Complementary medicine — popular, but full potential
remains untapped
Introducing a symposium on Far Eastern medicine on
September 3, Professor Peter Noyce, University of Manchester, United Kingdom,
described Far Eastern medicine as a significant force for change that
had to be taken into account in planning for and managing change in pharmacy
practice in every country of the world.
Demand growing
The demand for complementary medicine is growing
enormously. According to Dr Tat Leang Lee (National University of Singapore),
a study published in the Journal of the American Medical Association
in 1998 had shown that by 1997, 42.1 per cent of people in the United
States were using at least one form of complementary or alternative medicine,
representing an increase of over 8 per cent from 1990. However, only 38.5
per cent of these individuals disclosed this fact to their doctors.
The growth in popularity of complementary alternative
medicines (CAM) was partly the “fault” of Western doctors, he said. Antibiotic
resistance was but one illustration leading to a situation in which patients
were now increasingly being recommended to “eat this root” rather than
“take a pill”, reverting to a practice which was common as long ago as
2000BC. However, the full clinical potential of CAM remained untapped
in Western countries because Western practitioners knew little beyond
the bare essentials.
Traditional Chinese medicine (TCM), one type of
CAM, could trace its origins to several related traditions of healing
which had developed over the past 5,000 years in China, Japan, Korea and
parts of South East Asia. TCM included acupuncture, traditional Chinese
herbs, diet and nutrition, exercise, stress reduction and lifestyle counselling
and massage (known as tui na). In China, early publications on
herbal medicines appeared during the Shang-Zhou dynasties (2000– 220BC).
The two volume Huang Di Nei Jing (480–220BC) describing the theory and
practice of both internal medicine and acupuncture was thought to be the
earliest medical text in the world.
The earliest known work on Chinese herbs, Sheng
Nung Ben Cao Chien (ca 101BC), covered 365 agents, and some of the entries,
for example, “ginseng strengthens the mentality, relaxes stress”, had
been given some credence as a result of recent scientific investigations.
Later herbal publications followed, with the appearance of the first world
pharmacopoeia in 659AD. TCM continued to develop and after the 1949 communist
revolution, Chairman Mao encouraged its status to be elevated still further
with the establishment of more than 10 traditional medical colleges and
institutions.
The philosophy of TCM rested on the two theories
of yin-yang and the “five elements” (ie, wood, water, fire, metal, earth).
Yin-yang could be applied to the organic structure of the body, its physiological
functions and pathological changes and as a guide to clinical diagnosis.
Because CAM was becoming so popular it was important
to ensure its safety and efficacy, Dr Lee concluded. Issues to be grasped
in relation to its use worldwide included the lack of satisfactory research
on both efficacy and toxicity, lack of standardised treatments, inconsistencies
in training and licensing of practitioners, malpractice liability, professional
guidelines for referral to CAM practitioners and the atmosphere of mistrust
between the medical and alternative medical communities.
Contributing to the future
The next speaker suggested that Chinese medicine
could make a contribution to medicine of the future. The paradigm of current
mainstream pharmaceutical medicine was to identify single compounds that
could regulate a specific target associated with a given disease, according
to Professor Yung-Chi Cheng (Yale University School of Medicine, United
States).
This was fine as far as it went, but it might not
be the ideal approach for identifying medicines for the treatment and
prevention of chronic and age-associated diseases, since many of these
conditions were multifactorial.
In these cases, a combination of compounds with
different modes of action or different target specificities could well
achieve better therapeutic effects. What was needed, in other words, was
a new paradigm for developing medicines, and Chinese medicine (CM) could
make a significant contribution in this field.
Although ideas about disease treatment with CM were
somewhat different from those with Western medicine, integration of these
two approaches could be the most efficient way to develop medicines in
the future, he said.
To achieve such integration, modern science and
technology had to be used to study the action, efficacy and toxicity of
Chinese medicines. Thus, botanicals should be defined, authenticated and
documented as to their source and conditions of cultivation using modern
methodology. Manufacturing and preparation processes of Chinese medicines
should be carefully monitored and standardised. Claims for CM should be
verified from rigorous controlled trials. Interactions between Western
and Chinese medicines should be better studied and information obtained
centralised into accessible databases.
Further necessary issues to be addressed to advance
CM included introducing the medical establishment to the philosophy, principles
and practice of CM using modern scientific terminology.
This would be an enormous undertaking requiring
international collaboration and participation of governments worldwide.
For areas of the world that already had a strong focus on CM, government
and private enterprise had a moral responsibility to ensure the health
of their populations by improving the quality and verifying the effectiveness
of such medicines. And for those areas not familiar with CM, serious effort
should be made to take advantage of the knowledge already accumulated
to help improve treatment of those conditions unmet by current medicine.
Finally, CM should not be ignored as a potential
source for new medicines for mainstream use.
Safety — obtaining the evidence
In his presentation, Professor Paul Pui-Hay But
(Chinese University of Hong Kong) explained how the evidence for efficacy
and toxicity for TCM was obtained, from both “traditional” and more modern
“scientific” sources.
Information on the identity, therapeutic functions
and toxicities of a wide range of compounds appeared in written records
dating back thousands of years. Modern scientific research on the safety
of these compounds had generally confirmed these earlier empirical findings
as well as the validity of the various curing methods that were used for
reducing toxicity.
However, there were several limitations with the
traditional approach to obtaining evidence in that observations of toxicity
tended to be incomplete, inconsistent and possibly biased, and the variability
in content of herbal medicines made interpretation difficult. Chronic
toxicity due to prolonged use was rarely documented, and although it was
apparently minimised by continually changing the prescription to suit
the individual patient, this made the study of adverse reactions difficult.
In addition, mutagenic or carcinogenic properties of herbs were not recorded.
More modern “evidence-based” studies were conducted
from time to time by interested parties but information gathered tended
to be scattered, duplicated and often questionable as to its thoroughness
and reliability. The Chinese were currently directing efforts to improving
control of good agricultural practice, good clinical practice and good
manufacturing practice for CM and had developed various targets for this.
Adverse reactions to TCM fell into several categories,
notably use of the wrong herb, poor quality, excessive dosage, prolonged
use, contamination with Western pharmaceuticals, errors by patients and
practitioners and idiosyncratic responses. Many of these problems could
be avoided by proper regulation and training and special effort should
be made to document the chronic toxicity of TCMs and their interactions
with Western medicines, he concluded.
Education
The final speaker suggested that there was a huge
variation in US education of pharmacists on complementary medicines. Professor
Siu-Fun Wong (Western University of Health Sciences, California) said
that a 1997 survey had shown that only 4 per cent of consumers obtained
their information on herbal products from pharmacists.
Friends and family were an important source of information
for 41 per cent of consumers, and now, if the survey were to be repeated,
the internet would be a significant source. However, the quality of information
on the internet was often suspect and pharmacists could help interpret
it.
To provide information, pharmacists had to be educated
and trained, and the popularity of CAM had led to increased interest among
schools of pharmacy in the subject. Nevertheless, a 1997 survey found
that 13 of 60 schools responding to a questionnaire reported that herbal
products were not discussed at all, with a 1998 survey showing similar
results in 13 out of 50 schools. Among the schools which responded in
the latter survey, there was a big variation in the number of contact
hours for both herbal and CAM instruction ranging from 1.5 to 67 hours
among 36 of the 50 schools.
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