La Jolla Whole Health Clinic
February 12, 2008
I t's a national success story: Integrated medicine has truly arrived. A recent major news magazine cover says: "Top hospitals are now embracing such unconventional techniques as acupuncture, homeopathy and energy healing." Sadly, one journalist wants you to be very afraid of this very important movement that has the potential to significantly reduce medical costs and improve the health and wellness of our nation.
In the cover story for its January 21, 2008, issue, U.S. News & World Report health and medical writer Avery Comarow reports on the nationwide trend toward including complementary and alternative medicine (CAM) in hospital care and mainstream medicine. It has an upbeat title -- "Embracing Alternative Care: Top Hospitals Put Unorthodox Therapies Into Practice" -- but really the article is a thinly veiled CAM-slam. Heavy-handed and bordering on journalistic sensationalism, Comarow's piece is replete with erroneous research conclusions about CAM and sweeping omissions on its documented benefits and efficacy.
While the article seems to debate the scientific evidence behind CAM therapies, Comarow reports, "All 18 hospitals on U.S. News's most recent 'America's Best Hospitals' super-selective Honor Roll provide CAM of some type. Fifteen of the 18 also belong to the three-year-old Consortium of Academic Health Centers for Integrative Medicine, and 36 US teaching hospitals are pushing to blend CAM with traditional care." Can all of these elite centers, the emblems of Western medicine, be wrong? To find out, I went to an expert who is highly knowledgeable about CAM treatment modalities, naturopathic physician Mark A. Stengler, ND. His take: The trend speaks for itself -- if mainstream medicine is embracing CAM, it's for good reason.
WHAT COMAROW SAYS ABOUT CAM
Throughout the article, Comarow swims against the strong currents of CAM acceptance among America's premier hospitals and academic medical centers. He employs the old journalistic tactic of using words and phrases intended to shock or disturb his readers. Right from the get-go, the article's title contains the word "unorthodox" to mean "unconventional" therapies. Most telling about the U.S. News article's intentions is the usage of loaded language about CAM and the "thicket of therapies deemed to fall within CAM's broad reach"... citing "at one extreme" yoga and massage as having "some benefit, if only to lower stress and anxiety" and at the other end, therapies that "even many who applaud CAM's newfound academic popularity call 'woo-woo medicine' because of the sheer implausibility of their rationale," such as homeopathy. In what he calls "the broad middle," Comarow puts acupuncture, herbal medicine and "other CAM approaches that seem to benefit some people with certain conditions." In a dismissive review of CAM's history, he likens CAM's presence in academic centers before the mid-1990s to "a pack of scruffy mutts, noisy and unworthy of notice."
Dr. Stengler was shocked at Comarow's blatantly biased treatment of CAM throughout the article, with his selective focus on negativity and avoidance of well-documented CAM therapies. For instance, Comarow is especially critical of homeopathy, and ignores other well-accepted CAM therapies such as chiropractic care.
ERRONEOUS RESEARCH CONCLUSIONS
Public demand for CAM: Comarow disputes the "public's clamor" for CAM services by questioning statistics that support the trend. For instance, he deems as "highly misleading" surveys that show widespread CAM use, such as a 2004 Centers for Disease Control and Prevention (CDC) report that showed 62% of adult Americans had used some form of CAM in the previous year. According to Comarow, "the big numbers" reflect activities such as prayer, meditation and diet-based therapies. A "more selective reading," he proposes, would include yoga (5%), acupuncture (1.1%) and energy therapy (0.5%). Dr. Stengler counters that this view depends on how CAM is defined. When CAM therapies such as natural products (defined as non-vitamin and non-mineral, such as herbs and other products from plants) (18.9%)... deep breathing (11.6%)... chiropractic care (7.5%)... and massage (5%), in the CDC report are factored in, the numbers reflect a strong trend in various other areas of CAM as well. Furthermore, a study published in the Journal of the American Medical Association showed an increase from 36% to 46% in total visits to alternative medicine practitioners, from 427 million in 1990 to 629 million in 1997 -- a number that reportedly exceeded total visits to all US primary care physicians in the same year. A study in Alternative Therapies in Health and Medicine compared surveys on CAM use between 1997 and 2002 and found that over one in three respondents had used CAM in the previous year, representing about 72 million US adults. These numbers have increased since 1997 and 2002 and are now even higher, notes Dr. Stengler.
"Modest" results: Comarow concedes that a few CAM treatments have yielded "at least modest results," such as massage therapy for relieving post-operative pain and acupuncture for relieving discomfort and nausea from chemotherapy, surgery and dental procedures. In Dr. Stengler's view, the premise that a moderate benefit isn't good enough is faulty... especially in view of conventional medical treatments that in some instances yield modest results but have become accepted mainstream therapy, such as drug therapies to treat irritable bowel syndrome, chronic pain, psoriasis, addiction and fatigue. Another example: Cholesterol-fighting drugs such as statins, which continue to be prescribed for post-menopausal women though they don't appear to reduce mortality in this group. Or, more dangerous yet, the mainstream therapies that suppress one symptom only to deliver side effects that require additional treatments.
Nationality of study author bias: In another attempt at undermining CAM, Comarow comments "disconcertingly, some of acupuncture's claimed successes seem related to nationality of study authors," citing a 1998 analysis of 252 published trials in which 51 of the 52 studies conducted by researchers from Asian countries, where acupuncture is uncontroversial, had a 98% success rate. In comparison, "only 53% of the trials run by US investigators showed success." Dr. Stengler attributes some of this difference in success rates to the fact that Asian scientists have more thorough training in acupuncture compared with their US counterparts. Also, in 1997 the National Institutes of Health Consensus Statement stated acupuncture showed efficacy in treating post-operative dental pain and post-operative and chemotherapy-induced nausea and vomiting, and that it may also be useful for headache and low back pain.
DENYING THE EVIDENCE
Comarow states, "The effectiveness of most herbal remedies and supplements is largely an open question, and there are issues of toxicity, side effects and interaction with other medications." Amazed at this comment, Dr. Stengler retorts that Comarow overlooked tens of thousands of well-designed studies that demonstrate the effectiveness of vitamin, mineral and herbal therapies.
Moreover, the toxicity comment is just plain bogus, says Dr. Stengler. He finds that most CAM therapies are safely used by seasoned practitioners. In terms of side effects and risks, even conventional treatments come with those. Pharmaceutical drugs have their own problems, despite rigorous government approval, so let's allow their record to speak for itself. JAMA published an eye-opening report in 1998 that 106,000 hospital patients die each year from adverse reactions caused by prescription drugs. Over-the-counter or non-prescription nonsteroidal anti-inflammatory drugs (such as ibuprofen, aspirin and naproxen) are responsible for about 16,000 deaths each year. In 2005, the FDA received more than 300,000 serious adverse event reports about drugs. In the same year, it received only 500 such reports about dietary supplements.
OTHER BLUNDERS
Placebo effect: Comarow reports that a compelling argument posed by CAM critics is that "the risks of some therapies are real and the benefits illusory -- a placebo effect." Yet Comarow also reported on how the placebo effect can be effective in providing relief from symptoms such as pain. Comarow is trying to infer that much of CAM's success is due to placebo, which is a ridiculous conclusion, says Dr. Stengler. It is always a possibility that a therapy is having a placebo effect, but this is not unique to CAM. The same holds true for conventional therapies such as surgery, psychotherapy and pharmaceuticals. Comarow fell into the trap of thinking that because you can't explain a result, it must not exist. The fact is, we do know a lot about mechanisms behind therapies such as chiropractic, vitamin therapy, massage and others, says Dr. Stengler. He believes Comarow did not do his homework in this area, evident by his lack of interviewing experts in CAM for the article, who would have provided documented mechanisms for many of these therapies along with studies demonstrating efficacy.
CAM "mimics" the natural course of illness: Comarow suggests that CAM gets undeserved credit due to the natural course of chronic problems, which tend to ebb and flow over time. For instance, chronic pain from an arthritic knee or frequent headaches have cycles of remission, and sufferers may attribute the disappearance of pain to CAM therapy rather than the natural progression of the condition. Again, Dr. Stengler counters, the same can be said of conventional medicine, for example, where pain medication is prescribed for arthritic conditions or antibiotics are given for viral illnesses on which they may have no effect. Yet doctors continue to burden patients with the cost and risk of using these drugs.
Wrong definition for naturopath: To those in the field, Comarow's definition of "naturopath" reveals an utter lack of research -- not to mention being a display of naiveté on his part, says Dr. Stengler. Comarow defines these highly trained practitioners as "generally a non-MD who advocates nonmedical aids such as proper nutrition, colonic irrigation... and special water baths to stay healthy without drugs or surgery." Hogwash, retorts Dr. Stengler. Here's the truth about naturopathic doctors or naturopathic physicians (the proper terminology): Like MDs they complete a four-year Bachelors degree in science and then four years of medical school that also includes internship, plus two years of clinical residency. However the naturopathic physician's coursework includes not only the same scientific study of modern diagnostic tests, pharmacology, injection and intravenous therapy and so on as for medical doctors, but also additional training in natural medicine areas that include nutrition, homeopathy, botanical medicine, acupuncture and a variety of mind-body approaches. Also, he should have at least noted that with the greatest number of clinical training hours in these areas, NDs are the most well-trained doctors in the world in CAM, studying both conventional and natural medicine.
Read on for more from Dr. Stengler and the truth about integrative medicine...
