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Complementary & alternative medicine in practice and policy


Complementary and alternative medicine is a billion dollar business in Canada. 

Complementary and alternative medicine is rooted in different philosophies and standards of evidence than mainstream medicine. 

Many patients use both systems of medicine. 

Complementary and alternative medicine is defined as any medical system, product or practice that is not thought of as a standard of care. There are many complementary and alternative providers and products in Canada, including homeopaths, naturopathic doctors and traditional Chinese medicine practitioners who use products like herbs, homeopathic preparations, and vitamins.

Complementary medicine usually refers to the use of these services and products in conjunction with mainstream medicine, whereas alternative medicine means using them instead of mainstream medicine.

The business of complementary and alternative medicine

Over 5 million Canadians have reported using some form of alternative or complementary health product in the past year. Complementary and alternative medicine is big business in Canada, and is estimated to cost about $2.35 billion per year. Canadians who use these products and services largely pay out of pocket.

These treatments are rooted in a different belief system than the one underlying mainstream medicine. Mainstream medicine is scientifically based and focused on evidence, often using randomized controlled trials to demonstrate the benefits and harms of a treatment or procedure. However, critics point out that many treatments in mainstream medicine have not been rigorously evaluated.

Complementary and alternative medicine is based on tradition and belief, and doesn’t have a strong research tradition or infrastructure. However, the amount of research generating evidence about complementary and alternative medicine is growing. For example, the National Institutes of Health, the primary government research funding agency in the United States, has a center focused on improving the amount and quality of evidence in complementary and alternative medicine.

In spite of the lack of high quality evidence about the benefits and harms of many of these treatments, and the fact that Canadians usually pay for them out of pocket, over 76% of Canadians have purchased natural health products such as vitamins and herbal products, and about 70% of Canadians use these products at least once weekly.

How do these two philosophies of medicine co-exist in Ontario?

The growing use of complementary and alternative medicine has led to a broader regulatory focus on these products and professionals. In 2004, Health Canada created the Natural Health Products Directorate, which has been tasked with regulating natural health products and is supposed to ensure that Canadians have access to safe and high quality products. Similarly, in Ontario, legislation was passed in 2007 to regulate practitioners of traditional Chinese medicine and acupuncture, naturopathic medicine and homeopathy.

Kirsten Smith, a Toronto-based naturopathic doctor sees regulation as an opportunity for naturopathic medicine to gain broader acceptance, saying that “it validates the profession.” However, Heather Boon, a researcher at the University of Toronto and one of the founding chairs of the Canadian Interdisciplinary Network for Complementary and Alternative Medicine Research is concerned about the impact of regulating these groups.

Boon notes that “the big issue is that regulation is supposed to protect the public, and it is still not clear how the colleges, in regulating these groups, will do that.” Boon questions who will bear the costs of setting up expensive, bureaucratic infrastructure for regulation.  She says that practitioners will need to recoup the costs of expensive licensing fees, and the big question is “whether costs will increase for patients and end users.”

Acceptance from mainstream medicine?

In spite of the costs, and the lack of information about effectiveness, many Canadians have embraced complementary and alternative medicine, mostly using it in addition to mainstream therapies. Nicholas Ignatieff, a cancer patient who lives near Kingston, Ontario uses naturopathic and homeopathic remedies alongside mainstream chemotherapy treatment for his cancer, saying that “you can tell from the way that you feel that it’s a positive addition to your arsenal, and one that isn’t in conflict with conventional treatment.”

Mainstream medicine, however, has been slower to accept many of these products and practitioners.

Bill Evans, a medical oncologist and president of the Juravinski Cancer Center in Hamilton says that some “patients are afraid to tell their doctors” about the natural health products they are using, or practitioners they are seeing, for fear that “their doctor won’t approve, and at the least will scold them, and at the worst, withhold treatment.” However, it is crucial for doctors to know what treatments patients are using, because there is evidence that some natural products and prescription drugs can interact. In cancer, this is particularly problematic because herbs and vitamins have been found to interact with chemotherapy for about 25% of patients, who are using chemotheraphy in conjunction with herbs and vitamins.  Evans believes that doctors need to be asking their patients about their use of these treatments in a way that encourages full disclosure. Evans says that “this conversation, to some extent needs to be less judgmental than it has been.”

There are efforts to provide further guidance to doctors on how to have these conversations, and to learn about their patients’ use of complementary and alternative medicine. For example, the College of Physicians and Surgeons of Ontario is undertaking public consultation to update their policy that outlines how doctors should assess and treat patients using complementary and alternative medicines.

Reflections

Many Ontarians use both the mainstream and complementary and alternative health care systems at the same time, despite the two systems’ different underlying philosophies and approaches to evidence.

Ontarians avidly use the services of mainstream medicine and demand increasingly “high tech” tests and treatments. However, at the same time they are also skeptical about some of the claims of mainstream medicine. The skepticism is partly driven by well-publicized examples of unexpected harms of treatments like Vioxx and hormone replacement therapy, as well as the continued burden of diseases like multiple sclerosis and some cancers, which have established treatments, none of which work for all patients, and many of which come with a myriad of undesirable side effects.

Despite their skepticism of some of the claims of mainstream medicine, patients are increasingly willing to use complementary and alternative medicines, many of which have little evidence to support their impact on health outcomes. Many patients, however, are unconcerned about the lack of scientific evidence, and instead focus on historical experience. Ignatieff says “when you to turn to traditional Chinese medicine you are impressed that this is a huge global population that has used this approach for millennia.”

What is the most important reason for the growing use of complementary and alternative medicine?

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This article has been closed to comments. 16 comments

  1. Sarah

    Would have liked to see a more indepth discussion about the spectrum that is alternative medicine.

    • Karen Born

      Thanks Sarah – can you give us a bit more detail on what you mean by this … and if there are any references or useful sites within Canada or elsewhere that cover the spectrum of complementary & alternative medicine.

  2. Tara Gignac

    For a website with the tag-line “un-biased facts. informed opinions”, I’m not sure you are hitting the mark.

    The obvious bias towards conventional medicine, coupled with the lack of useful information about CAM therapies resulted in an article that came off as judgmental and dismissive of all those engaging in unconventional care – both the practitioners and patients.

    • Jeremy Petch

      Tara, please enlighten us as to what about CAM this article misrepresents through its supposed bias. Far from judgmental or dismissive, my impression is that the authors went to great pains to represent CAMs in a reasonable light.

  3. Ritika Goel

    As a practitioner, one of my major concerns is that due to a lack of regulation, often there is no way to verify what is actually in a bottle with a certain label. I do recall hearing of studies that found there to be surprising variability in what can actually be found within bottles with the same label. There is also a concern around the idea that natural products CAN’T cause harm. I look at what are considered ‘natural medicines’ the same way as I do the ones we prescribe – they are all chemicals and can therefore affect the body in various ways. After all, snake venom is natural too! I do not discourage my patients from using CAM but I do try to ensure they approach such treatments with appropriate vigilance. There are many products with research behind them, and often there is a lack of research due to lack of ‘big pharma’, however, a lack of regulation on contents of such products can be worrisome.

    • Jeremy Petch

      Ritika is quite right that there is indeed significant variability in the potency of natural products. This has to do with how they are regulated. Where mainstream pharmaceuticals are dosed based on the amount of active compounds they contain, natural products are dosed without isolating the active compounds. Since there is so much variation in nature, the total weight of a natural product proves to be a very inaccurate way of measuring how much of a medically active compound is actually in a given dose. The time of year a plant was harvested, where it was grown, how much sun, rain, fertilizer it got all affect the potency (the amount of the medically active compounds the plant contains) of the natural product. The result is that there is no standardization among natural products, such that one brand of a product may be many times stronger than another. This makes is very difficult to predict adverse effects or the extent of interactions the product may have with other medications.

      Interestingly, for anyone who has wondered what the difference is between Cold FX, generic knock offs, and Wild American Ginseng (from which Cold FX and knock offs are made), it is precisely this issue of dosing. Cold FX capsules contain 200mg of a patented compound, which is comprised of 80%+ of poly-furanosyl-saccharides, which they believe to be the active ingredient of Wild American Ginseng. Their ability to isolate the active ingredient allows them to guarantee the potency of their dosing, whereas if you were to just take Wild American Ginseng in its natural state, you could never be sure whether you were getting very much of the poly-furanosyl-saccharides, since there is so much variation in nature.

      • Jeremy Petch

        PS. I don’t work for whoever makes Cold FX, nor am I a shareholder. I just find it interesting that a company has built a business model around the a natural product, but taken a mainstream medicine approach to standardizing dosing to ensure quality. Seems like the best of both worlds to me.

  4. Rola Priatel

    Yes it does come down to the fact that it is a billion dollar industry and it is demanded by the consumers! We, as health professionals, need to educate ourselves and our patients. A good website is Natural Medicines Comprehensive Database, you do need to subscribe, same folks as the Pharmacist Letter or the Medical Letter…same type of practical evidence- based advice!
    Also, the comment above about the standardization of Cold Fx …I think we are getting closer in Canada to the European Commission E system of standardization of Comp medicines , we do have a few products with an identification number to indicate that the product has been tested by health canada to contain what it claims to contain on the bottle, of course that number has nothing to do with efficacy or safety data, just a check that it contains more than lactose and other fillers…

  5. Jess

    Well-written article.

    Yes, after having voted in the poll system above, I do think that the main reason why so many patients continue to seek alternative medicine is because the holistic therapies, herbal remedies, acupuncture, etc have been around for centuries. So, naturally (pun-intended) many patients strongly believe that there are some healing properties to these treatments. As well, complementary and alternative medicine (CAM) provides patients with more options. If you couple those two points, it becomes clear that the widespread acceptance of CAM has more to do with the psychological impact it has on patients than anything else. CAM treatments give more hope to patients, and as we have seen from the last US presidential election, hope is powerful – more powerful of a force than we consider it to be.

  6. Lara

    Although I agree that this is a well written article, and am thrilled that the topic has warranted attention here, I do think there is a slight bias towards mainstream/traditional/allopathic medicine in the article. Let me be clear before I go on….I do believe that there is a place for both alternative and allopathic medicine in the world and I look forward to the day when we strike a balance. Having said that, the one issue I have is that the article claims that alternative medicine does not have the strong ‘science’ to back it up. I have to disagree with this. I think the issue is more that the body of very valid and reliable evidence that does exist to support the efficacy of so called ‘alternative’ practices, is largely ignored by the media or dismissed by those who have a fear of change or avested interest in keeping allopathic medicine ‘in control’ so to speak. I am not suggesting that all alternative therapies are based on sound science (not all allopathic practices/medicines are either), but many are. For example, there is a growing body of evidence that scientifically supports the practices and principals of homeopathy and other energy medicines (and this is only one area where the ‘hard science’ does exsist). One could write a whole dissertation on the subject, and some have, but in an effort to keep my comments as succint as possible for this type of forum, I encourage you to do some digging of your own. With an unbiased and open mind, you will discover that there is a huge body of evidence out there to support the claims of many forms of alternative medicine. These studies are just as rigorus, and sometimes more so, than studies done showing support for the efficacy of mainstream or allopathic medical practices and pharmaceuticals. Here are some places to start…and this is just the tip of the ice berg http://www.naturalnews.com/031210_Luc_Montagnier_Homeopathy.html
    http://knol.google.com/k/scientific-research-in-homeopathy#
    http://www.amazon.com/Energy-Medicine-Scientific-James-Oschman/dp/0443062617#_

  7. Mandy

    Could you reference where you found the statistics on who uses CAM in Canada and how much they spend? I am doing a business plan and am having a hard time finding data any newer than 1997.

  8. Kirsten

    To clarify as per my quote, Naturopathic Doctors are regulated, however we are currently in the process of transitioning to a different governing body (the RHPA) which would be an improvement for both the public and the profession. The Board of Directors of Drugless Therapy – Naturopathy (BDDT-N), appointed by the Lieutenant Governor in council, has been responsible for public protection in Ontario with respect to the practice of Naturopathic Medicine since 1925. In order to practice Naturopathic Medicine in Ontario Naturopathic Doctors must be registered with the BDDT-N. The impact on the public and on the profession of transitioning to the RHPA has been thoroughly researched by a team of health care policy professionals.

    I am glad this article was published as it has generated some good discussion and many questions; namely blowing open the clear necessity to do a series of articles addressing these topics as they are the source of a lot of confusion for both the public and health care professionals, and frankly, it would be of great value to everyone to shed some light on the facts.

    Some ideas that come to mind are:

    What falls under the definition of alternative medicine (or CAM)?

    What is integrated medicine, and is this the inevitable model that we are moving towards? (It is certainly what a growing portion of the Canadian population wants).

    Clarifying the different types of alternative practitioners and the questions that patients/ consumers should be asking (re: regulation/licensure, education, scope of practice, etc.).

    Regulation: a brief summary regarding each of these professions.

    Regulation re: the purity of NHPs (natural health products): where is this at in Canada (NPNs, the process, what is means if products have NPNs, etc.), how does it compare to the US, to Europe. Currently this is an issue that effects all health care professions and all consumers.

    Regulation of access to, or prescription of, NHPs – currently you can buy them at the supermarket, online, get a tip from your personal trainer, or buy something in a health food store – and the potential exists for it to interact with medications. (NDs are the only health care professionals with the expertise to manage, drug/herb/nutrient interactions although increasingly there is an interest in this area from pharmacists). In some countries many of the things currently on our shelves are only available by prescription from a trained professional.

    Education of the allopathic community: what is the training/ regulation of these various professions? And what is their scope of practice that they have the right to practice free from prejudice? And that patients have the right to utilize different approaches to their care without discrimination, bad treatment or disrespect? NB. the CPSO has just released a new statement on how to manage patients who are using “alternative” / natural care, and interestingly, there are new rules for MDs using natural medicine in their practices.

    What role do alternatives approaches to health care play in terms of the various chronic diseases that are either epidemic or rapidly becoming so? Prevention, better lifestyle management, more responsibility and action required of the patient/ empowerment, treatment with less side effects?

    I optimistic that this forum can address many of these topics with clarity, facts and lack of bias.

    Kirsten

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