Alternative medicine practices are as diverse in their foundations as in their methodologies. Practices may incorporate or base themselves on traditional medicine, folk knowledge, spiritual beliefs, or newly conceived approaches to healing. Jurisdictions where alternative medical practices are sufficiently widespread may license and regulate them. The claims made by alternative medicine practitioners are generally not accepted by the medical community because evidence-based assessment is not available for the safety and efficacy of many of these practices. If scientific investigation establishes the safety and effectiveness of an alternative medical practice, it may be adopted by conventional practitioners. Because alternative techniques tend to lack evidence, some have advocated defining it as non-evidence based medicine, or not medicine at all. Some researchers have noted that the evidence-based approach to defining CAM is problematic because some CAM is tested, and research suggests that many mainstream medical techniques lack solid evidence.
A 1998 systematic review of studies assessing its prevalence in 13 countries concluded that about 31% of cancer patients use some form of complementary and alternative medicine. Alternative medicine varies from country to country; Dr. Edzard Ernst believes that in Austria and Germany CAM is mainly in the hands of physicians, although some estimates suggest that half of CAM is administered by physicians in the US. In Germany, herbs are tightly regulated, with half prescribed by doctors and covered by health insurance based on their Commission E legislation.
David M. Eisenberg defines it as "medical interventions not taught widely at US medical schools or generally available at US. hospitals," while Richard Dawkins sardonically defines it as a "set of practices which cannot be tested, refuse to be tested, or consistently fail tests."
The term "alternative medicine" is generally used to describe practices used independently or in place of conventional medicine. The term "complementary medicine" is primarily used to describe practices used in conjunction with or to complement conventional medical treatments. NCCAM suggests "using aromatherapy therapy in which the scent of essential oils from flowers, herbs, and trees is inhaled in an attempt to promote health and well-being and to help lessen a patient's discomfort following surgery" as an example of complementary medicine. The terms "integrative" or "integrated medicine" indicate combinations of conventional and alternative medical treatments which have some scientific proof of efficacy; such practices are viewed by advocates as the best examples of complementary medicine. Ralph Snyderman and Andrew Weil go so far as to claim that "integrative medicine is not synonymous with complementary and alternative medicine. It has a far larger meaning and mission in that it calls for restoration of the focus of medicine on health and healing and emphasizes the centrality of the patient-physician relationship." The combination of orthodox and complementary medicine with an emphasis on prevention and lifestyle changes is known as Integrated health.
Well-known proponents of evidence-based medicine, such as the Cochrane Collaboration and Edzard Ernst, Professor of Complementary Medicine at the University of Exeter, use the term alternative medicine but agree that all treatments, whether "mainstream" or "alternative", ought to be held to standards of the scientific method. Their view is that evidence-based medicine is an ideal state which has not yet been achieved by either current mainstream or alternative medicine. Ernst characterizes the evidence for many alternative techniques as weak, nonexistent, or negative, but notes that compelling evidence exists for others, particularly certain herbs and acupuncture – although this evidence does not mean these treatments are mainstream, especially not worldwide. What is alternative varies by discipline as well and country. For example, biofeedback is commonly used within the Physical Medicine & Rehabilitation community, but is considered alternative within the medical community as a whole, and some herbal therapies are mainstream in Europe, but are alternative in the United States.
Criticisms of CAM by mainstream physicians have been numerous. Barrie R. Cassileth has succinctly summed up the situation:
According to the NCCAM, formerly unproven remedies may be incorporated into conventional medicine if they are shown to be safe and effective. Several scientists share this point of view and state that "[o]nce a treatment has been tested rigorously, it no longer matters whether it was considered alternative at the outset. If it is found to be reasonably safe and effective, it will be accepted." According to them it is possible for a method to change categories (proven vs. unproven) in either direction, based on increased knowledge of its effectiveness or lack thereof. Prominent proponents of this position are George D. Lundberg, former editor of the Journal of the American Medical Association (JAMA), and Phil B. Fontanarosa, Senior Editor of JAMA," Richard Dawkins, Professor of the Public Understanding of Science at Oxford, and Stephen Barrett, founder and operator of Quackwatch, who argues that techniques currently labeled "alternative" should be reclassified as "genuine, experimental, or questionable. Genuine alternatives are comparable methods that have met science-based criteria for safety and effectiveness. Experimental alternatives are unproven but have a plausible rationale and are undergoing responsible investigation. ... Questionable alternatives are groundless and lack a scientifically plausible rationale. ... Blurring these distinctions enables promoters of quackery to argue that because some practices labeled "alternative" have merit, the rest deserve equal consideration and respect. Enough is known, however, to conclude that most questionable "alternatives" are worthless. Oxford University Press publishes a peer-reviewed journal entitled Evidence-based Complementary and Alternative Medicine (eCAM).
M.R. Tonelli argues that CAM cannot be evidence-based unless the definition of evidence is changed. He states that "the methods of developing knowledge within CAM currently have limitations and are subject to bias and varied interpretation. CAM must develop and defend a rational and coherent method for assessing causality and efficacy, though not necessarily one based on the results of controlled clinical trials." Further, A review of Michael L. Millenson's book Demanding Medical Excellence: Doctors and Accountability in the Information Age described it as "a wake up call to both medicine and nursing" due to what Millenson calls a "lack of scientific-based medical practice". According to the review, the book states that "85% of current practice has not been scientifically validated" and that it suggests that users of the research presented by Medline should question research articles rather than assuming they are accurate simply because of where they are published. The review states that Millenson's thesis and conclusion call for all health researchers and policy makers do a better job in assuring valid methodology and avoidance of bias in published research. Michael Dixon, the Director of the NHS Alliance stated that “People argue against complementary therapies on the basis of a lack of evidence. But I’d say only 10 per cent of what doctors do in primary care is evidence-based. Angell and Kassirer acknowledge that "many treatments used in conventional medicine have not been rigorously tested, either" but note that the scientific community is generally aware that this is a failing that needs to be remedied."
Many CAM methods are criticized by the activist non-profit organization Quackwatch.
NCCAM classifies complementary and alternative therapies into five major groups. The classification are rather loose, and there can be some overlap.
Edzard Ernst, Professor of Complementary Medicine at the University of Exeter, wrote in the Medical Journal of Australia that "about half the general population in developed countries use complementary and alternative medicine (CAM)."Survey results released in May 2004 by the National Center for Complementary and Alternative Medicine, part of the United States National Institutes of Health, found that in 2002 62.1% of adults in the country had used some form of CAM in the past 12 months and 75% across lifespan (though these figure drop to 36.0% and 50% if prayer specifically for health reasons is excluded); this study included yoga, meditation, herbal treatments and the Atkins diet as CAM. Another study suggests a similar figure of 40%. A British telephone survey by the BBC of 1209 adults in 1998 shows that around 20% of adults in Britain had used alternative medicine in the past 12 months. Ernst has been active politically on this issue as well, publicly requesting that Prince Charles recall two guides to alternative medicine published by the Foundation for Integrated Health, on the grounds that “[t]hey both contain numerous misleading and inaccurate claims concerning the supposed benefits of alternative medicine" and that "[t]he nation cannot be served by promoting ineffective and sometimes dangerous alternative treatments.” In general, he believes that CAM can and should be subjected to scientific testing.
The use of alternative medicine in developed countries appears to be increasing. A 1998 study showed that the use of alternative medicine had risen from 33.8% in 1990 to 42.1% in 1997. In the United Kingdom, a 2000 report ordered by the House of Lords suggested that "...limited data seem to support the idea that CAM use in the United Kingdom is high and is increasing." In developing nations, access to essential medicines is severely restricted by lack of resources and poverty. Traditional remedies, often closely resembling or forming the basis for alternative remedies, may comprise primary health care or be integrated into the health care system. In Africa, traditional medicine is used for 80% of primary health care, and in developing nations as a whole over one third of the population lack access to essential medicines.
Advocates of alternative medicine hold that the various alternative treatment methods are effective in treating a wide range of major and minor medical conditions, and contend that recently published research (such as Michalsen, 2003, Gonsalkorale 2003, and Berga 2003) proves the effectiveness of specific alternative treatments. They assert that a PubMed search revealed over 370,000 research papers classified as alternative medicine published in Medline-recognized journals since 1966 in the National Library of Medicine database. See also Kleijnen 1991, and Linde 1997.
Complementary therapies are often used in palliative care or by practitioners attempting to manage chronic pain in patients. Complementary medicine is considered more acceptable in the interdisciplinary approach used in palliative care than in other areas of medicine. "From its early experiences of care for the dying, palliative care took for granted the necessity of placing patient values and lifestyle habits at the core of any design and delivery of quality care at the end of life. If the patient desired complementary therapies, and as long as such treatments provided additional support and did not endanger the patient, they were considered acceptable. The non-pharmacologic interventions of complementary medicine can employ mind-body interventions designed to "reduce pain and concomitant mood disturbance and increase quality of life. Physicians who practice complementary medicine usually discuss and advise patients as to available complementary therapies. Patients often express interest in mind-body complementary therapies because they offer a non-drug approach to treating some health conditions. Some mind-body techniques, such as cognitive-behavioral therapy, were once considered complementary medicine, but are now a part of conventional medicine in the United States. "Complementary medicine treatments used for pain include: acupuncture, low-level laser therapy, meditation, aroma therapy, Chinese medicine, dance therapy, music therapy, massage, herbalism, therapeutic touch, yoga, osteopathy, chiropractic, naturopathy, and homeopathy.
The use of alternative medicine appears to be increasing, as a 1998 study showed that the use of alternative medicine had risen from 33.8% in 1990 to 42.1% in 1997. In the United Kingdom, a 2000 report ordered by the House of Lords suggested that "...limited data seem to support the idea that CAM use in the United Kingdom is high and is increasing."
In defining complementary medicine in the UK, the House of Lords Select Committee determined that the following therapies were the most often used to complement conventional medicine: Alexander technique, Aromatherapy, Bach and other flower remedies, Body work therapies including massage, Counselling stress therapies, hypnotherapy, Meditation, Reflexology, Shiatsu, Maharishi Ayurvedic medicine, Nutritional medicine, and Yoga.
A 2002 survey of US adults 18 years and older conducted by the National Center for Health Statistics (CDC) and the National Center for Complementary and Alternative Medicine indicated:
In the state of Texas, physicians may be partially protected from charges of unprofessional conduct or failure to practice medicine in an acceptable manner, and thus from disciplinary action, when they prescribe alternative medicine in a complementary manner, if board specific practice requirements are satisfied and the therapies utilized do not present "a safety risk for the patient that is unreasonably greater that the conventional treatment for the patient's medical condition.
Similarly "unconventional medicine courses are widely represented at European universities. They cover a wide range of therapies. Many of them are used clinically. Research work is underway at several faculties, but "only 40% of the responding [European] universities were offering some form of CAM training.
In Britain, no conventional medical schools offer courses that teach the clinical practice of alternative medicine. However, alternative medicine is taught in several unconventional schools as part of their curriculum. Teaching is based mostly on theory and understanding of alternative medicine, with emphasis on being able to communicate with alternative medicine specialists. To obtain competence in practicing clinical alternative medicine, qualifications must be obtained from individual medical societies. The student must have graduated and be a qualified doctor. The British Medical Acupuncture Society, which offers medical acupuncture certificates to doctors, is one such example, as is the College of Naturopathic Medicine UK and Ireland.
Due to the uncertain nature of various alternative therapies and the wide variety of claims different practitioners make, alternative medicine has been a source of vigorous debate, even over the definition of alternative medicine. Dietary supplements, their ingredients, safety, and claims, are a continual source of controversy. In some cases, political issues, mainstream medicine and alternative medicine all collide, such as the case where synthetic drugs are legal but the herbal sources of the same active chemical are banned. In other cases, controversy over mainstream medicine causes questions about the nature of a treatment, such as water fluoridation. Alternative medicine and mainstream medicine debates can also spill over into freedom of religion discussions, such as the right to decline lifesaving treatment for one's children because of religious beliefs. Government regulators continue to attempt to find a regulatory balance.
Jurisdiction differs concerning which branches of alternative medicine are legal, which are regulated, and which (if any) are provided by a government-controlled health service or reimbursed by a private health medical insurance company. The United Nations Committee on Economic, Social and Cultural Rights - article 34 (Specific legal obligations) of the General Comment No. 14 (2000) on The right to the highest attainable standard of health - states that
Specific implementations of this article are, of course, left to member states.
A number of alternative medicine advocates disagree with the restrictions of government agencies that approve medical treatments. In the USA, for example, critics claim that the Food and Drug Administration's criteria for experimental evaluation methods impedes those seeking to bring useful and effective treatments and approaches to the public, and protest that their contributions and discoveries are unfairly dismissed, overlooked or suppressed. Alternative medicine providers recognize that health fraud occurs, and argue that it should be dealt with appropriately when it does, but that these restrictions should not extend to what they view as legitimate health care products.
In New Zealand alternative medicine products are classified as food products, so there are no regulations or safety standards in place.
The production of modern pharmaceuticals is strictly regulated to ensure that medicines contain a standardized quantity of active ingredients and are free from contamination. Alternative medicine products are not subject to the same governmental quality control standards, and consistency between doses can vary. This leads to uncertainty in the chemical content and biological activity of individual doses. This lack of oversight means that alternative health products are vulnerable to adulteration and contamination. This problem is magnified by international commerce, since different countries have different types and degrees of regulation. This can make it difficult for consumers to properly evaluate the risks and qualities of given products.
As of 2005 the Cochrane Library had 145 CAM-related Cochrane systematic reviews and 340 non-Cochrane systematic reviews. An analysis of the conclusions of only the 145 Cochrane reviews was done by two readers. In 83% of the cases, the readers agreed. In the 17% in which they disagreed, a third reader agreed with one of the initial readers to set a rating. These studies found that for CAM, 38.4% concluded positive effect or possibly positive (12.4%) effect, 4.8% concluded no effect, 0.69% concluded harmful effect, and 56.6% concluded insufficient evidence. An assessment of conventional treatments found that 41.3% concluded positive or possibly positive effect, 20% concluded no effect, 8.1% concluded net harmful effects, and 21.3% concluded insufficient evidence. However, the CAM review used the 2004 Cochrane database while the conventional review used the 1998 Cochrane database.
Most alternative medical treatments are not patentable, which may lead to less research funded by the private sector; some have proposed adopting a prize system to reward medical research. However, public funding for research exists. Increasing the funding for research of alternative medicine techniques was the purpose of the US National Center for Complementary and Alternative Medicine. NCCAM and its predecessor, the Office of Alternative Medicine, have spent more than $1 billion on such research since 1992. The German Federal Institute for Drugs and Medical Devices Commission E has studied many herbal remedies for efficacy. The lack of legal pressure to prove efficacy may also reduce the amount of research.
Some skeptics of alternative practices point out that a person may attribute symptomatic relief to an otherwise ineffective therapy due to the placebo effect, the natural recovery from or the cyclical nature of an illness (the regression fallacy), or the possibility that the person never originally had a true illness. CAM proponents point out this may also apply in cases where conventional treatments have been used.
Forms of alternative medicine that are biologically active can be dangerous even when used in conjunction with conventional medicine. Examples include immuno-augmentation therapy, shark cartilage, bioresonance therapy, oxygen and ozone therapies, insulin potentiation therapy. Some herbal remedies can cause dangerous interactions with chemotherapy drugs, radiation therapy or anesthetics during surgery, among other problems. An anecdotal example of these dangers was reported by Associate Professor Alastair MacLennan of Adelaide University, Australia regarding a patient who almost bled to death on the operating table after neglecting to mention that she had been taking "natural" potions to "build up her strength" before the operation, including a powerful anticoagulant that nearly caused her death.
To ABC Online, MacLennan also gives another possible mechanism:
Conventional treatments are subjected to testing for undesired side-effects, whereas alternative treatments generally are not subjected to such testing at all. Any treatment — whether conventional or alternative — that has a biological or psychological effect on a patient may also have potentially dangerous biological or psychological side-effects. Attempts to refute this fact with regard to alternative treatments sometimes use the appeal to nature fallacy, i.e. "that which is natural cannot be harmful".
An exception to the normal thinking regarding side-effects is Homeopathy. Since 1938 the FDA has regulated homeopathic products in "several significantly different ways from other drugs." Homeopathic preparations, termed "remedies," are extremely dilute, often far beyond the point where a single molecule of the original active (and possibly toxic) ingredient is likely to remain. They are thus considered safe on that count, but "their products are exempt from good manufacturing practice requirements related to expiration dating and from finished product testing for identity and strength," and their alcohol concentration may be much higher than allowed in conventional drugs.
A study published in 1998 indicates that a majority of alternative medicine use was in conjunction with standard medical treatments. Approximately 4.4 percent of those studied used alternative medicine as a replacement for conventional medicine. The research found that those who used alternative medicine tended to have higher education or report poorer health status. Dissatisfaction with conventional medicine was not a meaningful factor in the choice, but rather the majority of alternative medicine users appear to be doing so largely because "they find these health care alternatives to be more congruent with their own values, beliefs, and philosophical orientations toward health and life." In particular, subjects reported a holistic orientation to health, a transformational experience that changed their worldview, identification with a number of groups committed to environmentalism, feminism, psychology, and/or spirituality and personal growth, or that they were suffering from a variety of common and minor ailments - notably anxiety, back problems, and chronic pain.
Authors have speculated on the socio-cultural and psychological reasons for the appeal of alternative medicines among that minority whose use them in lieu of conventional medicine. There are several socio-cultural reasons for the interest in these treatments centered around the low level of scientific literacy among the public at large and a concomitant increase in antiscientific attitudes and new age mysticism. Related to this are vigorous marketing of extravagant claims by the alternative medical community combined with inadequate media scrutiny and attacks on critics. There is also an increase in conspiracy theories towards conventional medicine and pharmaceutical companies, mistrust of traditional authority figures, such as the physician, and a dislike of the current delivery methods of scientific biomedicine, all of which have lead patients to seek out alternative medicine to treat a variety of ailments. Many patients lack access to contemporary medicine, due to a lack of private or public health insurance, which lead them to seek out lower-cost alternative medicine. Medical doctors are also aggressively marketing alternative medicine to profit from this market.
In addition to the social-cultural underpinnings of the popularity of alternative medicine, there are several psychological issues that are critical to its growth. One of the most critical is the placebo effect, which is a well-established observation in medicine. Related to it are similar psychological effects such as the will to believe, cognitive biases that help maintain self-esteem and promote harmonious social functioning, and the post hoc, ergo propter hoc fallacy. Patients can also be averse to the painful, unpleasant, and sometimes dangerous side effects of biomedical treatments. Treatments for severe diseases such as cancer and HIV infection have well-known, significant side effects. Even low-risk medications such as antibiotics can potentially cause life-threatening anaphylactic reactions in a very few individuals. More commonly, many medications may cause minor but bothersome symptoms such as cough or upset stomach. In all of these cases, patients may be seeking out alternative treatments to avoid the adverse effects of conventional treatments.