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Tuesday, June 11, 2013

Alternative, Holistic and Integrative Medicine: Definitions and Safety Considerations

Recently a patient of mine brought in a bottle given to her by her acupuncturist. She had turned to acupuncture with my encouragement after traditional medicine fell short at addressing her chronic pain. Indeed, there is data to support the efficacy of acupuncture in the management of chronic pain . I was encouraged to hear that this treatment, often labeled as “alternative,” seemed to be helping her substantially. 

However, my patient’s questions had to do with the ingredients of the herbal medication she was given  to help with weight loss and phlegm-- a potpourri of botanicals translated from Chinese to English. She asked for my assessment and blessing, reminding me that I was a self-proclaimed “holistic” doctor. Quickly I scanned the product’s label. It contained, among other things, Raphanus Semen, something I immediately felt that I personally would not care to ingest. Despite my initial concern, I promised to research the herbal supplement to the best of my ability.  Later, I discovered that Raphanus Semen was radish seed, which at least seemed less disgusting than what I had imagined.
This patient interaction brought to light two topics worth discussing:
1.       What is meant by “Holistic Medicine?”

2.       How does one assess the safety of complementary and alternative therapy, and more specifically, of botanicals and natural supplements?
I am fairly certain that “holistic” does not carry the same meaning to me as it does to many Americans.  In my view holism in medicine implies having a whole person view.  That is, seeing each patient, not just as a constellation of physical symptoms to diagnose and treat, but also within their psychosocial context.   After all, a person’s unique psychology and cultural background determine how he or she reacts to physical illness, diagnosis, medical advice, and treatment prescribed.  A doctor who makes attempt to understand these parts of his or her patients is apt to be more successful at treating them. However, most Americans tend to think of a “holistic doctor” as one who is well-versed in alternative therapies and who bucks standardized approaches endorsed by the medical establishment, including the pharmaceutical industry and the FDA.   This is not true of my practice, though I am aware of the existence of bias and limitation within the scientific process.
As of late, the term “Holistic Medicine” has actually become antiquated and has been replaced by the contemporary field of “Integrative Medicine.” As defined by the wise Dr. Andrew Weil, one of its best known proponents:
Integrative Medicine is healing-oriented medicine that takes account of the whole person (body, mind, and spirit), including all aspects of lifestyle. It emphasizes the therapeutic relationship and makes use of all appropriate therapies, both conventional and alternative.”
By this description I am an advocate of Integrative Medicine, though, the key point here is “use of all appropriate therapies.”  The unfortunate truth is that many physicians who profess to practice Integrative Medicine treat multiple diagnoses that are not at all well-established by science, for example, “adrenal fatigue.” In addition, many advocate use of products that lack sufficient evidence for safety and efficacy, for example DHEA or bio-identical hormones, and disavow standard FDA approved drugs for unclear reasons.  This business too can be a money-making operation, as some of these physicians do not bill health insurance for their services, run a multitude of diagnostic lab tests of uncertain significance, and may even sell their non-approved “natural” products for significant profit.
Which complementary and alternative therapies are safe and reasonable to try? There are a number of resources that can help to guide both doctors and patients, such as NIH’s National Center for Complementary and Alternative Therapy page on Herbs at a Glance. Unlike prescription drugs, the manufacturers of medicinal herbs and botanicals are not required to prove the safety and efficacy of their products prior to marketing them.  In addition to the definite possibility that these substances might be ineffective, there are two major safety considerations--their potential for causing drug interactions and the risk of product contamination. If you are researching for negative reports on a particular substance you may find the NIH's index "How Safe is this Product or Practice?" to be useful. 
In the case of my patient, she is on a fairly long list of medications for several serious health conditions.  For example, she has a history of pulmonary embolus and also has an inherited condition that makes her prone to clotting. For this she takes a blood thinner. Her other drugs include strong pain medications and several psychotropic drugs with narrow therapeutic indices. My immediate concern was for the possibility of botanical-drug interactions, which might increase or decrease levels of her prescription drugs and cause toxicity or adverse medical events.
It turns out that my research was unable to shed light on any reliable information whatsoever about Raphanus Semen, nor the remaining six ingredients of the herbal medication that she showed me. I was left to shrug my shoulders and advise her, in this case, “probably not a good idea.”  On the other hand, I support the use of acupuncture for chronic pain and have been known to advise melatonin for sleep, probiotics for various digestive ails, and even strontium for osteoporosis.