Complementary and Alternative Health Care: The Other Mainstream?
Complementary and Alternative Health Care: The Other Mainstream?
Research shows that, over the past several years, more and more
Canadians have been turning to complementary and alternative health
care (CAHC)
and natural health products (NHPs)
to treat illness and promote health. Now, legislators and policy
makers are facing some difficult questions about how to assure the
safety and effectiveness of such products and practices, while not
unnecessarily restricting consumer access. This in turn raises questions
about what constitutes an acceptable level of evidence for safety
and effectiveness.
This issue of the Health Policy Research Bulletin explores
these and other questions by:
- defining CAHC
and NHPs and
exploring how they are positioned among the array of health services
and products available to Canadians
- presenting key utilization data on CAHC
and NHPs and
examining how and why consumers are using them
- discussing the evidentiary challenges that governments face
in balancing safety and effectiveness needs with concerns about
consumer access and informed choice
- chronicling how Health Canada addressed these concerns in developing
the new regulatory framework for NHPs,
which comes into effect in January 2004
Finally, the authors question whether, by addressing these challenges,
CAHC
and NHPs will
become more integrated with conventional health care or whether
they will remain the "other mainstream."
Our mission is to help the people of Canada maintain
and improve their health.
Health Canada
About the Health Policy Research Bulletin
Health Canada's Health Policy Research Bulletin is published
three times a year. The Bulletin is part of a larger policy research
dissemination program designed to enhance Health Canada's policy-relevant
evidence base.
A departmental steering committee guides the development of the
Bulletin. The committee is chaired by Cliff Halliwell, Director
General of the Applied Research and Analysis Directorate (ARAD)
of the Information, Analysis and Connectivity Branch. The Research
Management and Dissemination Division (RMDD)
within ARAD
coordinates the Bulletin's development and production. RMDD
would like to thank the steering committee members for their contributions,
as well as Nancy Hamilton, Managing Editor, Jaylyn Wong, Assistant
Editor, and Tiffany Thornton, Coordinator. Special thanks go to
the Guest Editor of this issue, Philip Waddington, Director General
of the Natural Health Products Directorate, Health Products and
Food Branch.
We welcome your feedback and suggestions. Please forward your comments
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An electronic version of the bulletin is available.
Note: The information contained in this issue is accurate as of
October 2003.
Health Policy Research Bulletin
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Some Commonly Used Terms
Complementary and alternative health care (CAHC);
complementary and alternative medicine (CAM):
diagnosis, treatment and/or prevention that complements mainstream
medicine by contributing to a common whole, by satisfying a demand
not met by conventional approaches, or by diversifying the conceptual
framework of medicine.1 Some common
CAHC
practices include: chiropractic services, massage therapy and traditional
Chinese medicine. While CAM
is the term most often used internationally, CAHC
recognizes the diversity of practice areas, including medicine,
and is the term most commonly used by Health Canada in a policy
context.
Health: a state of complete physical, social and mental
well-being, and not merely the absence of disease or infirmity.2
Health care: refers to all services, products and activities
used by individuals for the purpose of promoting, maintaining, monitoring
or restoring health.3
Health promotion: the process of enabling people to increase
control over and to improve their health.4
Holistic health: physical, mental, emotional and spiritual
components of health, and their interrelationship.
Informed choice: the ability of individuals and groups to
make choices about their health based on their understanding of
the evidence, facts, benefits and risks related to the issue, product
or behaviour.5
Natural health products (NHPs):
NHPs include
herbs, vitamins, minerals, essential fatty acids and homeopathics,
etc.These products are used to prevent, diagnose or treat disease,
restore or correct function, or maintain or promote health. NHPs
may be derived from plants, animals or micro-organisms.6
Self care: the decisions and actions that individuals take
in the interest of their own health.7
For More Information . . .
For more information on natural health products, the new Natural
Health Product Regulations, or complementary and alternative health
care, please go to the Natural Health Products Directorate (NHPD)
website at: http://www.hc-sc.gc.ca/hpfb-dgpsa/nhpd-dpsn/index_e.html
or e-mail the NHPD
at: NHPD_DPSN@hc-sc.gc.ca
or call toll free 1-888-774-5555.
Alternative Practices and Products: A Survival
Guide
Michael J. Smith and Joan E. Simpson, Natural Health
Products Directorate, Health Products and Food Branch, Health Canada
Although many people are familiar with the terms "complementary
and alternative health care" (CAHC)
and "natural health products" (NHPs),
they often mean different things to different people. The authors
provide definitions for both terms and discuss how consumers' understanding
and use of these products and practices have been key factors in
the quest for "integrated health care."
Canadians are faced with a sometimes overwhelming choice of health
care options. In addition to the many choices offered as part of
conventional health care, they can also choose from among a range
of CAHC therapies
and NHPs. However,
the choice is not always as simple as picking between option A
- the conventional, or option B - the alternative. Increasingly,
consumers are regarding CAHC and NHPs as
useful tools in a comprehensive health care "toolbox" and are looking
at ways to combine conventional and alternative therapies and products
to achieve the best results.
What Is CAHC?
CAHC is
an umbrella term used to describe numerous individual therapies
and health care approaches (see
page 2). As many as 4,000 different practice or discipline
areas have been catalogued, including chiropractic, therapeutic
massage, homeopathy and herbalism.1 Until
recently, CAHC was
frequently defined as alternative to conventional health care.
However, the definition of CAHC is
evolving to better reflect Canadians' increasing use of these therapies,
especially as complements - rather than alternatives - to conventional
health care.2
CAHC therapies
range in complexity from entire systems of medicine, such as Aboriginal
healing and traditional Chinese medicine, to specific physical/spiritual/pharmacological
interventions, such as reflexology, relaxation therapy and herbalism.3,4The
majority of CAHC therapies
do not follow the biomedical model of conventional health care;
instead, they are often based on paradigms of health and healing
that are considered "outside the norm" in developed countries.
Although CAHC encompasses
a diverse range of therapies (see box
on page 3), they share some common characteristics. For example,
they:
- work in conjunction with the body's own self-healing mechanisms
- are "holistic"- i.e., treat the whole person
- involve the patient as an active participant
- focus on disease prevention and well-being
These characteristics are not exclusively the domain of CAHC.3 In
fact, many CAHC therapies
have more in common with conventional care than with other forms
of CAHC.
For example, massage therapy is more similar to physiotherapy than
it is to homeopathy.
A Sampling of CAHC Therapies
Alexander technique
Aromatherapy
Ayurvedic medicine
Bach flower therapy
Craniosacral therapy
Iridology
Kanpo medicine
Reiki
Rolfing
Tibetan medicine
Natural Health Products
Natural health products (NHPs)
is a general term (see page
2) used to describe a variety of products, such as herbal medicines,
homeopathic remedies and nutritional supplements. NHPs should
not be considered a subset of CAHC therapies,
as there are some important distinctions between the two. For example, NHPs are
generally self-selected by the consumer, while practitioners typically
play a key role in the use of CAHC therapies.
Moreover, NHPs -
like other health care products - are regulated by the federal
government, while primary responsibility for CAHC -
as for other health care services - rests with the provinces and
territories.
Continuum of Product and Practice
It is useful to consider CAHC and NHPs on
a continuum that positions specific products and practices in relation
to each other, as well as to those in conventional care. For example,
a product continuum could go from drugs to NHPs to
food. In constructing such a continuum or situating a specific
product or practice along it, a number of factors should be considered,
including:
- the potency of the pharmacological/therapeutic action
- the nature of the evidence base
- the degree of regulation
- the extent of cultural acceptance
Taking these factors into account, drugs are often placed at one
end of the product continuum: their use is typically supported
by rigorous scientific evidence; the products are of high quality;
and access is generally restricted to mitigate any potential risk.
Food products would fall at the opposite end of the continuum because
they pose low health risks and there is little need for supporting
evidence of their effectiveness. Food quality is assured through
regulation and consumer guidance (provided through informative
labelling), and products are widely available. Generally, NHPs fall
between food and drugs on the product continuum. The continuum
approach ensures that specific categories of products are not classified
as superior to one another, but are measured against appropriate
parameters and standards of evidence (see
article on page 23).
Where a product or practice is placed on the continuum would vary
from country to country. For example, reflexology is a relatively
minor therapy in North America, but is a major practice in Scandinavian
countries.5 Similarly,
while the evidence base for homeopathy is the same the world over,
the therapy enjoys a much higher profile in Britain than in North
America because of its widespread acceptance by British medical
practitioners.6 In
some countries, certain types of CAHC or NHPs are
considered a dominant healing practice, for example, traditional
Chinese medicine in China and Ayurvedic medicine on the Indian
subcontinent.7
While the concept of a continuum is informative, it is also useful
to keep in mind basic definitions, which are often influenced by
regulations. For example, if new evidence supports a specific health
benefit of a particular food, it is not automatically classified
as an NHP. This particular food might be closer to the middle of
the continuum than some NHPs,
but it would still be a food. In the same way, CAHC therapies
that are supported by scientific evidence - for example, acupuncture
to treat nausea8 or
chiropractic services for uncomplicated acute low back pain9 -
are not necessarily regarded as conventional care.
Integrative Health Care
Since many of the same people who are using CAHC therapies
and NHPs are
also using "mainstream" medicine, links need to be established
between the two types of health care options. Consumers have identified
this need and are the driving force behind the current move toward "integrative
health care." Integrative care is more than using CAHC/NHPs and
conventional care together. It is rooted in the belief that consumers
should have the ability to make informed choices about all their
health care options. This concept of integrative health care was
explored at a recent workshop sponsored by Health Canada's Health
Policy Research Program (see
page 35).10
Fundamental to integrative care is the notion that there must
be effective communication among all involved parties, including
the patient, the conventional health care provider, the complementary
health care provider and government. Enhancing communication is
particularly important as consumers appear to be reluctant to discuss CAHC and NHPs with
members of their conventional health care team. Until recently,
it has fallen to consumers themselves to bridge the divide between
alternative and conventional health care practitioners. However,
as more and more people turn to alternative interventions to complement
their conventional health care, practitioners from both sides are
starting to communicate with each other, individually and through
their organizations. Health Canada is facilitating such linkages
by working with community groups, non-governmental organizations
and educational bodies on initiatives aimed at better preparing
family physicians to counsel patients on the use of CAHC and NHPs,
and increasing research literacy among CAHC practitioners.11
A Final Word
Many of the health care products and practices that consumers
once considered to be alternative therapies are now viewed as complementary
to conventional approaches. Moreover, consumers are recognizing
the need for CAHC and NHPs to
be "integrated" with mainstream health care options and are calling
for action on this front. It has yet to be seen whether this vision
of integrated use will be realized, or if CAHC and NHPs will
remain distinct as the "other mainstream."
A Policy Challenge: Innovative Solutions
An interview with Philip Waddington, Director General of
the Natural Health Products Directorate, Health Products and Food
Branch, Health Canada, conducted by Nancy Hamilton, Managing Editor
of the Health Policy Research Bulletin.
An increasing number of people appear to be turning to complementary
and alternative health care (CAHC)
and natural health products (NHPs)
as a way of treating illness and promoting health. Does the evidence
support this observation?
Yes, as pointed out in the article on utilization trends (see
page 9), the research shows that the use of CAHC therapies
and NHPs has
been on the rise over the past several years. However, the evidence
also shows that while sales of NHPs increased
substantially four or five years ago, sales have now levelled
off and, in some cases, even declined.
To what do you attribute this recent decline?
While some of the decline is probably due to general economic
downturn, the feedback we've received indicates that the decline
may also be due to growing consumer dissatisfaction with the outcomes
of products that have been available in a relatively unregulated
marketplace. In other words, it could be a result of what we call "under-regulation." For
example, if consumers tried a product based on a specific health
claim and then found it did not deliver the expected effects, they
may have turned away from NHPs entirely.
I must add, however, that many manufacturers are making NHPs that
work well and meet consumer expectations.
Your last point suggests a relationship between what you call "under-regulation" and
consumer confidence.
To optimize consumer confidence, I believe governments need to
find a balance between "under-regulation" and "over-regulation." With
under-regulation, there are fewer barriers restricting consumer
access, so consumers have access to a wider array of products and
services. However, some of these are likely falling short in delivering
expected outcomes to consumers. In the case of over-regulation,
the market is more restricted. There are fewer products available,
but these are supported by a very strong evidence base. Our consultations
have shown that what people really want is a balance between these
two extremes. They want assurances that products are safe and effective,
but they also want access to as many options as possible.
How are CAHC practices
and NHPs regulated
in Canada?
CAHC practices
are regulated at the provincial level, so I'll only make a few
comments about them. Perhaps the most important point is that the
provinces and territories are all moving forward at different speeds.
Also, the regulatory environment varies from one practice to another.
For instance, while some practitioners, like chiropractors, are
regulated consistently across the country, others, like naturopaths,
are regulated differently in each province. Although the federal
government is not responsible for practitioner regulation, we are
consulting with practitioners and provincial governments as they
address issues related to scope of practice, training and accreditation.
Currently, NHPs must
fit into either the "food" or the "drug" category under the federal Food and Drugs Act (FDA).
According to the FDA, NHPs sold
for their nutritional value are regulated as food while those making
other health claims are regulated as drugs. However, there is widespread
concern that the Food and Drug Regulations (FDR)
are inappropriate for NHPs (see
article on page 19) and that their application might lead to
the removal of many NHPs from
the marketplace.
What approach did Health Canada take to resolve what appears
to be a regulatory dilemma?
The House of Commons Standing Committee on Health recognized that
application of the FDR to NHPs served
neither the consumer nor the industry. In its 1998 report, the
Committee recommended that a new regulatory approach be developed.
The Office of Natural Health Products - which later became the
Natural Health Products Directorate - was established within Health
Canada to oversee the development of a new framework that would
be more appropriate to the range of products in this sector.
A pivotal factor in this regulatory initiative has been the extensive
consultations held with all major stakeholders, including consumers,
manufacturers, practitioners and importers. I believe the time
invested in the consultative process has paid off well. As a measure
of its value, the new regulatory framework was approved with few
amendments and will come into force in January 2004. It is important
to clarify that this framework will apply only to NHPs sold
over the counter. Products that require practitioner intervention
or have a narrow safety margin will continue to be regulated as
before under the FDR.
What are the main pillars of this new regulatory framework and
what makes it unique?
The two main pillars of the framework are, first, the good manufacturing
practices (GMPs)
and site licensing arrangements and, second, the standards of evidence
(SOE) (see articles on pages 19 and 23).
What makes the framework unique is that the GMPs and SOE have
been developed with the specific characteristics of the industry
in mind. Our goal was to ensure that the GMPs would
maximize the benefits and minimize the negative impacts of the
new Regulations. Unlike the pharmaceutical industry, which tends
to be dominated by large-scale manufacturers, our Business Impact
Test shows a relatively large number of small- to medium-sized
NHP manufacturers. We also know that much of the innovation in
this industry occurs in smaller companies because they are able
to adapt more rapidly as new methods of processing or new products
are developed. Imposing unnecessarily strict GMPs could
have shut down many of the smaller operations, thereby limiting
innovation.
How have the SOE been
tailored to this sector?
Two points are key. First, the SOE for NHPs call
for an examination of the "totality of evidence." For example,
two Canadian randomized control trials are typically conducted
before a new drug can be brought into Canada. But, under the new SOE,
an NHP may not be considered new in Canada if it had been in use
somewhere else. In that case, data from the other country could
be used to substantiate safety and health claims for the product.
The second point relates to the different levels of evidence that
are allowed under the SOE.
The Committee recommended that the SOE be
appropriate for a range of health claims. For instance, if a product
makes treatment claims for a scratch or cut, then one level of
evidence is required. However, if the claims apply to a more serious
condition, a higher level of evidence is necessary.
What are some examples of the different levels of evidence provided
for under the new SOE?
As I mentioned, we consider the totality of evidence, including
how the product is made and sold, the safety profile of the ingredients
and how it is marketed in other countries, as well as evidence
from those jurisdictions. We take into account both the traditional
and scientific literature. If there are clinical trials, we look
at those. We also consider non-randomized trials, as well as expert
opinion reports (see article
on page 23).
Another level of evidence focuses on whether there has been a
history of traditional use. By this, we mean a practice of using
that product which has been passed down within a community from
one generation to the next. Under the new SOE,
a minimum of 50 years is required to make a claim for traditional
use. At the other end of the spectrum are products that are "globally" new
- they have never been used anywhere. In the case of a new product
where the company provides insufficient evidence that the product
can be used safely for the indicated conditions, additional testing
or clinical trials are required.
What will happen after the new NHP Regulations come into effect
in January 2004?
It will take six years to fully implement the new Regulations.
During the first two years, we'll focus on product safety by making
sure that all manufacturers have site licences and are using the
approved GMPs.
Approximately 10,000 NHPs (of
the estimated 50,000 to 60,000 on the market) currently have Drug
Identification Numbers (DINs)
issued under the FDR.
These products will have six years to transition to the new framework.
The NHPD will
be targeting compliance and enforcement actions on a risk-based
approach to gradually bring the remaining products into full compliance
throughout the first four years that the Regulations are implemented.
There is some uncertainty and a lot of work associated with implementing
such a novel regulatory approach, but we're committed to being
vigilant in our follow-up activities so that consumers can realize
the maximum benefits.
In closing, how would you respond to potential critics who might
say that support for CAHC and
the new regulatory approach for NHPs is
not sufficiently science based?
I believe we are science based. In my view, science is
the practice of observation, recording, making observation-based
changes and then moving forward. This is the approach that has
been taken by researchers, regulators and others working in the
field to ensure that consumers have access to products and practices
that are safe and effective. Our bottom line is about enabling
consumers to make informed choices about their health care options.
Utilization Patterns and Trends
Joan E. Simpson, Natural Health Products Directorate (NHPD),
Health Products and Food Branch, Health Canada
Special thanks for the input provided by Sari Tudiver,
Women's Health Bureau, Health Policy and Communications Branch; David Hoe, HIV/AIDS Policy, Coordination and Programs Division, Population
and Public Health Branch; Nancy Lloyd, Centre for Chronic
Disease Prevention and Control, Population and Public Health Branch;
and Isabelle Caron, NHPD.
The popularity of complementary and alternative health care (CAHC)
and natural health products (NHPs)
is well documented. Drawing largely from recent studies prepared
for Health Canada,1-3 this
article highlights current utilization patterns and trends, and
examines how and why consumers are using these therapies and products.
It also explores the challenges of gathering comprehensive information
on consumer utilization.
The Big Picture
There is strong supporting evidence that CAHC and NHPs are
a large and generally increasing part of the Canadian health care
reality.4 For example,
the Berger Population Health Monitor recently reported that the
proportion of Canadians using one or more NHPs in
the previous six months rose from 70 percent in 1999 to 75 percent
in 2001.5 Millar's
2001 analysis of National Population Health Survey data estimated
that 19 percent of Canadians made use of CAHC practitioners
in 1998 to 1999 (an increase of four percentage points from 1994
to 1995) for services ranging from chiropractic, yoga and massage
to acupuncture, homeopathy and meditation.6,7 A
1998 survey by the Fraser Institute estimated that Canadians spent
$3.8 billion on CAHC and NHPs between
1996 and 1997.
Although utilization of NHPs increased
significantly in the mid- to late 1990s, according to some measures
there has been a slight decrease in the past few years. For instance, Figure
1 indicates that while the use of herbal remedies more than
doubled during the period 1996 to 1999, there has been a subsequent
levelling off since then. This drop may be due to lessened product
demand (see interview on page
6), overall market reductions, or some combination thereof.
Figure 1: Use of herbal Remedies, 1996-2002
Note: These data do not include vitamin and mineral usage.
Source: Nonprescription Drug Manufacturers Association of Canada, updated to
2002 from Hay Health Care Consulting Group's Berger population Health Monitor,
Survey #23 (R.Marles).
Figure 2 presents trends in Canadians' use
of different types of CAHC practitioners
from 1994 to 2001. Overall, Canadians are making significant use
of health care approaches that, until recently, were considered
outside the scope of mainstream health care in North America.8
Figure 2: Use of CAHC practitioners,
1994-1995 to 2000-2001
Note: These data do not include visits to chiropractors, the most extensively
used CAHC practitioners
in Canada.
Source: National Population Health Survey, 1994-2000.
About Consumer Utilization Data
Information on consumer utilization offers insights into CAHC product
and practice issues, and can help determine the agenda for future
policy research. In his reports to Health Canada, De Bruyn1,2 describes
relevant data sources and groups consumer utilization studies into
three categories: research studies,9-12 studies
based on data from Canadian health surveys6,13-15 and
public opinion polls.16
Gathering comprehensive information on the use of CAHC and NHPs presents
many challenges, some relating to survey methodologies and others
to the definitions of CAHC and NHPs employed
in the studies. For instance, reports of CAHC use
are affected by respondents' understanding of the terms, as well
as their reasons for using a particular product or therapy. For
this reason, researchers usually decide to ask about specific CAHC products,
practice areas and practitioners in their surveys and define these
clearly for respondents. Utilization responses can also be affected
by consumers' views about whether a particular product or practice
(e.g., prayer, meditation, use of herbal teas) is a component of
health care or just part of daily living. Another significant challenge
is the need to appropriately represent Canada's ethnocultural diversity
in survey databases - clearly an area requiring further attention.1,17
Similar to enhanced utilization studies, gathering information
about the health outcomes of using NHPs and CAHC therapies
has not been a major focus of health policy research to date.
Why the Widespread Use?
A number of factors may account for the increase in popularity
of CAHC and NHPs,
such as the rising prevalence of chronic diseases, greater public
access to global health information, reduced deference for the
decision-making role of conventional health care providers, and
an increased sense of entitlement to quality of life.3
The reasons people give for using CAHC and NHPs range
widely, from maintaining health and improving quality of life and
well-being, to preventing disease, reducing stress, treating a
condition or disease, and easing symptoms.3 Eisenberg
et al.10 reported
that 58 percent of CAHC treatments
were used, at least in part, to prevent future illness or to maintain
health and vitality, while 42 percent were used to treat existing
illness.
Normally, consumers themselves select an approach, with perceived
effectiveness as the major reason for choosing between therapies. CAHC and NHPs tend
to be used more often for chronic conditions, such as back pain
and allergies, than for acute or life- threatening conditions.17,18 Moreover,
most people cite positive reasons for choosing CAHC and NHPs,
such as a desire to take control over their health, or compatibility
with their belief systems, rather than negative reasons such as
a fear of or disillusionment with conventional care.18 While CAHC and NHPs are
sometimes used as an alternative to conventional medicine, they
are generally employed as an adjunct to other therapies. According
to current estimates, only 6 percent of Canadians use CAHC and NHPs to
the exclusion of conventional medicine.17
Who Uses CAHC and NHPs?
Many consumer populations are using CAHC and NHPs,
including:3
- the concerned well (who aim to enhance their health for the
long term)
- people with specific health problems, ranging from minor to
major (e.g., mental health concerns, infectious disease, acute
illness or injury, mental illness, long-term disability, chronic
disease)
- people with a life-threatening illness
- the terminally ill
Utilization can also vary by specific population groups or among
people with different health problems.
Women
As Table 2 shows, women make greater use
of CAHC and NHPs than
men. In part, this is likely due to women's unique physiology and
reproductive roles, which may lead them to seek alternative or
complementary treatment, for example, to relieve nausea during
pregnancy, induce or decrease lactation and relieve menopausal
symptoms. As the "gatekeepers" of family health, women also tend
to play a key role in decisions about the type of practitioner
to be consulted and under what circumstances. Findings such as
these indicate that women and men may have differing CAHC and
self-care information needs.
People Living with Chronic Illnesses
The use of alternative therapies by chronically ill populations
has been the focus of several recent surveys. For example, surveys
of people suffering from arthritis and rheumatism report prevalence
rates ranging from 82 percent to 94 percent.20-22 A
British Columbia self-care study on the use of alternative therapies
among adults aged 50 and older with arthritis, heart disease or
hypertension concluded that "the illness context is critically
important in affecting the propensity of individuals to use alternative
therapies."23
People Living with HIV/AIDS
As discussed in the article
on page 16, the use of CAHC and NHPs is
particularly high for people living with HIV/AIDS.24 Multiple
reasons for this use are cited by consumers, most particularly
to gain control over their health, boost immune function, delay
and treat symptoms of the disease, help with side effects, relieve
stress and improve general well-being.
People Living with Cancer
The 1998 National Population Health Survey indicates that 10 percent
of Canadians with cancer report some use of alternative health
care, while the related medical literature suggests that upwards
of 60 percent of cancer patients use some form of CAHC.25 The
most commonly reported reasons are to boost the immune system,
improve quality of life and prevent recurrences. Among those living
with cancer, people with breast cancer, gastrointestinal cancer
and lung cancer are the most frequent users of CAHC and NHPs (see "Who's
Doing What?" on page 28). As well, CAHC is
commonly used for children with cancer; in one study, almost 60
percent of child patients were reported to have used one type of
complementary or alternative medicine (CAM)
during their cancer treatment.6
Table 1: Use of NHPs*
Use of NHPs is highest in British Columbia and lowest in the Atlantic provinces: Forty-one
percent of respondents in British Columbia reported using three
or more NHPs in
the previous six months, compared with 15 percent of respondents
in the Atlantic provinces.
Pharmacies and health food stores are the main source of NHPs: Fifty-eight
percent of respondents purchased their last NHP at a stand-alone
pharmacy, 22 percent at a health food store and 7 percent at a
supermarket or discount store pharmacy. Few NHP purchases were
made on the Internet.
More people are consulting their physician or pharmacist about NHPs: Between
1998 and 2000, there was a substantial increase in the number of
people discussing the use of NHPs with
their physician (from 31 percent to 38 percent) or pharmacist (from
22 percent to 38 percent). Women were more likely than men to discuss NHPs with
a conventional health care professional.
*Based on Hay Health Care Consulting Group's Berger Population Health Monitor, 2001.
Assessing Products and Practitioners
Canadians using CAHC and NHPs may
be doing so with or without the involvement of mainstream health
care providers or any other practitioner.8 For
this reason, it is critical that tools be provided to help consumers
make informed decisions about how to access and use the various
health care options (as discussed in the following article). Tables
1 and 2 highlight specific patterns and trends concerning access
to and utilization of NHPs and CAHC practitioners,
based on analyses of Canadian national population survey results.2 Although
not presented here, more in-depth analysis of user characteristics,
for example, use of NHPs and CAHC by
various ethnic groups, would be a valuable area for further study.
Moving Forward
Studies are needed to determine with greater detail the extent
to which Canadians are opting for CAHC and NHPs.
Enhanced studies on the utilization and health outcomes of these
products and practices would assist in evaluating the potential
for substantial health gains across population groups.
The demand for NHPs and CAHC has
implications for health care delivery in Canada. As discussed throughout
this issue, Health Canada's attention has been directed at several
key policy areas: developing an appropriate regulatory framework
for NHPs; assessing CAHC health
system impacts; and exploring the needs of specific consumer populations
for access to and utilization of holistic health care approaches.
Table 2: Use of Alternative Practitioners
(APs)*
More Canadians are using APs than ever before: The use
of APs among Canadians aged 18 or older increased from 15 percent
in 1994-1995 to 19 percent in 1998-1999. Since use of chiropractors
remained stable during that period, the overall increase may be
attributed to the growing popularity of other types of APs (e.g.,
massage therapists, acupuncturists, homeopaths or naturopaths).7
Use of APs increases with education and income: People
with some post- secondary education are more likely to consult
an AP than people with less than a high school diploma. People
with a household income of $50,000 or above consult an AP more
often than those with a household income under $20,000.7
Women are more likely than men to consult APs: Nineteen
percent of women reported consulting an AP in the previous year,
compared with 14 percent of men. However, men and women are equally
likely to consult a chiropractor.7
Residents of Western Canada are more likely to use APs: The use of APs increases from east to west, with the highest rate of use in Alberta. Between 3 percent and 9 percent of people in the Atlantic provinces report consulting an AP, compared with 15 percent in Québec and Ontario, and 21 percent to 25 percent in the western provinces. The higher use in Western Canada may be a reflection of provincial health care plans, which offer some coverage for chiropractic services.7
Use of APs is greater among people with chronic conditions or chronic pain: 2001 survey data indicate that 59 percent
of Canadians suffer from one or more chronic conditions.19 In
1998 to 1999, 25 percent of people with three or more chronic
conditions consulted an AP, compared with 11 percent of those
reporting no chronic conditions. Twenty-six percent of people
who reported chronic pain consulted an AP, compared with 15 percent
of those with no chronic pain. Use of APs was highest among people
suffering from back problems.
*Based on the 1998-1999 National Population Health Survey.
Did You Know?
Did You Know? is a regular column of the Health Policy Research
Bulletin examining aspects of health information, data and research
that may be subject to misconceptions. In this issue, we investigate
the perception that all natural health products and complementary
and alternative health care therapies are safe.
It's Natural, So It Can't Hurt Me - Right?
Michael J. Smith and Robin J. Marles, Natural Health
Products Directorate, Health Products and Food Branch, Health Canada
Many consumers and even some practitioners believe that natural
health products (NHPs)
and complementary and alternative health care (CAHC)
therapies are always safe, no matter what the dosage is or how
they are used (see Figure 1). Is this perception
accurate? If not, how can we help people make informed, healthy
choices, bearing in mind that the typical consumer of NHPs and CAHC is
proactive about health care, inquisitive and well educated?
Natural Does Not Necessarily Mean Safe
Like most other things in life - including drugs, food and even
motorcycle riding - the safety of NHPs and CAHC therapies
depends on the amount or dosage, the characteristics of the user
and the context in which they are used. More specifically, many
of the risks associated with NHPs and CAHC fall
into the following three categories:1
Figure 1: Perception of the Potential Risks
Associated with the Misuse of NHPs, 1998
Source: Canada Health Monitor, 1998 Price Waterhouse Coopers National Survey
Centre.
Errors of Omission
Put simply, this means that by not doing the right thing, you
are doing the wrong thing. For example, taking a herbal medicine
that is inappropriate may cause consumers to ignore more proven
or appropriate care (either complementary or conventional). As
a result, their condition may deteriorate.
Intrinsic Procedural Risks
These are problems that arise directly from using a product or
practice. Because the body's organ systems and metabolic processes
are complex and interactive, any health product is likely to have
side effects. There is also the risk that NHPs may
be adulterated with other substances (e.g., drugs), contain the
wrong herb, or be contaminated as a result of poor manufacturing
practices. NHPs may
also interact with other substances, including conventional drugs,
other NHPs or
even foods.
Situational Amplifications
In this case, the condition worsens - usually temporarily - as
a result of taking the "correct" NHP or CAHC.
An example is the temporary and minor muscle aches some people
experience after chiropractic manipulation.
Different Strokes (and Doses) for Different Folks
Not everyone responds the same way to conventional medications
or NHPs. For
example, children experience different growth and development characteristics
as neonates (< 1 month), infants (1-12 months), toddlers (12-42
months), preschoolers (3.5-6 years), children (6-12 years), and
adolescents (12-18 years). These stages of development affect how
children absorb, distribute, metabolize and excrete drugs, as well
as the product's actions. Children are also more susceptible than
adults to the effects and toxicity of some products, but are better
able to tolerate others.2-4
For many NHPs,
documents describing traditional use provide little or no specific
information on dosage for children, leaving parents and practitioners
to either guess at or calculate the appropriate amount. (The situation
is not much better for conventional drugs, since their use in children
is commonly "off-label" as well due to the lack of clinically-derived
information on children's dosage and pharmacology.) A number of
dosing formulae for children have been proposed for use by health
care practitioners, none of which is regarded as completely reliable.5,6
Similarly, seniors often have special safety issues because of
low body weight, coexisting health conditions and the use of multiple
medications, including both conventional drugs (over-the-counter
and prescription) and NHPs.
As NHP use is not generally recorded in a patient's history, it
is difficult to watch for NHP-drug interactions in seniors, or
in other groups with infectious or chronic diseases.7 Physicians
are encouraged to start medications at a low dose and to monitor
for side effects while increasing the dose to the lowest effective
level, which may also help to minimize interactions.8,9
Ginkgo Leaf Extract - An Example
Ginkgo leaf extract is an excellent example of how NHP use and
dosage varies by population. Ginkgo extract contains a blood-thinning
agent and has been clinically shown to reduce cognitive impairment
in geriatric patients by improving blood flow throughout the brain.10 However,
ginkgo may interact with other blood thinners to increase the risk
of hemorrhage, emphasizing the importance of good patient-physician
communication about the use of NHPs.
Advertisers have falsely extrapolated the benefits of ginkgo products
by promoting them to young people as a way of improving their memory
and cognitive functioning. Although these products are unlikely
to help young people (as most have normal blood flow in the brain),
ginkgo extract does have a potential use in children. Clinical
evidence supports its use as an adjunct in the treatment of bacterial
blood infections.11 However,
as children are not generally included in clinical trials, practitioners
can only guess at an appropriate dose.
A Question of Communication
Effective communication between consumers, conventional and complementary
health care providers, and government is critical in ensuring consumer
safety. Results from several surveys12 suggest
that two thirds of people who use NHPs and CAHC do
not tell their physicians they are doing so. Health Canada is collaborating
with partners such as the Association of Canadian Medical Colleges
to improve physicians' knowledge of CAHC and NHPs so
they can better counsel their patients.
When something does go wrong, consumers are less likely to report
the problem with an NHP than a drug, and are more likely to tell
a neighbour or family member than their doctor or pharmacist.13 Effective
reporting of adverse events is a major research priority and Health
Canada is working with domestic and international partners to ensure
proper reporting procedures, provide for effective risk communications
with CAHC providers,
and determine when an adverse event results from an adulterating
substance or other factor rather than the NHP itself.
Communication between CAHC providers
and conventional health care providers is a two-way process in
which the responsibility lies equally with both groups to establish
a good working relationship. For instance, conventional providers
may not always be familiar with a specific NHP or CAHC therapy
and, thus, they need to know when to refer a patient to a CAHC practitioner.
Similarly, CAHC providers
may not always have the necessary training to make the best decision
for a patient and must know when to make a referral to a conventional
practitioner. Increasing consumer and practitioner understanding
of the potential risks (and benefits) associated with CAHC and NHPs is
vital in helping Canadians use them safely, effectively and respectfully.
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