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Need to know: complementary medicine

Professor Edzard Ernst answers burning questions on alternative therapies from GP Dr Richard Stokell

1. My experience is that complementary therapies are not available on the NHS, except for services offered by local enthusiasts. Is this so?

In UK primary care, the supply of complementary medicine in the NHS is indeed patchy. Currently there are no national policy or guidelines on this. Some experts have called for a proper evaluation by NICE while others fear that the evidence base is not sufficiently strong so NICE evaluations would come out against complementary medicine.

There is some evidence that provision does indeed depend on whether there is an enthusiast working towards integrating it into local routine health care. Where complementary medicine is available, one does usually find such a person who drives the agenda forward, and where there is no such enthusiast, patients often cannot have complementary medicine on the NHS. Most experts agree this is far from ideal.

2. Many GPs practise acupuncture after attending only short courses while lay acupuncturists have often studied for several years. How does this affect the range of treatments and success they have in managing patients?

I don't think we can answer that question yet as the data is simply not available. We know, of course, that lay acupuncturists who believe in the traditional complementary medicine 'philosophy' treat practically all conditions while doctor acupuncturists tend to use it for pain management. But who is more successful? Do you need to study the ancient Chinese texts or does a weekend course suffice?

Don't forget that before a doctor went on a weekend course, he/she studied medicine for many years. I would prefer to be treated by a therapist who knows anatomy, physiology, pathophysiology, therapeutics, etc, than by one who is current in Taoist philosophy.

In Germany, researchers recently conducted a series of mega-trials of acupuncture involving about 5,000 patients and hundreds of therapists in total. The investigators conducted post-hoc analyses to determine whether the amount of training had an impact on the clinical benefit. The results indicate that the level of training does not affect the outcome.

3. Which patients should definitely not have acupuncture?

It depends who you ask. An acupuncturist would probably cite the absolute contraindications: bleeding disorder and early pregnancy (curiously this can also be an indication). A more sceptical person might insist that acupuncture should only be considered for patients who suffer from those conditions for which it is demonstrably effective ­ and those are the ones listed in the table overleaf.

4. Many GPs recommend glucosamine for osteoarthritis after promising results from two small-scale trials. Has the evidence become any stronger for its use and are there any other useful supplements for this condition?

There are now about 30 RCTs on this subject and the bottom line is that glucosamine is effective in alleviating OA symptoms and perhaps even reversing cartilage damage.

A Cochrane review in 2000 looked at 20 RCTs involving 2,570 patients. Analysis of 10 RCTs testing the Rotta brand of glucosamine showed superiority for pain (SMD -1.31, 95 per cent CI -1.99 to

-0.64) and function using the Lequesne index (SMD -0.51, 95 per cent CI -0.96 to -0.05) compared with placebo. Glucosamine was also found to be as safe as placebo in terms of the number of subjects reporting adverse reactions.

A further meta-analysis published in

JAMA last year concluded that although the effect sizes seen in the published studies are likely to be exaggerated by publication bias and quality issues, some degree of effectiveness appears probable.

5. For which conditions is there evidence to support the use of acupuncture?

If you ask questions about evidence in complementary medicine, experts (many of them self-appointed) are likely to start arguing about what 'evidence' means. I believe the worst thing that can happen to complementary medicine is that we introduce double standards (but proponents of 'integrated medicine' seem to lobby for exactly that).

Numerous systematic reviews of acupuncture trials have been published. The table on the right is a summary of the most up-to-date systematic reviews by indications.

In traditional complementary medicine, acupuncture is promoted as a panacea; it is alleged to correct the imbalance of the body's 'life forces' which are seen as the cause of all illness and therefore acupuncture can cure all illness. We cannot confirm this remarkably naïve notion. Not only does acupuncture not help in all conditions, in those for which it is effective it does not cure but only alleviates symptoms.

And for which other conditions may it be helpful? As science is a poor tool for proving negatives, the only correct answer probably is, virtually all.

6. How should I advise patients considering traditional Chinese medicine for eczema and how can they be sure they are seeing a reputable practitioner?

At present, Britain's high streets are swamped with Chinese herbal shops. Anecdotally, I have the impression that standards of patient safety and medical ethics vary widely. I therefore would not recommend visiting them.

Is Chinese herbal medicine effective for eczema? The data is not actually conclusive. Some investigations showed some herbal creams dished out by UK Chinese herbalists are heavily laced with corticosteroids. This is, of course, fraudulent and significantly tarnishes the business of traditional Chinese medicine.

7. Patients often ask about hypnotherapy for smoking cessation, fear of flying or needle phobia. What should I advise them?

A Cochrane review failed to demonstrate that hypnotherapy is effective for smoking cessation. I don't think trial evidence exists for fear of flying or needle phobia. There is evidence that hypnotherapy has analgesic effects and some that anxiety associated with pain is reduced by hypnotherapy.

8. Is there any evidence of the benefits of homoeopathy which might overcome the scepticism of an experienced GP?

Homoeopathy was very much in the limelight last year when Egger's Lancet paper seemed to show that homoeopathic remedies were placebos. This upset homoeopaths who pointed out flaws in Egger's analysis.

What they did not tell you is that there are now about a dozen systematic reviews that all arrive at this conclusion. So if it looks like a placebo, smells like a placebo, and tests like a placebo, perhaps it is a placebo!

What makes this subject interesting is the fact that many observational studies demonstrate that patients improve after consulting a homoeopath. Homoeopaths therefore insist the RCT is an unfair test of their approach. For me the solution is much simpler: homoeopathic remedies are placebos, but the homoeopathic consultation (often an hour or longer) could be quite an effective psychotherapy. I think it's time we consider this ­ if not we will be barking up the wrong tree for another 200 years.

Edzard Ernst is director of complementary medicine at Peninsula Medical School at the University of Exeter

Competing interests Edzard Ernst gives around 30 invited lectures a year and sometimes receives payment for them

What I will do now

Dr Stokell comments on the answers to his questions

· I will recommend glucosamine more for patients suffering from osteoarthritis.

· At present, I provide acupuncture for a limited range of conditions which fairly closely match those on Professor Ernst's list. I do think

there may be ways of making availability more universal on the NHS, as these are skills which can be easily learnt.

· If patients ask me about complementary therapies such as homoeopathy, I will have to give them my opinion. I find it difficult to balance their need to explore all options and the need to protect them from spending large amounts of money.

· I will buy a copy of The Desktop Guide to Complementary and Alternative Medicine ­ An Evidence-based Approach for our practice library

(published by Mosby/

Elsevier

­ www.elsevierhealth.com)

Richard Stokell is a GP in Birkenhead, Merseyside

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