Issues Magazine

Editorial

By By Sally Woollett

Complementary medicine incorporates complementary and alternative medicines (CAM) and therapies. Traditional and natural medicines can also be described using this term.

An overview of what's in this edition of Issues.

Complementary medicine considers the maintenance of wellness and the treatment of illness in four domains:

  • mind–body medicine, including meditation;
  • biologically based practices, including dietary supplements and herbal medicines;
  • manipulative and body-based practices, including osteopathy, naturopathy and chiropractic; and
  • energy medicine, including reiki and bioelectromagnetic-based therapies.

Complementary medicine is a burgeoning industry. According to a 2008 Australian Bureau of Statistics (ABS) report, the number of complementary health therapists jumped by 80% between 1996 and 2006. Although some of this increase is attributable to changes in classification, it’s still appreciable compared with a 31% increase in the number of health professionals over the same period.

Despite the industry’s growth, and some evidence of its use in chronic disease management, complementary medicine enjoys comparatively little research investment in Australia. Dimity Pinto of the National Institute of Complementary Medicine (NICM) says (p.23): “The key issue is identifying how to best bridge the major gap between the high level of use and a limited and confusing body of evidence”.

Overall, news media is failing to adequately untangle this body of evidence for the public, a worrying fact given that most people gain their understanding of health issues from media sources (p.17). In a recent study conducted using the online media monitor Media Doctor, University of Newcastle researcher Billie Bonevski and colleagues found that on average only five out of the 10 rating criteria were met: “When reporting CAM [complementary and alternative medicine], it appears the media are particularly inconsistent at reporting the costs, and potential harms and benefits.”

It is no surprise, then, that Dr Ken Harvey of La Trobe University describes a “discrepancy between the number of people who believe in and use complementary medicine and the strength of evidence to support that use” (p.7). Similarly beyondblue (p.43) cites a study finding that 57% of Australians “regarded vitamins, minerals, tonics or herbal medicines as likely to be helpful for treating depression, compared with 29% who regarded antidepressants as likely to be helpful”.

Although complementary medicine is popular, it’s by no means universally accepted. Peter Bowditch of the Australian Council Against Health Fraud (p.30) says that the common factor underlying homeopathy, chiropractic and acupuncture is that they “reject any idea that bacteria, viruses or allergens might have any influence on the human body … They also ignore any part played by diet or the immune system in maintaining health” Further, they only work if “the patient has a self-limiting or mild psychosomatic condition. They do not and cannot work for the sorts of things that do not get better by themselves.”

Commercial interests also muddy the waters of complementary medicine. During his time as a pharmacy assistant, Stuart Adams (p.26) says he “was instructed to shun peer-reviewed literature and instead consult the literature of supplement companies and other pro-CAM websites”. At present, in his opinion, “there is too much room for them [pharmacists] to exercise dishonesty and let their critical thinking lapse”.

Changes to regulations regarding efficacy and safety labelling could improve a system in which health advice can be compromised by financial incentive. BrainLink (p.14) warns that “some practitioners you consult (conventional, complementary or alternative) may receive some kind of benefit from supporting a particular treatment or product associated with that treatment”. Consumers should be prepared to ask pertinent questions at any type of health consultation.

The 2008 ABS report showed chiropractors to be the second-largest group of complementary health therapists in Australia. The Skeptics Association of South Australia accepts evidence that chiropractic is useful in the management of lower back pain, but not that it is an effective treatment for asthma or headache, or as a preventative or “maintenance” measure (p.33). However, Dennis Richards of the Chiropractors’ Association of Australia (p.35) disputes some of the claims made by the Skeptics, and defends modern chiropractic training.

Chiropractors are registered in all Australian states and territories, but variation in registration requirements between complementary health modalities, and between states and territories within a given modality, can be problematic. Without regulation of a given complementary medicine, consumers have no guarantee of education and training, standards of professional behaviour or complaint mechanisms.

Regulation of naturopathy is an example of the clash of industry interests and complementary healthcare practice. Jon Wardle of the University of Queensland (p.10) says that “over 90% of grass-roots naturopathic practitioners do actually want further regulation, despite the vast majority of the large organisations representing the complementary industry (and the practitioners that work in it) actively campaigning against it”. Resistance is largely because many of the bodies representing naturopaths also represent other complementary medicine practitioners or the interests of educators and manufacturers.

The Therapeutic Goods Administration (TGA) regulates complementary medicine products rather than healthcare practitioners or therapies. Among other things, the TGA considers therapeutic claims, toxicity and adverse effects. These considerations extend to post-market audits and to advertising (p.4).

However, Ken Harvey at La Trobe University says that “the current Australian regulatory system neither controls complementary medicine claims nor supports an evidence-based industry” (p.7). Most complementary products are “listed” by the TGA based on a self-assessment by the entity wishing to market the product. A review by Harvey of claims made for weight loss products found that “promotional claims made were often far in excess of the limited scientific evidence available”. He says that “because the TGA does not require clinical trial data of efficacy for ‘listed’ products, nor evidence of therapeutic equivalence with proven products, we can have no confidence that Australian formulations of complementary medicines are efficacious”. This is not a trivial matter given the high cost of some of these products and the potential for harmful interaction with conventional medicines.

Trixi Madon and Kristy Roberts of the Complementary Healthcare Council of Australia (p.20) concur that “there is still a critical need for more quality data, from within Australia, which demonstrates the clear health and economic benefit [of complementary medicines]”. They say that good evidence exists for the use of complementary medicine in the prevention of osteoporosis, osteoarthritis and mild depression. “Increasing the information base of complementary medicine efficacy and usage could make a positive contribution to Australian health policy,” they write.

Research and review may also help the integration of complementary healthcare with its mainstream counterpart. Charlie Xue and colleagues at RMIT University (p. 38) say that “integration requires not only further research evidence but also a well-trained workforce consisting of registered acupuncture practitioners who are able to provide good-quality clinical acupuncture services to the community and who are sufficiently well-educated in biomedical sciences to be able to effectively communicate with mainstream medical professionals”. Randomised controlled trials and systematic reviews of acupuncture have been conducted in recent years in Australia.

The challenge for complementary medicine, says Pinto, is the set-up of clinical trials, which “requires infrastructure, skilled researchers and funding”. The Federal government has announced over $7 million of research grants to “study the use of complementary medicine by consumers, to research mechanisms of action, and to perform clinical trials to determine efficacy and adverse effects” (p.7), including a $5.3 million initiative by the National Health and Medical Research Council to fund research that will contribute to the body of evidence relating to the use of complementary medicine in Australia. An NICM was established in 2007 with seed funding from the Commonwealth and NSW governments to “provide leadership and support for strategically directed research into complementary medicine and translation of evidence into clinical practice and relevant policy to benefit the health of all Australians” (p.23). beyondblue is currently funding further research into the use of CAM to treat depression (p.43).

On the integration front, Pinto writes that “many medical schools [are] revising their curricula to incorporate a complementary medicine component in courses including nursing and pharmacy”. And the Indigenous Bioresources Research Group at Macquarie University is working with Aboriginal elders to preserve cultural knowledge and to test plants used in aboriginal culture for medicinal purposes (p.45).