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Risks Associated With Complementary And Alternative Medicine (CAM): A Brief Overview

Having grown up on a dairy farm, I am one of the least likely people to object to the deification of yogurt. However, as a critical thinker, I cannot help but resist the idea (promoted by some health sites) that probiotics are a reasonable alternative to chemotherapy in the treatment of colon cancer. And there are many other equally unhelpful claims being made all the time. Fish oil for ALS anyone?

What amazes me about the “cherry yoga” camp (as my friend Bob Stern likes to call it), is that they aggressively market CAM as “harmless” and “natural.” They point to the warning labels and informed consents associated with science-based medicines as evidence that the alternative must be safer. In reality, many alternative practices are less effective, and can carry serious risks (usually undisclosed to the patient). For your interest, I’ve gathered some examples of risks associated with common alternative practices that have been described by the CDC and in the medical literature:

Colon cleansing: amebiasisruptured colon with pelvic  abscesses, Fournier’s gangrene

Herbal supplements: fulminant hepatic failure, bladder cancerarsenic poisoning, anticholinergic poisoninglead poisoning, severe hemorrhage, hepatic failure.

Acupuncturebilateral pneumothoraces (collapsed lungs) leading to death, transmission of hepatitis C

Chiropractic ManipulationsVertebral artery dissection and stroke, pediatric subarachnoid hemorrhage, paralysis, and misdiagnosed meningitis

Homeopathy – offered for malaria prophylaxis. All 5 contracted malaria.  Offered in lieu of standard of care treatment for melanoma (patient died), colloidal silver causes permanent skin disfigurement.

All CAM – can result in delay of effective care, thus worsening outcomes for cancer patients and others.

As you can see, all is not sweetness and light on the alternative medicine front. So next time your patient (or friend/loved one) expresses interest in CAM, please tell them to be careful. A full risk/benefit analysis is unlikely to be presented by the CAM practitioner or local GNC clerk. And while the CAM marketing engine cranks out endless images of tranquil yoga poses, the reality of potential liver failure, lead poisoning, strokes, paralysis, and gut infections are unlikely to be mentioned.

Posted in: Acupuncture, Chiropractic, Herbs & Supplements, Homeopathy

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26 thoughts on “Risks Associated With Complementary And Alternative Medicine (CAM): A Brief Overview

  1. Dr Benway says:

    You left out, “a lighter wallet.”

    Also, there’s the problem of side effects due to contaminants and adulteration with active pharmaceuticals. The lack of regulation is a serious problem.

    Update on the patient I share with Dr. Redacted. After all supplements stopped a month ago when weight was down to 131 with BMI of 17 (was over 150 in Nov when the supplements were started), weight now 138. I suspect something in there was doing something to the kid’s appetite. God knows what.

  2. Dr Benway says:

    Oh another problem: hypokalemia and arrhythmias. Had someone hospitalized for that due to diet herbs. They can make you poo.

  3. boris says:

    The patient in the linked melanoma study didn’t actual die (despite their own best efforts it seems).

  4. This is as good a place as any to include a report sent just yesterday from Cees Renckens in Holland:

    Dutch infant dies after “craniosacral” manipulation of neck and vertebral column

    In the Dutch Medical Journal authors from the University Hospital St. Radboud in Nijmegen reported a tragic case-history of which the summary follows here:

    A formerly healthy, three months old girl died after manipulation of the neck and the vertebral column by a so called “craniosacral therapist.” During continued and deep bending of the neck, the patient developed incontinence of faeces, atonia and respiratory arrest followed by asystolia. Based on findings at the physical examination of the body, an additional MRI examination and the autopsy, it is likely that the cause of death was a local neurovascular or a mechanic respiratory-induced problem. This is the second report of infant death after forceful manipulation of the neck. As long as there is no scientific evidence for the efficacy and safety of forceful manipulation of the neck and the vertebral column, we advise against this treatment for newborns and infants.

    Reference:
    Micha Holla, Marloes M. IJland et al. Ned Tijdschr Geneeskd, 2009; 22 April; 153:A290.

  5. Citizen Deux says:

    Issues with standardization of unregulated products (supplements, etc.) are staggering. A short review of data compiled by Consumer Labs reveals numerous incidences of products with contaminants, under or over dose components and other adulteratrions. Products which are touted as “safe” and marketed as supplements are routinely misproduced.

    Several vitamins were noted as having excessive amounts of vitamin A and iron, at near toxic levels for humans.

  6. SF Mom and Scientist says:

    I am concerned when I meet other parents who seek out CAM (specifically herbal supplements) for their young children because they think they are safer than regular medicine. (I’m never really sure what to call “regular” medicine.) I often hear them say things like “and there are no side-effects with (insert remedy here)”. One huge problem is that standard drugs are regulated and have to list every possible side effect, where CAM does not, giving people the impression that CAM is safer.

    When I tell them these supplements are actually much less safe because of the lack of regulation, they rarely believe. (I do work for the “enemy” after all.) Maybe next time I’ll send them this post.

  7. Harry says:

    Kimball,

    I’m having trouble finding a copy of that paper, could you please link me/us?

    Google and pubmed have failed me…

    -Harry

  8. AppealToAuthority says:

    A useful set of individual cases to use against the ‘herbs etc are always safe’ argument. But without large-scale numbers, these could represent risks at the same order of magnitude as dying in a car accident on the way to the doctor, so they are easily dismissed as red herrings by those who are not already convinced.

    Does anyone have any useful evidence, for example, that any particular herbal treatment is more risky (in terms of side effects) than the average ‘conventional’ treatment for the same problem — taking into account the proportion of non-evidence-based drug treatments that conventional treatment involves, and taking into account the unregulated nature of most herbal preparations?

    And then compare this to the overall health outcome — including the probability that either treatment will have a significant positive outcome for the complaint.

    This might be particularly useful for less serious complaints, where the vast majority of non-scientific treatment seems to go on.

    This would help us a lot – and also, would probably sound the alarm for the need for evidence based treatment in general practice for these complaints. Perhaps we can contribute to the reduction of over-prescription of antibiotics, as well as reducing consumption of dangerous plant preparations.

  9. AppealToAuthority,

    Why would that help? There is already ample evidence that the vast majority of herbal treatments don’t work at all.
    Regardless of the dangers of the herbal treatments, its the fact that the herbals don’t work that’s really important when you consider “overall health outcome.”

  10. daedalus2u says:

    I think this is the article, but I can’t tell for sure because I am illiterate in this language.

    http://www.ntvg.nl/publicatie/overleden-zuigeling-na-ocraniosacraleo-/volledig

  11. Newcoaster says:

    The main harms are financial, and delay in seeking effective treatment.

    Financially, sCAM is a goldmine, and it is often a cash business as well, with many of them working out of their homes, so we don’t even know the true cost of bunkum.

    Most sadly, by the time patients turn to effective proven treatments it is too late, and medicine is blamed for killing the patient after the sCAM product/philosophy/ kept him “well” for so long.

  12. AppealToAuthority says:

    whitecoattales: “Why would that help?”

    Well, I was addressing this post, which is about risks (actual harm) associated with “complementary and alternative medicine”; not about whether they work.

    It always helps to have sound arguments, and to avoid introducing red herrings – especially when your opponent is prone to flights of fancy. I don’t see evidence that the risks of actual harm from a lot of alt treatments are significant. The risks for most are that they displace effective treatment.

    Where the risk of actual harm is tiny, then that’s not a useful argument and we should focus our energies elsewhere – eg that they distract from real treatment, are a waste of money etc.

    ‘Regardless of the dangers of the herbal treatments, its the fact that the herbals don’t work that’s really important when you consider “overall health outcome.” ‘

    Only if we know that the (average) actual treatment people will receive from their health provider will be more effective, and will be less harmful. Eg in the case of colds and flu, it is likely that excessive early use of antibiotics is more harmful than, say, ‘homeopathic’ sugar or “laying on of hands”. Its almost certain that none of these affects the course of colds or flu through anything other than placebo effects.

    Whereas there are other conditions where some CAM treatments used are significantly dangerous, and where conventional treatments are relatively safe. If so, we need that information to argue effectively.

    Also, “overall health outcome” includes placebo effects – whether from the application of science-based medicine or something else. If conventional treatments are weak for a particular condition or patient, and the risks of a particular alternative therapy small and placebo effect is strong, then the argument against using it is ethical, not scientific.

    I’m trying to focus the public debate where we are strongest – and I don’t think that risk of direct harm from CAM is the main problem for many alt treatments. For those where it is, we should round them up.

  13. Harriet Hall says:

    There is another thing that concerns me, beside direct harm and indirect harm by postponing effective care.

    Even if studies show that a natural medicine works, there is no reliable safe source for these products. Under the DSHEA they are not regulated as medicines. There have been numerous reports of contamination with everything from floor sweepings to prescription drugs. And the amount of active ingredient is often wildly different from what it says on the label. Despite some private efforts to test and rate different brands, there is no guarantee that this year’s product will be of the same quality as last year’s. One of my colleagues refers to diet supplements as “street drugs” – you can never be sure what you’re getting.

    When comparing CAM to conventional treatment, it’s essential to avoid the false dichotomy fallacy. Chiropractors try to compare the risk of NSAIDs to the risk of neck manipulation, but those are not the only possible options.

  14. Eric Jackson says:

    Harriet Hall:

    My favorite has always been this little trifecta here: http://www.fda.gov/oc/po/firmrecalls/herbalscience04_08.html

    Human placenta, an extremely high potency carcinogen, and good old ephedra.

    And let’s not forget that some of these herbal preparations contain radically varying amounts of compounds, which can wreck havoc with a variety of medications (PMID 11772128). There’s a great deal of Cytochrome P450 induction and inhibition going on, and what’s somewhat freaky is that the published data on some things like Echinacea preparations have completely contradictory results, have shown between no inhibition, weak inhibition, induction and 80% inhibition of 3A4, and there are multiple different species within the genus (sold under the same name frequently), and different preparations from different plant portions.

  15. AppealToAuthority says:

    Harriet: “Even if studies show that a natural medicine works, there is no reliable safe source for these products.”

    If studies show it works, it should be integrated into science-based medicine, and the safe source problem addressed directly through regulation.

    You are right, its very hard for a doctor to ‘prescribe’ a herbal product if it has not been defined well. Much of the stuff peddled by Big Herba (I just made that name up) plays on the ‘natural’ origin of a herb and its ‘healing’ reputation, while actually being a radically different, highly processed product which may or may not contain those aspects of the plant which might be useful, and may well concentrate aspects which are not.

    If the ‘natural medicine’ doesn’t seem to be amenable to extraction and regulation of a particular active agent (or the herb becomes problematic when processed commercially, eg kava), then regulation of the plant itself might be necessary.

    Most of the thousands of herbs sold as therapeutic are not proven to work, many are proven not to, and some are know to be toxic. But of those sold in the greatest quantities, some do work – eg St Johns Wort. Like most drugs that work, it also has side effects and interactions with other drugs, that need to be addressed properly. If the plant option has less serious side effects and interactions than the chemical one, then we should use it in preference in those cases.

    A lot of people have a strong beleif that if something comes from a plant that has coexisted with people for a long time, then it is likely to be safer to ingest than a recently-produced chemical.

    As far as I know, there is no evidence to support this belief (and of course many plants are toxic). And even if this belief was validated, the testing regime given to drugs should level the playing field.

    Unfortunately, I don’t think we’re going to get conversion any time soon to people believing this. So, we are starting on the back foot with many people. Thus, our arguments and evidence have to be more carefully done than theirs, to have a chance of changing opinions and saving lives.

    Perhaps my different point of view is that I am arguing for science amongst ordinary folk, to get them to change their behaviour in relation to important things like health care, climate change etc. Whereas most of the (excellent) writers on this blog are working within the medical establishment, trying to fight off institutional corruption by bad science and anti-science tendencies.

    It may well be that the useful forms of argument are different in the two venues, even though the facts are the same. I also imagine that it is far more personally debilitating to be fighting within your profession, so that even though you have much better access to information and tools, the emotional toll quite reasonably produces the occasional slippage.

  16. Jules says:

    Does CAM lead to a delay in seeking appropriate care, or is it the high cost of health care that leads people into thinking, “Well, I don’t really want to go to the doctor’s for this cough. Maybe this [favorite herbal remedy] will work.” I mean, there are all sorts of reasons why people will delay seeking care–not insured, no time, they don’t think it’s serious, it must be that cold going around, their co-pay just went up, their doctor has inconvenient hours–that have nothing to do with CAM being “better”, and everything to do with money, time, and that one bad story about some friend of a friend who went to the hospital and came out in a casket.

    I just don’t think that the advent of CAM alone is to blame for its popularity.

  17. Joe says:

    @Jules, you have missed the point. It doesn’t matter why a person turns to quackery. Deferred treatment of serious illness can have disastrous consequences.

  18. Jurjen S. says:

    daedalus, that’s the correct article all right. As the parent of a small child, that does not make for comfortable reading, but if anyone wants a translation (bearing in mind that I am not a medical professional), I’ll be happy to oblige.

  19. Scott says:

    A very recent example of the risks is Hydroxycut:

    http://www.fda.gov/bbs/topics/NEWS/2009/NEW02006.html

  20. Harriet Hall says:

    AppealToAuthority said

    “If the plant option has less serious side effects and interactions than the chemical one, then we should use it in preference in those cases.”

    That’s the problem. Natural medicines are typically not studied to the point where we can accurately compare their side effects to those of prescription drugs. Also, the history of pharmacology tells us that a purified active ingredient almost always works as well as the whole plant extract, and it seems logical that all the other ingredients in the plant are unnecessary if not harmful.

    St. John’s wort appears to be effective for mild to moderate depression, but is there any good reason why we should prefer it to a pharmaceutical antidepressant that has been better studied?

  21. Joe says:

    Here is a free article that discusses Hydroxycut, and reviews other hepatotoxic products: http://www.wjgnet.com/1007-9327/14/6999.asp

    If I may add to Harriet’s comment- St. John’s wort is known to interfere with some drugs. One could hope to find an active ingredient in it that does not do so. Additionally, when it is chemically standardized it is only standardized to one component, so the true dose is not controlled.

    Recently, I was moved to investigate the oft-stated claim that aspirin is found in willow bark. It is not, the primary active ingredient in the bark is salicin. During the course of that project, I came to realize that early nineteenth century scientists were isolating active ingredients from herbs (salicin from willow, salicylic acid from meadowsweet); yet, nearly 200 years later herbalists want to avoid that kind of work. They are regressing rather than progressing.

  22. Jules says:

    St. John’s wort appears to be effective for mild to moderate depression, but is there any good reason why we should prefer it to a pharmaceutical antidepressant that has been better studied?

    @ Harriet:

    From a personal point of view: SJW is much, much cheaper and doesn’t require a prescription. Both are considerations to keep in mind when you’re living uninsured (and therefore technically illegally) in another country, don’t really speak the language too well, and can’t find the time to see a doctor. And now that I have insurance, I still don’t have time to see a doctor (I’ve stopped taking SJW for now; the days are getting longer and I don’t seem to need it).

    But I suspect that this is more a case for personalized medicine than discussion of medicine as a whole. It may be that, as we acquire a better understanding of the human proteome, that our understanding of why something works well for one person does not work for others. Cancer drugs are a case in point–biomarkers determine which drugs will be the most effective–but there’s no reason to think that the same principle should not be true for drugs in general.

  23. Jurjen S. says:

    One thing I was happy to read in that report:

    De gebeurtenissen van deze ziektegeschiedenis waren voor het openbaar ministerie aanleiding om een onderzoek in te stellen.

    The events in this case history prompted the public prosecution service to initiate an inquiry.

    I’m not sure how far the prosecution are going to take this, but it strikes me that they should be able to make a charge of involuntary manslaughter stick in this case. One way or the other, I hope they manage to stop this “therapist” from ever touching another person, especially children.

  24. AppealToAuthority says:

    ” is there any good reason why we should prefer it to a pharmaceutical antidepressant that has been better studied?”

    * depression most likely has multiple causes and multiple mechanisms
    * biological, psychological and social factors seem to make people differentially vulnerable to depression
    *people appear to be differentially sensitive to the antidepressant effects of the various drugs
    *people appear to be differentially sensitive to the side-effects of the various drugs
    * selection of drugs for a particular patient is currently not highly evidence-based: after narrowing the field, the common pattern is prescribing a series of drugs until one is found that works.
    * the side-effects of the main pharmaceuticals are very unpleasant for a significant number of people
    * the side-effects of SJW that have been documented are less severe for most people
    * SJW seems to work for a larger proportion of cases (of mild-medium depression) than any one of the pharmaceutical antidepressants

    Therefore, in medical practice, we should see SJW as a useful tool in a difficult field. And should create pressure for standardised formulations.

    At a research level, it may be that the difficulty mimicking its effect with an extracted single active ingredient from it may represent an opportunity to develop anti-depressants which use a complex of ingredients to achieve their effect.

    Of course, it may turn out that SJW has some long-term bad effects on people, which only long term studies will show. But that is true of many drugs that are used every day.

    What we know at the moment is SJW works for many people, and what we don’t know is why it, or any other treatment, works for one person and not the next.

    In the meantime, there seems no less reason for doctors to consider it than the others. And many reasons to study its effects better.

    On the bigger picture: Val Jones’ list of bad outcomes is very useful to counter the absolutist “alternatives are always safe” assertions.

    However, it is a list of risks, not a risk analysis. Even though they are small in proportion, the sheer number of bad outcomes in conventional medicine makes it easy for our opponents to argue that it is bad, based on a fallacious use of the bad outcomes data. We should not fall into the trap of doing the same.

  25. tmac57 says:

    I just saw a good article about CAM put out by the AP titled:
    AP IMPACT: “Alternative medicine goes mainstream.”
    It is one of the few mainstream articles out there that pretty much gets it right. See the article here:
    http://news.yahoo.com/s/ap/20090607/ap_on_he_me/us_med_unproven_remedies

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