Alternative medicine ain't disco

What nostrums are your patients taking? If you don't know, you won't be able to help them.

By Tom Richards, MD
Family Physician/Sheridan, WY

How many pills?" I asked a patient I'll call Ed Moore. I'd been called to the ED to evaluate his chest pain.

"Twenty three—almost a meal in themselves," Ed answered with a wry smile.

I smiled back, glancing at my notes for details. "So, you stopped taking the pills your doctor prescribed: the two for your blood pressure, one for your heart failure, and one to thin your blood? And you replaced them with these herbal supplements?"

Ed nodded uncomfortably.

"And this was about three weeks ago?"

"Yeah. A friend of mine lent me this tape on herbal medicine. The guy on the tape said that doctors are just in it for the money, and I'd be better off taking these supplements because they're natural—not chemicals." He paused, looking at the floor, and said, "Now I think maybe he's the one who's just in it for the money. I guess I should have known better."

I shrugged. In these situations, I usually launch into my standard lecture about untested medicines sold by people whose main motivation is cash rather than cure. I remind my patients that many of our most effective medicines come from natural sources, but are purified and quantified to maximize their therapeutic power and minimize side effects. Some people consider these medicines man-made "chemicals," and therefore somehow inferior to their "natural" unaltered precursors. What's lost in this reasoning is that everything we see, touch, and feel is a chemical of some sort. There isn't a known substance that isn't basically composed of elements from the periodic table.

Touting alternative medicine as "natural" and "safe"

The marketers of many alternative therapies want the public to equate their nostrums with the words "natural" and "safe." It's a good strategy, even though it isn't always true. They spend an enormous amount of money to promote herbs and supplements, but very little to test their validity or explore their hazards. These products are classified as foods, not medicines, and aren't regulated as such by the FDA. Imagine all the money the pharmaceutical companies could save if they didn't have to test their drugs before applying for FDA certification.

The marketing worked on Ed Moore but the herbal supplements didn't. His congestive heart failure had worsened, he was no longer anticoagulated, and his blood pressure was uncontrolled. Whatever else those supplements had done for him, they weren't treating his cardiovascular pathology.

Ed's chest pain turned out to be new onset unstable angina, and he ended up having a multivessel bypass. I still don't know whether his cardiac problems were the result of not taking his prescribed medicines, or some effect from the supplements, or perhaps just coincidence. I didn't even ask what herbs and supplements Ed was taking, since I wouldn't have known what to do with such information anyway. Worse still, I wasn't willing to figure it out. Basically, I was just being lazy. As a result, I missed the chance to learn from my best teacher—my patient.

What to say when confronted by patients with "vitamania"

I dismissed Ed's case as just one more example of "vitamania." I don't know how many times patients have asked me about herbs and supplements, or how many have come to the office with copper bracelets on their wrists or magnets in their shoes. My typical response has been: "I can't tell what this therapy will or won't do. It's never been well studied." I warn patients about the potential for adverse interactions with other previously prescribed medicines.

But until I met Ed Moore, I'd never told my patients about the importance of continuing their prescribed medications even if they chose to go the "natural" route. It never occurred to me that they would just stop their medicines when they started using herbs and supplements. But a lot of people apparently do just that.

They won't tell you they've stopped, however. They'll nod and smile, then go their merry way. And they won't bring the subject up again. When that happens, we lose an opportunity, and quite possibly a patient. If they're really determined to try the supplements, they'll simply find another physician who will support that decision. Our patients and our profession deserve a better answer from us than, "I don't know."

Waiting for the alternative medicine fad to pass won't work. This isn't disco; we won't wake up one morning to find that the herbal circus has left town. It's here to stay. Our patients want to use alternative medicines, and they expect us to advise them knowledgeably. After all, that's what they pay us for—our knowledge and our advice. If we insist on leaving a void in that knowledge, we aren't doing our jobs.

Like every challenge in life, however, this one has a built-in opportunity: a chance for us to focus on prevention as well as treatment, and to open our minds and our practices to new ideas. It won't be easy. In fact, I can already hear the groans from my colleagues wondering, "Where am I going to find time for all that? I can hardly keep up with all the new research as it is."

You'll find the time where you find it for everything else: in little bits here and there. I've chosen to take the time to learn, not be-cause I need one more thing to fill my free time, but because I really don't see any alternative.

For more information

You'll find useful information on dietary and herbal supplements on audiotapes, in journal articles and books, and at medical conferences. Another good source is the PDR for Herbal Medicines, also published by Thomson Medical Economics. Most pharmacy schools now offer courses on herbal medicines and supplements, including drug interactions. So if you're not sure, you can always pick up the phone and consult your local pharmacist.

Finally, there are several good Web sites on alternative medicines and dietary and herbal supplements. Among them: The National Institutes of Health's National Center for Complementary and Alternative Medicine at www.nccam.nih.gov (which has a link called "CAM on PubMed" that lists journal citations); and the FDA's Center for Food Safety and Applied Nutrition at www.cfsan.fda.gov .

Thomas Richards. Alternative medicine ain't disco.

Medical Economics

Mar. 7, 2003;80:90.