WHAT IS COMPLEMENTARY MEDICINE?

The definition of complementary and alternative medicine (CAM) has been the subject of some debate. In 1995 the following definition was formulated at a conference held by the National Institutes of Health’s Office of Alternative Medicine in the USA, with the aim of producing a definition that has the broadest and most consistent applicability and that excludes bias and partisanship:

Like many definitions produced by committees, this definition seems a little unsatisfying. Simply dividing interventions into those that are part of the politically dominant health system and those that are not does not provide useful insight. This classification is also subject to regional political differences that may be unrelated to healthcare.

Rather than focus on political acceptance as the basis for defining alternative and complementary medicine, a discussion paper by the Australian Medical Council addresses ‘unorthodox therapies’ and states that ‘the practices they embrace are by definition unscientific and of unproven efficacy until proved otherwise (in which case they become part of mainstream medicine)’ (Australian Medical Council, ‘Undergraduate medical education and unorthodox medical practice’, unpublished discussion paper, 1999).

The division of therapies into unorthodox or mainstream based on scientific merit is a little simplistic and open to subjective interpretation. For example, there are many practices that can be considered mainstream but are not necessarily scientifically proven, and many practices that can be considered ‘unorthodox’ but have scientific support. Furthermore, scientific evidence for a therapy may exist for only a specific clinical condition, or a therapy may be considered orthodox in one context, such as the use of vitamin supplements for treating a deficiency syndrome, but unorthodox in another, such as the use of vitamins in megadoses.

When defining therapies on political or scientific grounds, further confusion is added by the time that it takes to gain wide acceptance. For example, even though scientific evidence in support of acupuncture has been accumulating since the discovery of endogenous opioids in the mid-1970s, and government rebates via Medicare have been available for acupuncture for nearly two decades, this therapy is not universally accepted as mainstream.

Overall, it is generally accepted that there are two broad classes of medicine, and terms such as ‘conventional’, ‘mainstream’, ‘orthodox’, ‘biomedicine’ and ‘scientific medicine’ are often contrasted with ‘unconventional’, ‘complementary’, ‘alternative’, ‘unorthodox’ and ‘fringe medicine’. Perhaps the most common distinction is between ‘conventional’ and ‘complementary’ therapies, yet these terms seem to defy precise definition. Even so, complementary medicine generally refers to the use of interventions that complement the use of drugs and surgery. The range of such therapies is vast and includes treatments based on traditional philosophies, manual techniques, medicinal systems, mind–body techniques and bioenergetic principles (Table 1.1). These techniques vary widely with respect to levels of efficacy, cost, safety and scientific validation, yet they often share common principles, including the concept of supporting the body’s homeostatic systems, as well as acknowledging the role of lifestyle practices, personal creativity, group sharing, the mind–body connection and the role of spiritual practice in health.

TABLE 1.1 The Range of Complementary Therapies

COMPLEMENTARY MEDICINE IN AUSTRALIA

The practice of complementary medicine is flourishing in Australia. In 2000 it was estimated that about 50% of the Australian population took a ‘natural supplement’, about 20% formally saw a complementary medicine practitioner, and public spending on complementary medicines (A$2.3 billion in 2000) was more than four times patients’ contributions for all pharmaceutical medications (MacLennan 2002). A follow-up survey performed in 2004 found that although spending on complementary medicines had decreased to A$1.8 billion, there was a slight increase in the number of people taking natural supplements and visits to complementary medicine practitioners rose to 26.5% (MacLennan et al 2006). More recent statistics reveal that up to 70% of the Australian population has used complementary medicine in a number of different forms (Xue et al 2007). Data from the Australian Bureau of Statistics indicates that in the 10 years leading up to 2006, the number of people visiting CM practitioners within a 2 week period rose from approximately 500,000 to 750,000 and over the same period there was an 80% increase in the number of people employed as a CM practitioner. The most commonly consulted CM practitioners were chiropractors, naturopaths and acupuncturists (Censuses of Population and Housing and from the ABS 2004-05 National Health Survey).

These figures are comparable to those from the USA, which further suggest that the use of CAM is increasing. Between 1990 and 1997 expenditure on these therapies in the USA increased by 45.2%, with the total of more than US$21 billion exceeding out-of-pocket expenditures for all US hospitalisations. Furthermore, visits to CAM practitioners exceeded total visits to all US primary-care physicians (Eisenberg 1998).

Similarly, use of complementary therapies by general practitioners seems to be increasing. Recent surveys have estimated that 30–40% of Australian GPs practise a complementary therapy and more than 75% formally refer their patients for such therapies (Cohen et al 2005, Hall 2000, Pirotta 2000). It is also estimated that more than 80% of GPs think it appropriate to practise therapies such as hypnosis, meditation and acupuncture and that most GPs desire further training in various complementary therapies (Cohen et al 2005, Pirotta 2000).

Interestingly a recent survey of Australian GPs found that, based on their opinions, complementary therapies could be classified as follows: non-medicinal and non-manipulative therapies such as acupuncture, massage, meditation, yoga and hypnosis, which GPs considered to be highly effective and safe; medicinal and manipulative therapies, including chiropractic, Chinese herbal medicine, osteopathy, herbal medicine, vitamin and mineral therapy, naturopathy and homeopathy, which more GPs considered potentially harmful than potentially effective; and esoteric therapies such as spiritual healing, aromatherapy and reflexology, which were seen to be relatively safe yet also relatively ineffective. Furthermore, according to GPs the risks of complementary therapies were seen to arise mainly from incorrect, inadequate or delayed diagnoses and interactions between complementary medications and pharmaceuticals, rather than the specific risks of the therapies themselves (Cohen et al 2005).

The interest of GPs in CAM is supported by the forming of links between the Australasian Integrative Medicine Association and the Royal Australian College of General Practitioners with the release of a joint position paper on complementary medicine (RACGP/AIMA 2005), as well as the introduction of teaching of CAM in undergraduate medical courses. Further academic support is evident by the establishment of departments of complementary medicine at respected universities and a proliferation of peer-reviewed journals documenting the growing body of rigorous research in the field. In line with these developments, the status of complementary medicine practitioners has been elevated, with the establishment of degree courses in natural medicine and formal registration of some professions.

There appear to be many reasons for the popularity of complementary medicine. Certainly, orthodox medicine does not have a monopoly on cure and, despite its effectiveness in treating trauma and acute disease, when it comes to chronic illness there are many people in the community who continue to suffer despite its best efforts. The public are also demanding greater autonomy and involvement in their own healthcare, and want to prevent or slow down ageing and achieve higher levels of functioning. Additionally, the exponential increase in scientific studies being published on complementary medicine therapies has no doubt added to the public’s interest and confidence in its use.

Although interest in CAM has increased among both practitioners and patients, this has been paralleled by increased support from the federal and state governments. In Australia this has been demonstrated by the granting of degree status to schools of natural medicine, the exemption of some complementary therapies from the Goods and Services Tax, and government support for private health insurance companies, many of which cover complementary medicine. The federal government has also provided these therapies with formal recognition by establishing an Office of Complementary Medicine as part of the Therapeutic Goods Administration and the Complementary Medicine Evaluation Committee (CMEC), and the Victorian Government is the first outside of China to regulate the practice of traditional Chinese medicine (TCM). From the viewpoint of government spending, this encouragement makes fiscal sense, as natural therapies do not attract Medicare benefits and spending on complementary medicines is patient- rather than government-funded.

Despite moves to support complementary therapies, in practice it seems that there are two distinct healthcare systems operating in parallel, and interaction is still in its infancy. It is estimated that, of the patients who go to complementary practitioners, more than 57% do not inform their doctor they are doing so (MacLennan et al 2006). This lack of communication is potentially hazardous, as it raises the possibility of treatment interactions; this is even more significant when it is considered that in the USA more than 80% of people seeking complementary treatment for ‘serious medical conditions’ were found to be receiving treatment from a medical doctor for the same condition (Eisenberg 1993).

COMPLEMENTARY MEDICINE IN NEW ZEALAND

Complementary medicine has been practised in New Zealand since the 19th century (Duke 2005). In 1908, the Quackery Prevention Act was enacted to prevent the sale of dubious medicines or medical devices and represents an early attempt to regulate the practice of CAM. At the time, what is now termed CAM had achieved a level of acceptance among the medical profession; however, a division began to emerge between medical and complementary practices because of the Act.

Over the past decade, studies indicate that conventional medical practitioners in New Zealand practise some form of complementary therapy or refer their patients to complementary medicine practitioners (Duke 2005). One study of 226 GPs in Wellington suggested that they saw their role as ranging from comprehensive provider of both conventional and complementary medicine to selective practitioner of some options (Hadley 1988). Of these GPs, 24% had received complementary medicine training, 54% wanted further training in a complementary therapy, and 27% currently practised at least one therapy. The study also found that acupuncture, hypnosis and chiropractic were the most popular therapies among this group.

In June 2001, the Ministerial Advisory Committee on Complementary and Alternative Health (MACCAM) was established in order to advise the New Zealand Minister of Health. Policies regarding regulation, consumer information needs, research evidence and efficacy and integration were investigated, together with a range of strategies to allow CAM to contribute to the mainstream objectives of the New Zealand Health Strategy (MACCAM 2004).

Currently, the New Zealand Charter of Health Professionals estimates that there are 10,000 CAM practitioners nationally. The 2002–03 New Zealand Health Survey (n = 12,000) indicated that approximately 24% of adults had visited a CAM practitioner over the 12-month study period (MACCAM 2004). Massage therapists, chiropractors, osteopaths, homeopaths or naturopaths were the most commonly consulted CAM practitioners. The survey found that 32.5% of people seeing CAM practitioners did so for the treatment of a chronic condition, long-term illness or disability, while 33% also saw a GP for the same condition. A belief that CAM practitioners can provide help with conditions that other healthcare professionals are unable to treat was the main driving force behind their choice. Most referrals came from friends; however, 12% reported that they had been referred to the service by a medical doctor.

THE MEDICAL SPECTRUM

The range of available therapies is vast, but there is a common benchmark for all — reducing human suffering. On this criterion, it is possible to classify all medicine into good and bad, with good medicine defined as effective, safe, practical and, ideally, evidence based, and bad medicine defined as ineffective or potentially harmful.

Additionally, the different therapies can be seen to exist across a spectrum with multiple dimensions, such as safety, efficacy, practicality, availability, utility and cost-effectiveness. At one end of this spectrum is the science of medicine, which aims to understand and combat the disease process from a pathophysiological perspective. Therapies using this approach are often at the core of mainstream medicine, require practitioner intervention, target a specific organ, system, tissue or biochemical process, and are usually subsidised by the public purse. At the opposite end is the art of medicine, which aims to support the body’s homeostatic processes to facilitate healing and enhance the subjective sensation of wellness. Therapies using this approach often involve philosophical systems with a spiritual dimension, are highly individualised, consider the whole person and may require significant patient involvement and cost. When considering the different dimensions of medical practice, it becomes clear that best practice should incorporate both approaches and combine the art and science of medicine.

Health and disease can also be considered to inhabit opposite ends of an illness–wellness spectrum, with health being classified into three broad areas — ill-health, average health and enhanced health (Figure 1.1) (see also Chapter 12). In the past, Western medicine has focused on helping people move from ill-health to average health and has viewed the absence of disease as an ideal goal. In relatively recent times, preventative treatment has also been incorporated into medical management, in an attempt to reduce the incidence or exacerbation of disease states. In comparison, CAM has always maintained a focus on preventative approaches and moving people from average health to a state of enhanced health. In Eastern medicine there is a concept of a ‘perfect health’ state, in which a person is totally balanced and ‘at one with the universe’, and hence in a state of perpetual bliss or ‘nirvana’.

FIGURE 1.1 Conceptualisation of the spectrum of health