Talking about Complementary and Alternative
Medicine – a Resource for Clinicians
JULY 2013
Many Australians report that they self-prescribe complementary and alternative medicine (CAM),
but they do not disclose this information to their clinicians. 1 Without a full understanding of their
patients’ health practices, it is difficult for clinicians to provide safe and holistic healthcare.
This resource is intended to facilitate discussions about CAM use between clinicians and their
patients. It provides clinicians with prompts for:
•
•
•
initiating a conversation about CAM use
discussing evidence and the effectiveness of CAM
discussing the potential risks of CAM use.
The document also includes background information on the use and regulation of CAM in Australia,
and provides sources of referral for clinicians and patients seeking further information on CAM.
The information contained in this resource is targeted at medical practitioners, nurse practitioners,
pharmacists and allied health professionals.
Complementary and Alternative
Medicine and its use in Australia
The term CAM is used to describe a wide range
of health care practices, therapies, and products
that are not generally considered within the
domain of conventional medicine.2 Defining CAM
can be difficult, as new therapies are constantly
emerging, and because the boundaries between
CAM and conventional medicine are often
blurred, with specific CAM practices becoming
more widely accepted over time. Cultural or
personal beliefs may also influence what a
patient considers to be ‘CAM’.
CAM products and therapies are considered to
be ‘complementary medicine’ when used
together with conventional medicine, or
‘alternative medicine’ when being used as an
alternative to conventional medicine.2 In
Australia, CAM is generally viewed by consumers
as part of a holistic view of health and is often
used in conjunction with, not in isolation from,
other strategies for achieving and maintaining
good health.
It is estimated that more than two thirds of the
Australian population use CAM products and
services, and nationally, the annual 'out of
pocket' expenditure on CAM is estimated to be
around $4 billion.
Information on CAM
As the use of CAM continues to grow in Australia,
there have been calls for improvements in the
information available on CAM for Australian
health consumers, to assist them in making better
informed decisions. In 2009, an independent
evaluation of CAM resources commissioned by
NPS MedicineWise found that the sources of
information available to consumers are of variable
quality and reliability.4 As a consequence, some
consumers may be relying on inaccurate or
misleading statements when deciding whether a
particular CAM is an appropriate healthcare
option.
The Consumers Health Forum of Australia have
also raised awareness of information gaps faced
by patients when considering CAM treatments –
including information on regulation, consumer
protection, efficacy and evidence.5
In addition to the lack of public consumer
information on CAM, a national consumer survey
conducted in 2008 by NPS MedicineWise found
that only half of those reporting to use CAM
mentioned or discussed their treatment with a
doctor.1
There are a variety of reasons for patients not
disclosing CAM use to their clinician, including:
• a belief that CAM products and therapies are
‘natural’ and ‘safer’ than conventional
medicines
• a lack of awareness that CAM is medicine
• a lack of awareness of the risk of unintended
drug interactions
• discomfort in raising the topic
• fear of the practitioner’s response.
However, one of the most common reasons
given by patients about why they have not
discussed their CAM use is that their clinician has
failed to ask.3 This was confirmed by a survey of
healthcare professionals conducted by NPS
MedicineWise in 2008, which found that
clinicians often did not initiate discussions about
CAM with their patients and were often unaware
of their patients’ CAM use.6 In response, NPS
MedicineWise called for the promotion of active
discussions about CAM between consumers and
health care providers.
talking about complementary and alternative medicine – a resource for clinicians • 2 of 8
Asking about CAM use
It is important for clinicians to get a full picture of
all conventional and CAM practices a patient is
using to manage their healthcare. A first step in the
process may be to include a question about the use
of CAM on ‘personal details’ forms for new
patients, and/or to request that patients bring a list
of all therapies they use with them to
consultations.7
Clinicians should consider initiating discussions with
their patients about CAM, using questions that
elicit the relevant information.
Benefits of the CAM
•
What made you decide to try this
medicine/therapy?
•
How long have you been using the
medicine/therapy? Are you going to
continue using it?
•
Do you feel you are benefiting from
the medicine/therapy?
Details of the CAM products
•
How often do you take the product?
•
What is the dosage, and how much of
the active ingredient is in each dose?
•
Where are you getting this product
from?
•
Are you using this treatment instead of,
or in addition to, your regular
medications?
CAM use
• What else have you tried for this problem?
• Have you used any herbal or natural
remedies, vitamins or supplements that
you have bought from a supermarket,
chemist or health food store, or that you
have grown or prepared yourself?
• Have you seen a complementary or
alternative healthcare practitioner
(naturopath, herbalist, chiropractor etc.)?
• Have you tried changing your diet because
you thought it might help this problem, for
example by adding or eliminating particular
foods or food groups?
Details of the CAM practitioners
•
What experience does your practitioner
have in treating your condition?
•
Do you know if your practitioner has any
relevant qualifications, professional
registrations or memberships?
•
Are you comfortable with the costs per
session, and are you aware of the likely
total cost of treatment?
•
Would you feel comfortable for your CAM
practitioner to let me know about your
treatment and progress?
talking about complementary and alternative medicine – a resource for clinicians • 3 of 8
Discussions about evidence
Clinicians should encourage their patients to make
well informed decisions about their healthcare
and communicate to patients the importance of
considering scientific evidence to make these
decisions. It may be important to explain that
most complementary medicines are classed as
‘listed’ medicines by the Therapeutic Goods
Administration (TGA), which means that the TGA
has not evaluated their effectiveness (see further
discussion on regulation of CAM in Australia
below).8
It is useful to know what emphasis the patient
places on evidence. Some do not consider
scientific evidence to be important. Others do not
know how to consider evidence, choosing instead
to rely on personal success stories of friends,
family or colleagues. Some cultural practices can
be closely linked with CAM use, which is
important for clinicians to identify when
discussing scientific evidence.
You may like to consider information targeted at
consumers about the strength of different types
of evidence, including a summary of the ‘levels of
evidence’ from the Cochrane Consumer Networka
and information on ‘understanding clinical trials’
from NPS MedicineWise.b The NHMRC’s resource
on ‘Decisions about Tests and Treatments:
principles for better communication’c (targeted at
both patients receiving treatment and clinicians
delivering healthcare) may also be useful in
facilitating discussions about evidence.
a The Cochrane Consumer Network’s webpage on ‘levels of
evidence’ is available at http://consumers.cochrane.org/levelsevidence
b NPS MedicineWise’s information on ‘understanding clinician
trials’ is available at http://www.nps.org.au/conditions-andtopics/topics/how-to-be-medicinewise/regulation-clinical-trials/
understanding-clinical-trials
Discussing evidence
• How do you know that the CAM treatment
works?
• Are you aware of any risks associated with
the CAM treatment?
• Is there scientific research evidence (not just
personal stories) to back up statements
about effectiveness and safety?
— Has the research been published and
peer reviewed?
— Who paid for the research? Do they
have a vested interest in the conclusions
of the research – for example, will they
benefit commercially or otherwise if the
research is positive?
Discussing reliability of information
• Who is the author of the information and
what is its purpose?
• Where has the information come from? For
example, is it based on research studies or
personal stories?
• What are the author’s qualifications?
• Does the information explain how treatments
work, and their benefits and risks?
• Does the author or website owner have a
commercial interest in promoting the
treatment?
• How is the treatment described by the
manufacturer or provider?
c NHMRC’s resource on Making Decisions about Tests &
Treatments: principles for better communication is available
at http://www.nhmrc.gov.au/_files_nhmrc/publications/
attachments/hpr25_0.pdf
talking about complementary and alternative medicine – a resource for clinicians • 4 of 8
Discussing effectiveness
Do your patients know whether their CAM is
effective? You can help them identify any
evidence of effectiveness for the CAM they use.
They may need support and encouragement in
thinking critically about the source and quality of
information.
Clinicians should encourage patients to make a
decision based on evidence, such as evidence
published in reputable peer-reviewed journals or
by government, rather than using CAM simply
because of something they have seen in an
advertisement or on a website, or because of a
personal success story. Clinicians may also
encourage their patient to seek information from
a source other than the CAM provider.
Clinicians may need to advise their patients to be
cautious where claims made for CAM products
are not underpinned by quality evidence. This
might include suggesting patients return for
regular reviews to monitor progress if they
choose to use a CAM.
Patients should be encouraged to think twice
about statements describing the therapy as a
'quick fix', 'scientific breakthrough', 'miracle cure',
'secret ingredient', or 'ancient remedy', or similar.
It may help to suggest to patients that if it sounds
too good to be true – such as a claims that a
therapy can cure a disease or treat a variety of
conditions – it usually is.
Discussing potential risks
Do your patients know whether their CAM is
safe? As with all therapeutic goods, there are
potential risks associated with CAM use. It is
often difficult for consumers to know if an
individual CAM is safe or potentially harmful, and
this may differ from patient to patient. Clinicians
should explain to their patients that
all health and treatment decisions involve
weighing up potential benefits and potentials risks
to decide whether the treatment is appropriate
for them.
NPS MedicineWise have found that many
consumers are not aware of the side effects of
some complementary medicines and their
potential interactions with conventional
medicines, which may put some users at
unnecessary risk of harm.1 Clinicians may need to
consider and explain to their patients the risk of
adverse reactions (including unintended medicine
interactions). If considered clinically necessary,
general practitioners may refer their patient to a
pharmacist for a Medicare- supported Home
Medicine Review to prevent medication-related
problems.
Some complementary medicines contain
ingredients that are contraindicated in individuals
that suffer from certain conditions or have
allergies. For example, the National Asthma
Council Australia warns that Echinacea, which is
sometimes used as a CAM treatment for the
common cold, may trigger an allergic response or
exacerbate symptoms when used by asthma
patients.9 Similarly, complementary medicines
containing St John’s Wort can reduce the
therapeutic effects of many pharmaceutical
medicines including anti-depressants, epilepsy and
HIV medications, and the oral contraceptive pill,
leading to potentially significant consequences for
the patient.10
Where CAM is used in place of conventional
medicine, clinicians should discuss with their
patient the health and financial consequences of a
delay in accessing conventional treatment which
may (potentially) be more effective. Clinicians
should especially advise caution in cases where
CAM of uncertain effectiveness is used as a
replacement for conventional medicine of known
effectiveness.
talking about complementary and alternative medicine – a resource for clinicians • 5 of 8
Regulation of Complementary and
Alternative Medicine in Australia
Based on these risks, the appropriate evaluation
process is applied based on a two-tiered
classification system:
In Australia, CAMs containing herbs, vitamins,
minerals and nutritional supplements, homeopathic medicines and some aromatherapy
products are regulated as complementary
medicines under the Therapeutic Goods Act
1989 by the TGA. Therapeutic goods must be
entered on the Australian Register of
Therapeutic Goods (ARTG) before they can be
lawfully supplied in Australia. There are about
10,000 complementary medicines on the
ARTG.11
• Registered medicines (labelled as Aust R), which
include all prescription and some nonprescription medications, are considered to be of
relatively higher risk and are individually
evaluated by the TGA for quality, safety and
efficacy prior to market entry.
The TGA uses a ‘risk-management’ approach to
regulate medicines supplied in Australia. A
number of factors are used to determine the
risks associated with a particular medicine,
including:
• the toxicity of the ingredients
• the dosage form of the medicine
• whether the medicine is indicated for a
serious form of a disease, condition or
disorder, or for the treatment, cure,
management or prevention of a disease,
condition or disorder
• any possible side effects and interaction
with other medicines
• whether there may be adverse effects from
prolonged use or inappropriate selfmedication.
• Listed medicines (labelled as Aust L) are
considered to be of lower risk and are required to
meet certain criteria in relation to safety and
quality of manufacture, but the TGA does not
evaluate their effectiveness prior to market
approval or review sponsor- held evidence prior
to listing on the ARTG.
Most, but not all, complementary medicines are
classed as listed medicines, where they only contain
ingredients that have been determined as being of
low risk and only make limited therapeutic claims.9
There is no assurance that CAM products purchased
in other countries or on the internet have been
manufactured to Australian standards of quality and
safety.12
In Australia, the regulation of CAM therapists varies
across modalities. Some specific CAM modalities
(including Chinese medicine, chiropractic and
osteopathy) are now regulated by a National Board
established under the Australian Health Practitioner
Regulation Agency,13 but the majority of other CAM
modalities are largely self-regulated, and this
regulation often differs between each State and
Territory. Most CAM therapists are affiliated with a
professional association, but membership is usually
voluntary and any agreed standards of care do not
have legal obligations.14
talking about complementary and alternative medicine – a resource for clinicians • 6 of 8
Further information
For clinicians
Systematic reviews on CAM by the Cochrane Collaboration
(http://www.thecochranelibrary.com/view/0/browse.html?cat=ccochcomplementaryalternativemedicine)
US Government’s National Center for Complementary and Alternative Medicine website, Time to Talk: Resources for
Health Care Providers (http://nccam.nih.gov/health/providers)
Australian Medical Association Position Statement Complementary Medicine – 2012 (https://ama.com.au/positionstatement/complementary-medicine-2012)
NPS MedicineWise Review of the Quality of Complementary Medicines Information Resources:
Summary Report, March 2009
(http://www.nps.org.au/__data/assets/pdf_file/0005/69656/CMsInfoSummary.pdf)
TGA Webpage The regulation of complementary medicines in Australia – an overview
(http://www.tga.gov.au/industry/cm-basics-regulation-overview.htm)
TGA Adverse Events Database (http://www.tga.gov.au/daen/daen-entry.aspx)
Izzo A. and Ernst. E. Interactions between herbal medicines and prescribed drugs: An updated systematic review.
Drugs 2009:69(13): 1777-1798
(http://www.cenegenicsfoundation.org/library/library_files/Interactions_between_herbal_medicines_
and_prescribed_drugs_An_updated_systematic_review.pdf)
Medicare Australia’s Home Medicines Review program (http://www.medicareaustralia.gov.au/provider/pbs/fourthagreement/hmr.jsp)
For patients
Cochrane Summaries – independent high-quality evidence summaries for health care decision making
(http://summaries.cochrane.org/)
Australian Government’s HealthInsite web portal
(http://www.healthinsite.gov.au/topics/Complementary_and_Alternative_Therapies)
NPS MedicineWise Topic, Using Complementary Medicines (http://www.nps.org.au/conditions-andtopics/topics/how-to-be-medicinewise/using- complementary-medicines)
Victorian Government’s Better Health Channel website, Complementary and alternative medicine
(http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/ct_alternative)=
Health Voices Journal of the Consumers Health Forum of Australia, Complementary Medicines: How well do
consumers know their product, Issue 11, November 2012 (https://www.chf.org.au/pdfs/chf/HealthVoices_NOV12_ComplementaryMedicine.pdf)
US Government’s National Center for Complementary and Alternative Medicine website, Time to Talk: Be an
informed consumer (http://nccam.nih.gov/health/decisions)
talking about complementary and alternative medicine – a resource for clinicians • 7 of 8
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Xue CL, Zhang AL, Lin V, Costa CD, Story DF. Complementary and alternative medicine use in Australia: A national
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McGuire TM, Walters JA, Dean AJ, Van Driel M, Del Mar C, Kotsirilos V et al. Review of the Quality of Complementary
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talking about complementary and alternative medicine – a resource for clinicians • 8 of 8