Complementary & alternative medicine in practice and policy
Complementary and alternative medicine is a billion dollar business in Canada.
Complementary and alternative medicine is rooted in different philosophies and standards of evidence than mainstream medicine.
Many patients use both systems of medicine.
Complementary and alternative medicine is defined as any medical system, product or practice that is not thought of as a standard of care. There are many complementary and alternative providers and products in Canada, including homeopaths, naturopathic doctors and traditional Chinese medicine practitioners who use products like herbs, homeopathic preparations, and vitamins.
The business of complementary and alternative medicine
Over 5 million Canadians have reported using some form of alternative or complementary health product in the past year. Complementary and alternative medicine is big business in Canada, and is estimated to cost about $2.35 billion per year. Canadians who use these products and services largely pay out of pocket.
These treatments are rooted in a different belief system than the one underlying mainstream medicine. Mainstream medicine is scientifically based and focused on evidence, often using randomized controlled trials to demonstrate the benefits and harms of a treatment or procedure. However, critics point out that many treatments in mainstream medicine have not been rigorously evaluated.
Complementary and alternative medicine is based on tradition and belief, and doesn’t have a strong research tradition or infrastructure. However, the amount of research generating evidence about complementary and alternative medicine is growing. For example, the National Institutes of Health, the primary government research funding agency in the United States, has a center focused on improving the amount and quality of evidence in complementary and alternative medicine.
In spite of the lack of high quality evidence about the benefits and harms of many of these treatments, and the fact that Canadians usually pay for them out of pocket, over 76% of Canadians have purchased natural health products such as vitamins and herbal products, and about 70% of Canadians use these products at least once weekly.
How do these two philosophies of medicine co-exist in Ontario?
The growing use of complementary and alternative medicine has led to a broader regulatory focus on these products and professionals. In 2004, Health Canada created the Natural Health Products Directorate, which has been tasked with regulating natural health products and is supposed to ensure that Canadians have access to safe and high quality products. Similarly, in Ontario, legislation was passed in 2007 to regulate practitioners of traditional Chinese medicine and acupuncture, naturopathic medicine and homeopathy.
Kirsten Smith, a Toronto-based naturopathic doctor sees regulation as an opportunity for naturopathic medicine to gain broader acceptance, saying that “it validates the profession.” However, Heather Boon, a researcher at the University of Toronto and one of the founding chairs of the Canadian Interdisciplinary Network for Complementary and Alternative Medicine Research is concerned about the impact of regulating these groups.
Boon notes that “the big issue is that regulation is supposed to protect the public, and it is still not clear how the colleges, in regulating these groups, will do that.” Boon questions who will bear the costs of setting up expensive, bureaucratic infrastructure for regulation. She says that practitioners will need to recoup the costs of expensive licensing fees, and the big question is “whether costs will increase for patients and end users.”
Acceptance from mainstream medicine?
In spite of the costs, and the lack of information about effectiveness, many Canadians have embraced complementary and alternative medicine, mostly using it in addition to mainstream therapies. Nicholas Ignatieff, a cancer patient who lives near Kingston, Ontario uses naturopathic and homeopathic remedies alongside mainstream chemotherapy treatment for his cancer, saying that “you can tell from the way that you feel that it’s a positive addition to your arsenal, and one that isn’t in conflict with conventional treatment.”
Mainstream medicine, however, has been slower to accept many of these products and practitioners.
Bill Evans, a medical oncologist and president of the Juravinski Cancer Center in Hamilton says that some “patients are afraid to tell their doctors” about the natural health products they are using, or practitioners they are seeing, for fear that “their doctor won’t approve, and at the least will scold them, and at the worst, withhold treatment.” However, it is crucial for doctors to know what treatments patients are using, because there is evidence that some natural products and prescription drugs can interact. In cancer, this is particularly problematic because herbs and vitamins have been found to interact with chemotherapy for about 25% of patients, who are using chemotheraphy in conjunction with herbs and vitamins. Evans believes that doctors need to be asking their patients about their use of these treatments in a way that encourages full disclosure. Evans says that “this conversation, to some extent needs to be less judgmental than it has been.”
There are efforts to provide further guidance to doctors on how to have these conversations, and to learn about their patients’ use of complementary and alternative medicine. For example, the College of Physicians and Surgeons of Ontario is undertaking public consultation to update their policy that outlines how doctors should assess and treat patients using complementary and alternative medicines.
Many Ontarians use both the mainstream and complementary and alternative health care systems at the same time, despite the two systems’ different underlying philosophies and approaches to evidence.
Ontarians avidly use the services of mainstream medicine and demand increasingly “high tech” tests and treatments. However, at the same time they are also skeptical about some of the claims of mainstream medicine. The skepticism is partly driven by well-publicized examples of unexpected harms of treatments like Vioxx and hormone replacement therapy, as well as the continued burden of diseases like multiple sclerosis and some cancers, which have established treatments, none of which work for all patients, and many of which come with a myriad of undesirable side effects.
Despite their skepticism of some of the claims of mainstream medicine, patients are increasingly willing to use complementary and alternative medicines, many of which have little evidence to support their impact on health outcomes. Many patients, however, are unconcerned about the lack of scientific evidence, and instead focus on historical experience. Ignatieff says “when you to turn to traditional Chinese medicine you are impressed that this is a huge global population that has used this approach for millennia.”