Perspectives1 July 1997
    Author, Article, and Disclosure Information

    Abstract

    Alternative medical therapies, such as chiropractic, acupuncture, homeopathy, and herbal remedies, are in great public demand. Some managed care organizations now offer these therapies as an “expanded benefit.” Because the safety and efficacy of these practices remain largely unknown, advising patients who use or seek alternative treatments presents a professional challenge. A step-by-step strategy is proposed whereby conventionally trained medical providers and their patients can proactively discuss the use or avoidance of alternative therapies. This strategy involves a formal discussion of patients' preferences and expectations, the maintenance of symptom diaries, and follow-up visits to monitor for potentially harmful situations. In the absence of professional medical and legal guidelines, the proposed management plan emphasizes patient safety, the need for documentation in the patient record, and the importance of shared decision making.

    References

    • 1. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States. Prevalence, costs, and patterns of use. N Engl J Med. 1993; 328:246-52. Google Scholar
    • 2. Eisenberg DM. The invisible mainstream. Harvard Medical Alumni Bulletin. 1996; 70:20-5. Google Scholar
    • 3. Phalon R. New support for old therapies. Forbes. 20 December 1993:254-55. Google Scholar
    • 4. Neff R. They fly through the air with the greatest of … ki? Business Week. 23 January 1995:60. Google Scholar
    • 5. Carton B. Health insurers embrace eye-of-newt therapy. Wall Street Journal. 30 January 1995:B1. Google Scholar
    • 6. Scheck A. Alternative medicine is next health trend. Investor's Business Daily. 20 June 1995. Google Scholar
    • 7. Dunkin A. “Complementary” medicine: is it good for what ails you? Business Week. 27 November 1995:134. Google Scholar
    • 8. Hilts PJ. Health maintenance organizations turn to spiritual healing. The New York Times. 27 December 1995:B10. Google Scholar
    • 9. Egan T. Seattle officials seeking to establish a subsidized natural medicine clinic. The New York Times. 3 January 1996:A6. Google Scholar
    • 10. Jackson C. Alternative medicine goes mainstream. The Tampa Tribune. 8 January 1996:8. Google Scholar
    • 11. Russell S. HMOs try dose of alternative medicine. San Francisco Chronicle. 22 January 1996:A1. Google Scholar
    • 12. Bloomberg Business News. Oxford Health plans to cover alternative care. The New York Times. 9 October 1996:A11. Google Scholar
    • 13. Lagnado L. Oxford to create alternative-medicine network. Wall Street Journal. 7 October 1996:B9. Google Scholar
    • 14. Krauss C. Pataki outlaws herbal stimulant linked to deaths. The New York Times. 24 May 1996:B1. Google Scholar
    • 15. Cowley G. Herbal warning. Newsweek. 6 May 1996:60. Google Scholar
    • 16. Anderson IB, Mullen WH, Meeker JE, Khojasteh-Bakht SC, Oishi S, Nelson SD, et al. Pennyroyal toxicity: measurement of toxic metabolite levels in two cases and review of the literature. Ann Intern Med. 1996; 124:726-34. Google Scholar
    • 17. National Institutes of Health. Office of Alternative Medicine. Alternative Medicine: Expanding Medical Horizons. Washington, DC: US Gov Pr Office; 1994. Google Scholar
    • 18. Zwicky JF. American Medical Association. Reader's Guide to Alternative Health Methods. Chicago: American Med Assoc; 1993. Google Scholar
    • 19. Collinge W. Complete Guide to Alternative Medicine. New York: Warner Books; 1996. Google Scholar
    • 20. Micozzi MS, ed. Fundamentals of Complementary and Alternative Medicine. New York: Churchill Livingstone; 1996. Google Scholar
    • 21. Fugh-Berman A. Alternative Medicine: What Works. Tucson, AZ: Odonian Pr; 1996. Google Scholar
    • 22. Burton Goldberg Group. Alternative Medicine: The Definitive Guide. Puyallup, WA: Future Medicine; 1993. Google Scholar
    • 23. Marti JE, Hines A. The Alternative Health and Medicine Encyclopedia. New York: Gale Research; 1995. Google Scholar
    • 24. Lerner M. Choices in Healing: Integrating the Best of Conventional and Complementary Approaches to Cancer. Cambridge, MA: MIT Pr; 1994. Google Scholar
    • 25. U.S. Congress Office of Technology Assessment. Unconventional Cancer Treatments. OTA-H-405. Washington, DC: US Gov Pr Office; 1990. Google Scholar
    • 26. Goleman D, Gurin J. Mind/Body Medicine: How to Use Your Mind for Better Health. Yonkers, NY: Consumer Reports Books; 1993. Google Scholar
    • 27. Stalker D, Glymour C, eds. Examining Holistic Medicine. Buffalo, NY: Prometheus Books; 1989. Google Scholar
    • 28. Butler K, Barrett S. A Consumer's Guide to Alternative Medicine: A Close Look at Homeopathy, Acupuncture, Faith-Healing, and Other Unconventional Treatments. Buffalo, NY: Prometheus Books; 1992. Google Scholar
    • 29. Barrett S. Health Schemes, Scams, and Frauds. Mt. Vernon, NY: Consumers Union; 1990. Google Scholar
    • 30. Raso J, Barrett S, eds. Mystical Diets: Paranormal, Spiritual, and Occult Nutrition Practices. Buffalo, NY: Prometheus Books; 1993. Google Scholar
    • 31. Gevitz N. Other Healers: Unorthodox Medicine in America Baltimore: Johns Hopkins Univ Pr; 1988. Google Scholar
    • 32. O'Connor BB. Healing Traditions: Alternative Medicine and the Health Professions. Philadelphia: Univ of Pennsylvania Pr; 1995. Google Scholar
    • 33. Kaptchuk T. The Web That Has No Weaver: Understanding Chinese Medicine. New York: Congdon & Weed; 1983. Google Scholar
    • 34. Pizzorno JE, Murray MT. A Textbook of Natural Medicine. Seattle, WA: John Bastyr Coliege Publications; 1993. Google Scholar
    • 35. Bellavite P, Signorini A. Homeopathy: A Frontier in Medical Science. Berkeley, CA: North Atlantic Books; 1995. Google Scholar
    • 36. Vithoulkas G. The Science of Homeopathy. New York: Grove Pr; 1980. Google Scholar
    • 37. Weiner M, Goss K. The Complete Book of Homeopathy. New York: Bantam Books; 1982. Google Scholar
    • 38. Wardwell WI. Chiropractic: History and Evolution of a New Profession. St. Louis: Mosby-Year Book; 1992. Google Scholar
    • 39. Moore JS. Chiropractic in America. The History of a Medical Alternative. Baltimore: Johns Hopkins Univ Pr; 1993. Google Scholar
    • 40. Tyler VE. Herbs of Choice: The Therapeutic Use of Phytomedicinals. Binghamton, NY: Haworth Pr; 1994. Google Scholar
    • 41. Tyler VE. The Honest Herbal: A Sensible Guide to the Use of Herbs and Related Remedies. 3d ed. Binghamton, NY: Haworth Pr; 1993. Google Scholar
    • 42. Weiss RF. Herbal Medicine. Beaconsfield, United Kingdom: Beaconsfield Publishers; 1988. Google Scholar
    • 43. Werbach MR, Murray MT. Botanical Influences on Illness: A Sourcebook of Clinical Research. Tarzana, CA: Third Line Pr; 1994. Google Scholar
    • 44. Conference calendar. Alternative Therapies in Health and Medicine. Aliso Viejo, CA: Innovision Communications. 1997; 3:125. Google Scholar
    • 45. Upcoming conferences and training seminars. Alternative & Complementary Therapies. Larchmont, NY: Mary Ann Liebert. 1997;3:72. Google Scholar
    • 46. Forthcoming meetings of interest. Advances: The Journal of Mind-Body Health. Kalamazoo, MI: John E. Fetzer Institute. 1997; 13:79. Google Scholar
    • 47. Huxtable RJ. The harmful potential of herbal and other plant products. Drug Saf. 1990; 5(Suppl 1):126-36. Google Scholar
    • 48. de Smet PA. Health risks of herbal remedies. Drug Saf. 1995; 13:81-93. Google Scholar
    • 49. de Smet PA, Dukes MN, eds. Drugs used in non-orthodox medicine. In: Dukes MN, ed. Meyler's Side Effects of Drugs. 12th ed. Amsterdam: Elsevier; 1992:1209-32. Google Scholar
    • 50. de Smet PA, Keller K, Hansel R, Chander RF, eds. Toxicological Outlook on the Quality Assurance of Herbal Remedies: Adverse Effects of Herbal Drugs. Berlin: Springer-Verlag; 1992:1-72. Google Scholar
    • 51. de Smet PA. Is there any danger in using traditional remedies? J Ethnopharmacol. 1991; 32:43-50. Google Scholar
    • 52. D'Arcy PF. Adverse reactions and interactions with herbal medicines. Part 1. Adverse reactions. Adverse Drug React Toxicol Rev. 1991; 10:189-208. Google Scholar
    • 53. D'Arcy PF. Adverse reactions and interactions with herbal medicines. Part 2-Drug interactions. Adverse Drug React Toxicol Rev. 1993; 12:147-62. Google Scholar
    • 54. Woolf GM, Petrovic LM, Rojter SE, Wainwright S, Villamil FG, Katkov WN, et al. Acute hepatitis associated with the Chinese herbal product jin bu huan. Ann Intern Med. 1994; 121:729-35. Google Scholar
    • 55. Segelman AB, Segelman FP, Karliner J, Sofia RD. Sassafras and herb tea. Potential health hazards. JAMA. 1976; 236:477 Google Scholar
    • 56. Ridker PM, McDermott WV. Comfrey herb tea and hepatic veno-occlusive disease. Lancet. 1989; 1:657-8. Google Scholar
    • 57. Tai YT, But PP, Young K, Lau CP. Cardiotoxicity after accidental herbinduced aconite poisoning. Lancet. 1992; 340:1254-6. Google Scholar
    • 58. Vanherweghem JL, Depierreux M, Tielemans C, Abramowicz D, Dratwa M, Jadoul M, et al. Rapidly progressive interstitial renal fibrosis in young women: association with slimming regimen including Chinese herbs. Lancet. 1993; 341:387-91. Google Scholar
    • 59. World Health Organization. Herbal Medicines Containing Germander Withdrawn. PHA Information Exchange Service. Geneva: World Health Organization; 1992. Google Scholar
    • 60. Jimson weed poisoning-Texas, New York, and California, 1994. MMWR Morb Mortal Wkly Rep. 1995; 44:41-4. Google Scholar
    • 61. Lead poisoning associated with use of traditional ethnic remedies-California, 1991-1992. MMWR Morb Mortal Wkly Rep. 1993; 42:521-4. Google Scholar
    • 62. Smith GW, Chalmers TM, Nuki G. Vasculitis associated with herbal preparation containing Passiflora extract [Letter]. Br J Rheumatol. 1993; 32:87-8. Google Scholar
    • 63. Bailey DG, Arnold JM, Spence JD. Grapefruit juice and drugs. How significant is the interaction? Clin Pharmacokinet. 1994; 26:91-8. Google Scholar
    • 64. Chan TY, Chan JC, Tomlinson B, Critchley JA. Chinese herbal medicines revisited: a Hong Kong perspective. Lancet. 1993; 342:1532-4. Google Scholar
    • 65. Conn JW, Rovner DR, Cohen EL. Licorice-induced pseudoaldosteronism. Hypertension, hypokalemia, aldosteronopenia, and suppressed plasma renin activity. JAMA. 1968; 205:492-6. Google Scholar
    • 66. Dandekar UP, Chandra RS, Dalvi SS, Joshi MV, Gokhale PC, Sharma AV, et al. Analysis of a clinically important interaction between phenytoin and Shankhapushpi, an Ayurvedic preparation. J Ethnopharmacol. 1992; 35:285-8. Google Scholar
    • 67. Fushimi R, Tachi J, Amino N, Miyai K. Chinese medicine interfering with digoxin immunoassays [Letter]. Lancet. 1989; 1:339. Google Scholar
    • 68. Goldman JA, Myerson G. Chinese herbal medicine: camouflaged prescription antiinflammatory drugs, corticosteroids, and lead. Arthritis Rheum. 1991; 34:1207. Google Scholar
    • 69. Gordon DW, Rosenthal G, Hart J, Sirota R, Baker AL. Chaparral ingestion. The broadening spectrum of liver injury caused by herbal medications. JAMA. 1995; 273:489-90. Google Scholar
    • 70. Hogan RP 3d. Hemorrhagic diathesis caused by drinking an herbal tea. JAMA. 1983; 249:2679-80. Google Scholar
    • 71. Kane JA, Kane SP, Jain S. Hepatitis induced by traditional Chinese herbs: possible toxic components. Gut. 1995; 36:146-7. Google Scholar
    • 72. Kempin SJ. Warfarin resistance caused by broccoli [Letter]. N Engl J Med. 1983; 308:1229-30. Google Scholar
    • 73. Larrey D, Vial T, Pauwels A, Castot A, Biour M, David M, et al. Hepatitis after germander (Teucrium chamaedrys) administration: another instance of herbal medicine hepatotoxicity. Ann Intern Med. 1992; 117:129-32. Google Scholar
    • 74. Roberts IF, West RJ, Ogilvie D, Dillon MJ. Malnutrition in infants receiving cult diets: a form of child abuse. Br Med J. 1979; 1:296-8. Google Scholar
    • 75. Sherlock P, Rothschild EO. Scurvy produced by a Zen macrobiotic diet. JAMA. 1967; 199:794-8. Google Scholar
    • 76. Kamb ML, Murphy JJ, Jones JL, Caston JC, Nederlof K, Horney LF, et al. Eosinophilia-myalgia syndrome in L-tryptophan-exposed patients. JAMA. 1992; 267:77-82. Google Scholar
    • 77. Hertzman PA, Blevins WL, Mayer J, Greenfield B, Ting M, Gleich GJ. Association of the eosinophilia-myalgia syndrome with the ingestion of tryptophan. N Engl J Med. 1990; 322:869-73. Google Scholar
    • 78. Vitamin preparations as dietary supplements and as therapeutic agents. Council on Scientific Affairs. JAMA. 1987; 257:1929-36. Google Scholar
    • 79. Megavitamin and megamineral therapy in childhood. Nutrition Committee. Canadian Paediatric Society. Can Med Assoc J. 1990; 143:1009-13. Google Scholar
    • 80. Taylor GD, Turner AR. Cutaneous abscess due to Nocardia after “alternative” therapy for lymphoma. Can Med Assoc J. 1985; 133:767. Google Scholar
    • 81. Oliver LD, Mehta R, Sarles HE. Acute renal failure following administration of ethylenediamine-tetraacetic acid (EDTA). Tex Med. 1984; 80:40-2. Google Scholar
    • 82. Powell FC, Hanigan WC, Olivero WC. A risk/benefit analysis of spinal manipulation therapy for relief of lumbar or cervical pain. Neurosurgery. 1993; 33:73-9. Google Scholar
    • 83. Fast A, Zinicola DF, Marin EL. Vertebral artery damage complicating cervical manipulation. Spine. 1987; 12:840-2. Google Scholar
    • 84. Lee KP, Carlini WG, McCormick GF, Albers GW. Neurologic complications following chiropractic manipulation: a survey of California neurologists. Neurology. 1995; 45:1213-5. Google Scholar
    • 85. Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH. Spinal manipulation for low-back pain. Ann Intern Med. 1992; 117:590-8. Google Scholar
    • 86. Haldeman S, Rubinstein SM. Cauda equina syndrome in patients under-going manipulation of the lumbar spine. Spine. 1992; 17:1469-73. Google Scholar
    • 87. Assendelft WJ, Koes BW, van der Heijden GJ, Bouter LM. The efficacy of chiropractic manipulation for back pain: blinded review of relevant randomized clinical trials. J Manipulative Physiol Ther. 1992; 15:487-94. Google Scholar
    • 88. Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG. Manipulation and mobilization of the cervical spine. A systematic review of the literature. Spine. 1996; 21:1746-59. Google Scholar
    • 89. Coulter I, Hurwitz E, Adams A, Meeker W. The Appropriateness of Spinal Manipulation and Mobilization of the Cervical Spine: Literature Review, Indications and Ratings by a Multidisciplinary Expert Panel. Santa Monica, CA: RAND; 1995. Google Scholar
    • 90. Friedman RA. “Natural” doesn't mean safe [Editorial]. The New York Times. 19 April 1996:A29. Google Scholar
    • 91. Russell FE, Carlson RW, Wainschel J, Osborne AH. Snake venom poisoning in the United States. Experiences with 550 cases. JAMA. 1975; 233:341-4. Google Scholar
    • 92. Epstein WL. Plant-induced dermatitis. Ann Emerg Med. 1987; 16:950-5. Google Scholar
    • 93. de Smet PA, Keller K, Hansel R, Chander RF, eds. Adverse Effects of Herbal Drugs. Berlin: Springer-Verlag; 1993. Google Scholar
    • 94. Newall CA, Anderson LA, Phillipson JD. Herbal Medicines: A Guide for Health-Care Professionals. London: Pharmaceutical Pr; 1996. Google Scholar
    • 95. Blumenthal M, Hall T, Rister R, Gruenwald J, Riggins C, eds. Klein S, Gruenwald J, Rister R, translators. Commission E Monographs. Austin, TX: American Botanical Council; 1996. Google Scholar
    • 96. Wilkinson JA. The internet as a research and information tool for herbal medicine. British Journal of Phytotherapy. 1995; 4:34-45. Google Scholar
    • 97. ter Riet G, Kleijnen J, Knipschild P. Acupuncture and chronic pain: a criteria-based meta-analysis. J Clin Epidemiol. 1990; 43:1191-9. Google Scholar
    • 98. Patel M, Gutzwiller F, Paccaud F, Marazzi A. A meta-analysis of acupuncture for chronic pain. Int J Epidemiol. 1989; 18:900-6. Google Scholar
    • 99. Kleijnen J, ter Riet G, Knipschild P. Acupuncture and asthma: a review of controlled trials. Thorax. 1991; 46:799-802. Google Scholar
    • 100. ter Riet G, Kleijnen J, Knipschild P. A meta-analysis of studies into the effect of acupuncture on addiction. Br J Gen Pract. 1990; 40:379-82. Google Scholar
    • 101. Kleijnen J, Knipschild P, ter Riet G. Trials of homoeopathy [Letter]. BMJ. 1991; 302:316-23. Google Scholar
    • 102. Reilly D, Taylor MA, Beattie NG, Campbell JH, McSharry C, Aitchison TC, et al. Is evidence for homoeopathy reproducible? Lancet. 1994; 344:1601-6. Google Scholar
    • 103. Bigos SJ, Bowyer OR, Braen RG, et al. Clinical Practice Guideline. Number 14. Rockville, MD: Agency for Health Care Policy and Research, U.S. Department of Health and Human Services; 1994. Google Scholar
    • 104. Vickers AJ. Can acupuncture have specific effects on health? A systematic review of acupuncture antiemesis trials. J R Soc Med. 1996; 89:303-11. Google Scholar
    • 105. Glock M, Friedman R, Myers P. National Institutes of Health Technology Assessment Statement. Integration of Behavioral and Relaxation Approaches into the Treatment of Chronic Pain and Insomnia. Bethesda, MD: National Institutes of Health; 1995; NIH publication no. PB96113964. Google Scholar
    • 106. Carron H, Epstein BS, Grand B. Complications of acupuncture. JAMA. 1974; 228:1552-4. Google Scholar
    • 107. Rampes H, James R. Complications of acupuncture. Acupuncture in Medicine. 1995; 13:26-33. Google Scholar
    • 108. Cheng TO. Acupuncture and acquired immunodeficiency syndrome [Letter]. Am J Med. 1989; 87:489. Google Scholar
    • 109. Kent GP, Brondum J, Keenlyside RA, LaFazia LM, Scott HD. A large outbreak of acupuncture-associated hepatitis B. Am J Epidemiol. 1988; 127:591-8. Google Scholar
    • 110. Slater PE, Ben-Ishai P, Leventhal A, Zahger D, Bashary A, Moses A, et al. An acupuncture-associated outbreak of hepatitis B in Jerusalem. Eur J Epidemiol. 1988; 4:322-5. Google Scholar
    • 111. Stryker WS, Gunn RA, Francis DP. Outbreak of hepatitis B associated with acupuncture. J Fam Pract. 1986; 22:155-8. Google Scholar
    • 112. Vittecoq D, Mettetal JF, Rouzioux C, Bach JF, Bouchon JP. Acute HIV infection after acupuncture treatments [Letter]. N Engl J Med. 1989; 320:250-1. Google Scholar
    • 113. Angell M. Disease as a reflection of the psyche [Editorial]. N Engl J Med. 1985; 312:1570-2. Google Scholar
    • 114. Sale JD. Overview of Legislative Developments Concerning Alternative Health Care in the United States. Kalamazoo, MI: John E. Fetzer Institute; 1994. Google Scholar
    • 115. Kassirer JP. Adding insult to injury. Usurping patients' prerogatives. N Engl J Med. 1983; 308:898-901. Google Scholar
    • 116. Tresolini CP. Health Education and Relationship-Centered Care. San Francisco: Pew Health Professions Committee; 1994. Google Scholar