Medical Library
Evaluating Alternative Medicines
by Steven Brown, M.D., Ph.D.
©2008
Bob just found out he has high blood pressure. His doctor recommended medication, but Bob wonders what his other options might be. He sits down at his computer and types “high blood pressure cures” into his search engine.
“Hmmm… 500,000 hits,” he groans.
As he starts to open them in new tabs, he finds that many offer amazing results. Could it be true that taking a proprietary blend of 30 different natural substances would lower his blood pressure as well as a prescription drug, but with no side effects?
An engineer by training, Bob knows enough to be skeptical. Still, he wonders how to wade through these claims. He hopes there is an easy answer.
What principles will allow him to understand the alternative medicine options? Here are six tips that will help him. The first gives a lot of the required background, so it will take longer to process. Read it patiently. The other five tips will make more sense and be easier to execute if you understand the first.
- Understand the history of medicine: Thousands of years of failure and one hundred years of success. “Those who forget the lessons of history are doomed to repeat it.” What is the history of conventional medicine? What is the history of alternative medicine?
Until the 20th Century, doctors chose treatments based on ideas, traditions, and random observations, without much true scientific research. We now know that many of these treatments were harmful. An obvious example is bleeding: from the time of ancient Greece, doctors took blood from people with fevers. As you probably already know from your history class, this treatment may have hastened George Washington’s death. The practice continued into the 19th Century.
When scientific scrutiny became a part of medicine, doctors were able to develop effective treatments, and abandon these older, ineffective approaches. As a result, life expectancy increased by 30 years during the 20th Century.
Today, the randomized controlled trial is the centerpiece of medical investigation. In such a trial, investigators randomly assign people with a disease to one pill versus another. The doctors record all outcomes, both positive and negative. They then analyze the results statistically. Neither the doctors nor the patients can know who is getting the old drug or the new drug until after the experiment is complete. This rule balances psychological effects in the patients, and prevents bias on the part of the scientists. Why go to all this trouble? Because all treatments have risks, and no treatment works for everybody.
All medications will hurt some fraction of the people who receive them. Even an aspirin has some risk of causing stomach ulcers. For medicines used to treat high blood pressure, harmful side effects need to be less than one in a hundred, or no one will prescribe the medicine. For medicines used to treat serious conditions, like cancer, 90% of people may have side effects from a particular chemotherapy, but we tolerate the side effects to get rid of the cancer.
Effectiveness of any medicine is also less than 100%. A blood pressure medicine or an antibiotic may work for 80% of those who take it. On the other hand, if there are no good alternatives, a chemotherapy drug may be reasonable even if it only works for 30% of those with a particular cancer.
The principles here are that 1) any medicine strong enough to help will also be strong enough to have some risk of harm, and 2) no medicine works for everybody. Only by looking at enough people, and gathering as much information as possible, can we understand the pros and cons of a treatment. The fact that another civilization used a product for thousands of years should not inspire confidence. And a study done in only 10 people might be enough to raise our interest, but it is not adequate to determine if a product is safe or effective.
When the FDA considers an application for a drug, they review the evidence of risk and benefit from randomized controlled trials, typically involving thousands of patients. Despite this scrutiny, too often, the FDA has to pull a drug off the market after only 6 months. Why? Usually it is because the side effect has a lower incidence than one in thousand. A study in 2000 people may not reveal such an adverse effect. But when the drug is released to the market and used in two million people, the problem becomes obvious.
In 1994, the Drug Supplement Health and Education Act created a new category of “nutritional supplements.” Congress exempted these products from FDA review for safety and effectiveness. As a result, the FDA does not regulate even popular products like glucosamine and Echinacea the way they regulate over the counter medications. In fact, regulation on food dyes is stricter than regulation on alternative medicines.
How do we know that alternative medicines are safe or effective? For the most part, we don’t. Most of the studies done on these products have involved only small numbers of patients. Unfortunately, the few large studies done on supplements have been disappointing. For example, Echinacea did not work for colds, and glucosamine did not work for arthritis of the knee. There have also been cases when supplements caused great harm, as with the weight loss supplement, ephedra, that killed Baltimore Orioles pitcher Steve Bechler. Still worse, studies have demonstrated that contamination of these products with poisonous metals and conventional pharmaceuticals is all too common.
In the same way that doctors should not believe everything drug companies tell them about their products, you should not believe everything supplement companies tell you about theirs.
Now that you understand the history of these products, let’s talk about how to get information for yourself.
- Ask your doctor. Your doctor will know more than you might think about alternative medicine products that have some evidence of effectiveness. Like anyone else, doctors are fascinated by the idea that a simple, folk-tradition product may be helpful. Mainstream medical journals enthusiastically publish large studies on alternative medicines (unfortunately, so far, most of these studies have been disappointing). In addition, these products now form a multi-billion dollar industry. You can be sure other patients are asking about these treatments.
On the other hand, there is an increasing awareness of the risks of these products. Researchers also discover new interactions between alternative and conventional medicines every week. If you are taking any conventional medications, you should talk to your doctor before you try an alternative product.
- Have realistic expectations. If something sounds too good to be true, it probably is not true. If a website claims to have “secret” information that is either unknown to your doctors or suppressed by the medical establishment in a great conspiracy, be skeptical.
When evaluating claims on websites, be sure that references are included. The references should include the names of the authors, the name of the journal, and the date and page numbers where the article appeared. The absence of references should be a big red flag. Any reputable scientific report will contain references to the original articles.
A favorite trick of disreputable sites is to say that “Harvard University” or “The Mayo Clinic” found that a product works. Scientific institutions do not make claims about products. Individual researchers at these places study treatments and give reports in medical journals. These reports are always complicated, showing pros and cons, and explaining the limitations of the research. What a particular researcher said at Harvard 50 years ago has nothing to do with mainstream thought at Harvard today.
- Do an internet search using the product name and the word “safety.” This type of search will help you learn about harmful effects of the product you are considering. As we discussed above, any substance strong enough to have a positive effect on your body will also have some risk of harm. The question is not, “Does this product have potential side effects.” The question is, “What are the potential side effects of this product?” In many cases, the potential side effects are unknown, because no one has studied the product adequately. However, if there are known dangers, you want to find out before you take the pill into your body.
- Search these three websites for your product. The Quack Watch website is an excellent source of information about alternative treatments. The articles on this site are readable and well researched. They cite references in the medical literature so you can read the original research for yourself if you wish.
As it turns out, a relatively small group of charlatans promote many alternative medicine scams. The Quack Watch website documents the background, previous legal troubles, and previous hoaxes of some of the individuals who prey on the sick and vulnerable.
The National Center for Complementary and Alternative Medicine (NCCAM) operates another must-review website. This entity is within the National Institutes of Health, and exists to promote research and information about alternative medicine. Since it is a political entity, the information is not as straightforward as that on Quack Watch. For example, if you search under “bitter orange,” you learn that this product has been reported to cause “heart attack and stroke in healthy people.” It also explains that it is similar, both chemically and as a drug, to ephedra, which was taken off the market. Nonetheless, the site then offers only the relatively mild suggestion that this product “may not be safe to use.”
A third excellent source of information is the Mayo Clinic site. This site devotes a specific section to alternative medicine. It even gives letter grades to various treatments. Unfortunately, like the NCCAM site, grade inflation is a major issue. Read the information critically and skeptically.
- Find a safe supplier. Since they are not adequately regulated, alternative medicine products may not contain what the label claims. Still worse, poisonous substances and conventional pharmaceuticals often contaminate alternative medicines. Although new regulations started a two-year phase-in beginning in June 2008, experts warn that these regulations will not correct the problem. Because of the purity issue, companies such as ConsumerLab.com have started as watchdogs to analyze alternative medications. The United States Pharmacopeia (USP) also has a verification program. If you decide to take an alternative medicine, be sure to use these organizations to find a safe supplier.
After understanding these principles, Bob decided to go back to his doctor and just ask him about alternative approaches.
“Bob, there are a couple of approaches that do not involve conventional pharmaceuticals that help. As we already discussed, exercise and a low salt diet help. Calcium and magnesium supplements work, but they only lower blood pressure by 2 or 3 points. Biofeedback also typically provides only a small improvement, and the improvement is usually temporary. Since your blood pressure is already 15 points over goal, these approaches will probably not be enough for you. Other so-called ‘alternative’ treatments do not have adequate evidence of safety or effectiveness at this point.”
“Doc, I really don’t want to take medicine if I have a choice.”
“Remember, ‘alternative medicines’ are medicines, too. The main difference is the amount of research that backs them up. We had already talked about giving you 6 months to exercise, lose weight, and minimize your salt intake to see how you do without medicine. If you want to add calcium and magnesium to this approach, that would be great. But let’s suppose that you come back in 6 months, and your blood pressure is still 155/90. Remember that life expectances increased by 30 years during the 20th Century. A big part of the improvement involved preventive strategies like blood pressure control. Frankly, I don’t like pills, either. But I do like the idea of living longer, and reducing your risk of stroke.”
“So do I, doc. So do I.”
If you want to learn more about this topic, my book Navigating the Medical Maze has a big section on how to evaluate alternative medicine. I also have an article in the online magazine Faith and Fitness that goes through this specific approach to evaluating an alternative product, and gives three specific examples. You can read the article here.