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Professor Ernst is from the Department of Complementary Medicine, School of Sport Medicine and Health Sciences, University of Exeter.
Correspondence to: E. Ernst, MD, PhD, Department of Complementary Medicine, University of Exeter, 25 Victoria Park Rd, Exeter EX2 4NT, United Kingdom, e-mail: E.Ernst{at}exeter.ac.uk
In this issue of CHEST (see page 1461), Blanc et al report the results of a California survey showing that, in 1999, the 1-year prevalence of "alternative therapy" (AT) usage by patients suffering from asthma or rhinosinusitis was 42%. This figure exactly matches the 1-year prevalence figure determined in 1997 for the general population of the United States.1 In the survey by Blanc et al, the most frequently used oral treatments were ephedra, Chinese herbal mixtures, and caffeine products.
Should these findings worry us? Safety concerns exist particularly in relation to ephedra and Chinese herbal mixtures. Ephedra has been linked with serious cardiovascular and neurologic problems, including 10 recent fatalities.2 Chinese herbal mixtures have been associated with direct toxicity, adulteration by conventional drugs, contamination by heavy metals and other toxic compounds, as well as misidentification of plant material.3 Most ATs are self-prescribed, and Blanc et al show that many patients take conventional drugs concomitantly. We also know that many patients do not readily disclose their AT use to their doctors.1 Blanc et al also suggest that, in some cases, ATs are not used as an adjunct but as true alternatives to conventional care. These circumstances make adequate supervision of AT use through physicians unlikely and render herb/drug interactions a distinct possibility.4 It is obvious, therefore, that the findings of Blanc et al are of concern to chest physicians and other health-care providers.
Why are so many of our patients keen to try ATs? This apparently simple question cannot find an easy answer. There are numerous "push" and "pull" factors and different patient populations will have different reasons.5 Dissatisfaction with orthodox medicine is often cited, but this is probably less important than one intuitively thinks.6 Desperation might be a more important contributor in certain cases. Pull factors are philosophical congruence with AT, the desire to have personal control over health care, and the promise of time, empathy, and understanding offered by providers of ATs.5
Is the presently frantic adoption of ATs by our patients all bad news, or do some of these treatments convey real benefits to our patients? We recently conducted a series of in-depth systematic reviews of the clinical trial evidence for or against ATs in relation to asthma (and numerous other conditions).5 In relation to asthma, we found clearly negative (proof of ineffectiveness) evidence for chiropractic spinal manipulation, discouraging evidence for acupuncture, and unequivocal evidence for yoga, relaxation therapies, homeopathy, and autogenic training. But there were also encouraging trial results, namely for biofeedback, breathing exercises, Chinese herbal medicine, hypnotherapy, massage therapy, and meditation. Unfortunately for many of these treatments, the level, volume, and quality of the evidence were not sufficient to be compelling. Moreover, it seems important to point out that the ATs classified as encouraging were not usually curative but were aimed at alleviating symptoms and at improving quality of life.
How does this evidence compare to the information our patients are regularly exposed to? To answer this question, we extracted the asthma-related recommendations offered in seven leading lay books on "alternative" medicine.5 The results are as surprising as they are disquieting. No less than 117 different ATs were recommended as treatments for asthma. There is little doubt, therefore, that our patients are being seduced into using unproven, often untested, and sometimes disproven treatments for their asthma. There is even less doubt that a considerable gap exists between the hard evidence and the promotional information available on ATs.
So, what can be done to ease the problem and increase consumers’ safety? First and foremost, it seems obvious that this area must be investigated with rigor, backed up by adequate expertise and funds.7 But this research will take years, and we clearly need to act now. Doctors should take note that many of their (asthma) patients use ATs. In pointing out this fact very clearly, the work of Blanc et al has perhaps its primary importance. Doctors also should actively ask their patients about AT use; simply hoping they will tell the full story does no longer suffice. Furthermore, physicians need to understand the motivations of patients using AT.5 This will make it easier for them to adequately deal with the complex issues involved. A high-handed, dismissive approach, which we are so easily capable of, is clearly counterproductive. It would simply confirm some of the patients’ attitudes that led them to using ATs in the first place. Honesty and clarity, it seems, are preferable. These qualities entail objectively and dispassionately explaining the facts about efficacy and safety of ATs. But this also means that physicians have to take the phenomenon of complementary or alternative medicine seriously and acquaint themselves with the existing evidence.5 The notion that no trial data exist in this area is as prevalent among skeptics as it is wrong.
Many asthma patients feel caught between their physicians’ ignorance about ATs and a flood of misleading information from sources ranging from the Internet to lay literature. In the interest of their safety, of optimal health care, and of simple honesty, it is time that we start clearing up this profoundly confusing and potentially dangerous mess.
References
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