORING

WHAT WE DO • BROAD-BASED COMMITTEE
•BASIC SCIENTISTS

•STATISTICIAN
•CLINICIANS

HOW WE DO IT

THE BROAD STROKES
1. CLIENT HAS A QUESTION 2. CLIENT FORWARDS INITIAL INFORMATION

3. PRELIMINARY REVIEW BY CHAIR
4. SEARCH OF SCIENTIFIC LITERATURE

HOW WE DO IT

THE BROAD STROKES
5. INPUT FROM PROPONENTS 6. SELECTION OF CLINICAL TRIALS (OR BEST EVIDENCE)

7. REVIEW BY ENTIRE COMMITTEE
8. MEETING

9. FINAL DOCUMENT TO CLIENT

ARE THERE DANGERS?

TOPICS TO BE COVERED
• THE DI BELLA AFFAIR
• DIRECT HARM • EXAMPLES OF FINANCIAL HARM • DIVERSION FROM PROPER TREATMENT

THE DI BELLA AFFAIR
• 1997/88 ITALY • THE “CURE” FOR THOUSANDS:
SOMATOSTATIN,MELATONIN,BROMOCRIPTIN, VITAMINS, CYCLOPHOSPHAMIDE

• NEVER TESTED IN HUMANS OR ANIMALS • COST: UP TO $5000 / MONTH

...THE DI BELLA AFFAIR
• PATIENTS SUE GOVERNMENT • PRESS HAILS DI BELLA AS A HERO • COURT ORDER PUBLIC PAYMENT FOR 2000 TREATMENTS AND 10 CLINICAL TRIALS

...THE DI BELLA AFFAIR
• CLINICAL TRIALS SHOW NO EFFECT, BUT SIGNIFICANT SIDE EFFECTS

...THE DI BELLA AFFAIR

• OVERALL DIRECT COSTS:

•$20 MILLION

...THE DI BELLA AFFAIR
• WHAT ABOUT THOSE WHO DELAYED TREATMENT WHILE „EXPLORING THE OPTIONS‟? • WHAT ABOUT THOSE WHO CHOSE THE “CURE” OVER PROVEN THERAPY?

INDIRECT COSTS

INCALCULABLE

...THE DI BELLA AFFAIR

HOW WERE PEOPLE‟S OPINIONS FORMED?
• “THERE IS OVERWHELMING EVIDENCE THAT THE MEDIA CONTRIBUTED MOST TO THE AFFAIR” • “THIS SAD STORY HAS REVEALED HOW POORLY THE MASS MEDIA…UNDERSTAND MEDICAL MATTERS”

HOW WERE PEOPLE‟S OPINIONS FORMED?
• PASSALACQUA ET AL • SURVEY OF CANCER PATIENTS DURING THE AFFAIR • MOST PEOPLE GOT THEIR INFORMATION FROM TV/RADIO/PRESS

ONLY 1% FELT THE THERAPY WAS

INEFFECTIVE

HOW WERE PEOPLE‟S OPINIONS FORMED?
• 63% OF THOSE SURVEYED STATED THEY WOULD TRY AN UNPROVEN THERAPY IF IT “OFFERED A CHANCE OF CURE”

TAKE HOME LESSONS
• CAVEAT EMPTOR • DESPERATE AND VULNERABLE PEOPLE WANT HOPE, NOT PROOF • FREEDOM OF CHOICE IN THIS CONTEXT ALL TOO OFTEN MEANS FREEDOM TO EXPLOIT • POOR UNDERSTANDING OF SCIENTIFIC ISSUES CAN LEAD TO SQUANDERED FUNDS • THE MEDIA HAVE A RESPONSIBILITY

MYTH
• NATURAL = SAFE

FACT

• MANY NATURAL SUBSTANCES ARE VERY POISONOUS, INCLUDING SOME HERBAL REMEDIES

TOBACCO

ARISTOLOCHIA
CHAPARELLE GERMANDER

EPHEDRA
JUST TO NAME A FEW

MYTH
• MANY ALTERNATIVE REMEDIES
HAVE ABUNDANT SCIENTIFIC

PROOF BEHIND THEM

FACT
• EVEN THE MOST STUDIED HERBAL
REMEDIES SUCH AS ECHINACEA

AND GINKO BILOBA HAVE ONLY
VERY WEAK SUPPORTING STUDIES AND NO SYSTEMATIC LONG-TERM SAFETY DATA

MYTH
• IT’S BEEN USED FOR CENTURIES, THEREFORE IT MUST WORK AND MUST BE SAFE

FACT
• SMOKING WAS USED AS A REMEDY BY SOME TRIBES • PREJUDICE, SEXISM AND RACISM HAVE BEEN AROUND FOR CENTURIES • MORE AND MORE „ANCIENT REMEDIES‟ ARE BEING FOUND DANGEROUS WITH PROPER STUDY

MYTH
• CONVENTIONAL MEDICINE KILLS MORE PEOPLE THAN ALTERNAIVE MEDICINE

FACT
• WHILE MANY MEDICATIONS CAN HAVE SERIOUS SIDE EFFECTS THEY ARE USED ONLY WHEN THE POTENTIAL BENEFIT OUTWEIGHS THE RISKS (CHEMO, FOR EXAMPLE)

IF A TREATMENT HAS NO PROVEN BENEFIT, THEN NO LEVEL OF RISK IS ACCEPTABLE

MYTH
• THE CONVENTIONAL MEDICAL
ESTABLISHMENT HAS IGNORED OR

SUPPRESSED THE HIGH QUALITY
EVIDENCE IN FAVOR OF ALTERNATIVE MEDICINE

FACT
• ALL TREATMENTS PROVEN EFFECTIVE HAVE BEEN ACCEPTED BY CONVENTIONAL MEDICINE

MYTH
• ALTERNATIVE MEDICINE IS GENTLE, NONINVASIVE AND PERFECTLY SAFE

FACT
• COLON THERAPY - BOWEL PERFORATION &
ELECTROLYTE DISTURBANCE

• CHELATION-HEART FAILURE, ELECTROLYTE
IMBALANCE

• CHIROPRACTIC - STROKES FROM NECK
MANIPULATION

• ACUPUNCTURE - HEPATITIS TRANSMISSION,
PNEUMOTHORAX

• ETC., ETC...

WHY IS IT ALTERNATIVE?
• ALL TREATMENTS PROVEN EFFECTIVE HAVE BEEN ACCEPTED BY CONVENTIONAL MEDICINE

ANTI-PUBLIC-HEALTH ATTITUDES
OPPOSITION TO IMMUNIZATION
• CHIROPRACTORS • NATUROPATHS • HOMEOPATHS

DIVERSION FROM PROPER CARE
• ANECDOTES • PUBLISHED REPORTS • SYSTEMATIC STUDY URGENTLY NEEDED

IS ALTERNATIVE MEDICINE GETTING A „FREE RIDE‟?

TYRELL DUECK
• 13 YO BOY WITH OSTEOGENIC SARCOMA. • PARENTS DO ‘RESEARCH’ AND CHOOSE ALT. MED. • DELAY GETTING CHEMO • REFUSE AMPUTATION WHILE CURE RATE STILL 65%

TYRELL DUECK
• COURT BATTLE DROPPED ON NEWS OF METASTASIS • TO MEXICO FOR: VITAMINS, SHARK CARTILAGE, HERBS, APRICOT SEEDS, GARLIC • MEDIA PRESENTS BOTH SIDES AS EQUALLY REASONABLE

TYRELL DUECK
• FAMILY SPENDS $65 000 • TYRELL DIES IN PALLIATIVE CARE WARD IN SASKATCHEWAN

COMMENT FROM THE MEDIA
• Tyrell Dueck is dead, killed by cancer and . . . you pick. • The refusal of the 13-year-old, who loved hunting and fishing, to let doctors amputate his diseased leg? • His fundamentalist parents’ sincere, but mistaken, belief that prayer and alternative therapies could cure him? • The irresponsibility of a Mexican clinic which duped a desperate, gullible family into believing its apricot seeds and shark-cartilage cures were more than bunkum? • The failure of the Saskatchewan courts to immediately insist that Tyrell be treated -- a lapse which allowed his malignancy to become inoperable? Toronto Globe and Mail

WHAT CAN BE DONE?
• Link regulation of health professions to validity of the treatments • Enforce laws against practicing medicine without a license • Protect the public by preventing false or misleading health claims

SUMMARY
• ALTERNATIVE MEDICINE IS GENERALLY UNPROVEN • EXPLOSIVE GROWTH • MAY BE AN ADD-ON TO EXISTING HEALTH SYSTEM • OBJECTIVE EVALUATION IS URGENTLY NEEDED TO PLAN HEALTH SPENDING