Hello, I’m Geraldine Moses. Welcome to this program
on Complementary Medicines – The Best Advice. In Australia today, over 60% of people
use some kind of complementary medicine. To help consumers use them wisely, it’s important that health professionals
are familiar with these medicines as they are pharmacologically
active substances with the potential for adverse reactions
and drug interactions. However, surveys indicate
that only half of all users inform their medical practitioners about their use
of complementary medicines. So health professionals also need
the skills to encourage consumers
to disclose their use and make rational decisions
about the potential benefits and risks in managing their health. This program looks at these key issues, including the quality,
safety and efficacy of comp meds. We’re not going to be judging whether
specific remedies work or not, our focus is on skills for health
professionals to help their patients. We want you to be able to ask the right
questions and to give the best advice. As usual, you’ll find a number
of useful resources available at the Rural Health Education
Foundation’s website – that’s www.rhef.com.au Now let’s meet our expert panel. Firstly, Dr Trevor Cheney
is a general practitioner from Bellingen in New South Wales and the VMO
at Bellinger River District Hospital. He has practised for 14 years
as a rural GP throughout Australia. His group practice successfully blends
integrative medicine and complementary therapies
into daily GP practice. – Welcome, Trevor.
– G’day. Dr Ken Harvey
is a public health physician with a particular interest
in medicines policy. He currently holds the position
of Adjunct Associate Professor, School of Public Health
at La Trobe University in Melbourne. – Welcome, Ken.
– Thanks, Geraldine. Professor Stephen Myers is the
Foundation Director of NatMed-Research, in Plant Science
at Southern Cross University. He initially qualified as a naturopath
and, later, as a medical doctor. He also has a PhD in pharmacology. – Welcome, Stephen.
– Thanks, Geraldine. Dr Evelin Tiralongo
is a senior lecturer in Pharmacy at Griffith University’s Pharmacy School
on the Gold Coast in Queensland. She is a registered pharmacist
with extensive practical knowledge in complementary medicines
and retail pharmacy. – Welcome, Evelin.
– Thanks, Geraldine. And, finally, Dr Jon Wardle. He is a practising naturopath
and a research scholar at the School of Population Health
at the University of Queensland. His PhD was on the use of complementary
medicines in rural practice. – Welcome to you all.
– Thanks, Geraldine. Now, Jon, I wonder if you could
just briefly tell us a little bit about your findings in your PhD because we have a rural and remote
audience out there. Tell us what your findings were. Certainly. The whole impetus
behind doing the PhD was the evidence that suggests
complementary medicine is used more in rural populations
than urban, which is kind of a surprise to most. GERALDINE: More in rural practice. Wow. Even in areas that are well served
by general practitioners so it’s not necessarily
they can’t find a real doctor, so they see a CAM practitioner. It was actually several cultural reasons
and historical reasons for that use. And the way I like to remind
general practitioners is that their patients are more likely than
not to be seeing a CAM practitioner, using a CAM product
and more likely than not to not want to talk about it
with their doctor. So I think this is a very timely,
uh, talk today. Yes. Now, Evelin,
we can tell by your German accent that you were not born in Australia
but you studied pharmacy in Germany. Can you tell us a little bit about your
view of complementary medicines and the way we’re different in Australia
about how we call them these things. Yeah, I studied in Germany, so, for me, the term complementary
medicine is quite strange. In fact, I wasn’t introduced
to this term until I immigrated to Australia in 2003. So for me, during my study in Germany, we were taught on herbal medicine
and homeopathic medicine as part of our degree and we practised
it as part of mainstream so it’s more like… what’s effective
and what’s ineffective and I think that’s what
we tried to bring out today and tonight in this show
that we’re trying to go by the evidence rather than calling it too much
complementary medicines. Now, Stephen, you’ve crossed
the boundary between naturopathy and clinical medicine, and you’re also
involved with the TGA, I understand, Therapeutic Goods Administration. Perhaps you can tell us what we should
be seeing as complementary medicines. What’s the definition? Well, the definition
of complementary medicines and I think the first thing that
we need to actually acknowledge is that there is a body of knowledge
called complementary medicine which involves both therapies
such as acupuncture, traditional Chinese herbalism,
Western herbal medicine, naturopathy, and then the medicines,
the ingestible medicines that are actually used. The Therapeutic Goods Administration actually says
that complementary medicines, also known as traditional medicines
and alternative medicines, are made up of a range of substances that include vitamin, mineral, herbal
medicines, aromatherapy, and homeopathic products. So it’s this eclectic range
of different substances. It’s important to note that it doesn’t
include prescription medicines, that’s completely
a separate component. Complementary medicine may become
a prescription medicine but it’s regulated very differently and it doesn’t include
any parenteral medicines so if it’s for injection, it doesn’t fall under the realm
of complementary medicine. They used to define it by a whole range
of different substances but they’ve now got
a more broader definition. And what would you say would be the most
popular or most commonly used complementary medicines
at the moment in Australia? Well, probably the one
that everyone in the audience will actually know about is fish oils. There was a time that
that was very fringe therapy. And I would even question whether
it’s a complementary medicine anymore because it’s so embedded
in mainstream medicine now. – Calcium is a complementary medicine.
GERALDINE: You’re joking. No. And folate, which we actually
obviously use in pregnancy. GERALDINE: Every pregnant woman. Neural tube defect,
that’s a complementary medicine. It’s a vitamin
that fits under the definition and is regulated by
Therapeutic Goods Administration as a complementary medicine. Ken, I’ll pass to you
about this definition. Are you comfortable with that?
Do you think that serves our purpose when we’re trying to help people
with comp meds? Well, I think it’s important. Um… the other important thing
that Stephen didn’t mention is that consumers can get a feel
for whether something is regulated as a complementary medicine because it has on the label an AustL
for a listed product. As Stephen said, the regulatory process
for listed products is very different to those
of registered products of prescription medicines. It’s a more light touch regulation,
we can perhaps go into that later. Yes, and, Trevor,
as a person in general practice who uses these medicines, how do you feel about the way
complementary medicines are regulated and this definition
that we’re using tonight? As a… I did orthodox training. I did a scientific training in medicine, which I love and respect
and I use every day, but I’ve noticed ever since I graduated,
there were still holes and, in actual fact,
not everybody fits the paradigm. And I ended up…
I’ve seen a lot of patients who do not fit the paradigm and another 25% who
that drug doesn’t work for whatever and they come back to a GP and say,
well, what am I going to do now? And so that made me take
a scientific approach and say let’s keep questioning, and that’s what my training is,
to be scientific, to question, what else can I do
to service this patient? The boundary
of what is complementary and not seems to me to be rather shifty
in modern practice. You just mentioned fish oil, calcium. Calcium was in, now it’s actually
going out again in medicine. Glucosamine has been out and then in
and now is being questioned but I think the evidence
is rising for it. I use a lot of nutritional therapy
which I learnt in basic medical school and we all forgot when we graduated and that’s considered complementary but it’s absolutely essential
to basic health. So the boundary for me is fuzzy, when you start learning
about these different therapies. What it does is add a whole new set
of tools to your armamentarium. So you can treat a person
that fits the paradigm orthodoxly, you can treat somebody who is not
prepared to take that paradigm and have the conversation with them, or you’ve got this whole new branch
of options you can use that also work. It’s been shown actually
that practitioners who have additional knowledge of complementary
medicines are better practitioners because they have a higher
self-awareness and also more knowledge about evidence-based practice
because they’re looking at those skills not only with regards
to complementary medicines but also with regards
to their conventional medicines. Jon, you’ve done some broad study about
who uses complementary medicine. Can you please describe who are the most
common users of comp meds? It’s not that different
from who the most common users of health services more generally are. Higher education, higher income usually, because it does exist
as an out-of-pocket expense outside the health system
for most people. Generally women, which also use
health services a lot more, and younger women,
18-34 usually, and that’s probably, I guess,
a product of the fact that, you know, we don’t unquestionably take on
what our doctor tells us without actually looking
for other options… GERALDINE: So you think
it’s a gen Y thing? Gen Y thing, but people are more
educated about their health. Health literacy is rising. We’ve seen the growth
of the expert patient and also, I think,
with that case of women, there’s a lot of women’s health problems which don’t necessarily fit into
conventional treatment really easily, and rather than just accepting, women
are out there looking for options. Does this profile of the patient fit
what you saw in your research into who uses comp meds
in rural settings? It’s pretty similar
and there’s been a lot of work done with the Australian Longitudinal Study
on Women’s Health which generally shows
the same patterns exist. The usage is a little higher
in rural areas. Also, Stephen, there’s the question
about people… People always talk about how much money
is spent on comp meds. Could you briefly tell us about those
studies that have been done? Fundamentally, the interesting aspect
of that is that Australians don’t actually pay the real cost
for medicines out of our pockets. Our government actually underpins
the cost of medicines through the Pharmaceutical
Benefits Scheme. And, you know, currently the figures
seem to be on parity that the public spend about $2 billion
on, out of pocket, for medicines on the
Pharmaceutical Benefits Scheme and about $2 billion out of pocket
for complementary medicine. So there’s… certainly good evidence to suggest that the public
are interested in purchasing, uh, these products even if they have to pay
for them themselves for the benefits that they perceive
they actually give them. – Could I make a comment?
GERALDINE: Yes. Other practitioners
have probably heard this as well. Whenever you talk about
complementary medicines, always the lead comment
is how much people spend and I think it’s a real distraction, and I think it also raises
a competition issue. They spend that money, they shouldn’t… the complementary practitioners
don’t deserve that amount of money. It’s missing the point. The point is do we have therapies
outside one paradigm that work and do we have things that are dangerous
– that’s what we need to know. And the money’s a bit of a distraction. It’s important for governments,
not for a practitioner. There’s a critical issue there,
you know. From my perspective, one of the problems
is the 65-year-old woman who might come to see you
who’s a pensioner who has got osteoarthritis and the option is that you might
be able to give her a medicine on the Pharmaceutical Benefits Scheme
that might take away her pain but may actually deteriorate
her kidneys and give her a risk
of gastrointestinal bleeding. Yet, equally effective medicines
in terms of removing the pain aren’t on the Pharmaceutical
Benefits Scheme. So at some stage,
we have to talk those economic issues. KEN: If I could just make
a comment there. It’s perfectly possible for the sponsor
or the manufacturer of a complementary medicine who believes
it’s efficient and effective to put in a submission to the
Pharmaceutical Benefits Scheme and to get it subsidised and, indeed, some have tried to do that
with glucosamine, for example, it didn’t get up because it was not
thought to have the evidence and cost effectiveness data there. So, again, the system is not unfair, it simply asks
that the complementary medicine person provides the evidence
to the government committee and then it would be subsidised. Well, I hear that, Ken. One of the things that I’d argue
is that it’s in the public benefit that the government actually makes
some decisions that certain medicines
are in the public’s benefit and that, actually, for those things
that are generic and they’re in the public domain and there’s no patent associated with it
and no company specifically pushing it that we make those medicines available. We’ll come back to cost
and who should pay for the medicines when we talk about, um… which work,
I suppose, and equity of access. So we’ll now go to our first case study
who’s John, a 55-year-old professional
with a BMI of 27. He has a stressful and sedentary job, he runs twice a week and plays a bit
of competition tennis on the weekends to keep fit. But he’s also got a bit of hypertension and hypercholesterolemia. He’s had that for about five years, for which he takes a low dose of perindopril and amlodipine, 40mg of simvastatin a day and a bit of low-dose aspirin. Lately, he’s been experiencing significant knee pain during and after tennis and his local pharmacist has suggested that he takes 1,500mg a day of glucosamine sulphate as well as 8-10 capsules a day of fish oil to relieve the pain. He presents to his local GP
for a second opinion on this regimen, especially since it’s quite expensive, which is relevant
to our recent discussion. So, Trevor, let’s say this John
presents to you, how would you approach him
and also his decision to follow the pharmacist’s advice
to purchase these medicines? Ahem. Firstly, he’s come for an opinion and as a qualified doctor, people sometimes forget our job is actually to take a very professional
approach to this. Firstly, I want to be asking
why is he having knee pain, why he’s on perindopril,
why he’s on amlodipine, one of the least evidence-supported
medications that is one of the highest sellers
from pharmaceutical industry, and why he’s on simvastatin. I’d really like to look
at all those things because his knee pain is not just, um…
necessarily ‘I play tennis, I get knee pain.’ There are a number of issues
in his history that, as a doctor, as a practitioner, I need to actually go into first. But I’m actually happy to have
the conversation with him about the glucosamine and the fish oil because I’ve also seen evidence
to say they’re beneficial. Are you suggesting
that you first want to establish that the diagnosis is correct,
that he has osteoarthritis? Well, that’s right. I’m questioning
whether he actually has osteoarthritis. Even then, is there a role for fish oil
in the management of OA? I believe that’s controversial and, um… I’ve seen lots of conflicting
information about that. In terms of my own practice, it’s one of the options that I discuss
with people and people want to try it. Some people come back and say, ‘I can’t
believe how much better I feel.’ And I can’t deny that reality. If they are that much better,
that’s fantastic. If they’re not, I say,
‘Don’t waste the money.’ So should this guy
first have come to you before he purchased
the complementary medicines? I think it’s great that the pharmacist
suggested he actually get investigated and that’s really… the key is a team
within the therapeutic alliance with pharmacists, the GPs,
nurse practitioners, whatever, saying, hang on,
what we’re missing here, we really need to check into this guy because it may be arthritis, it may
actually be simvastatin-induced muscle weakness and wasting, which, at 55, is pretty horrible
and is actually often ignored. So that actually needs to be looked at. At first glance,
this case looks pretty simple. They look like effective therapies with
very little risk and lots of benefit. But, Evelin,
I wonder if you’d like to comment on, perhaps, what else the pharmacist
could have done. If I would have been the pharmacist
who’d first seen that patient, I would have not… I’d have probably
suggested those as a possibility but would have said to see
the medical practitioner to actually get a diagnosis. I would have made a referral
to the practitioner and said, ‘What is your knee pain?
Is it osteoarthritis? Look at the exercise you’re doing.’ Also diet and lifestyle issues may play
a role for this particular person. I think, as pharmacists, we get trained
in looking at those things and we should remind ourselves that we should look
at those other possibilities. And then, if you look at glucosamine, there is evidence out there
that it is useful in osteoarthritis and it depends really on
what evidence you look at. Whether… which salt is really
the most effective one and there’s a big debate
on which product to use. But it seems to be that glucosamine
sulphate is appropriate but I would have probably also said chondroitin sulphate should be used
in combination with that because there is evidence for it. And with fish oil, of course, with regards to the indication, it could be used on that patient but it’s not as high in evidence
for a particular osteoarthritis. So if you do, as a pharmacist,
if the patient comes to you, I think you need to establish first
whether it is the indication, what the patient actually has
to make an appropriate counselling. I’m perfectly happy with trying
to tail a therapy to the patient but, I mean, there are some facts. Glucosamine, as Evelin said, there’s variable evidence,
often it’s product specific. It’s been taken off the Danish
reimbursement system because it was felt
there wasn’t sufficient evidence to subsidise glucosamine. Fish oil again, I mean,
there’s good evidence for its use in rheumatoid arthritis and, certainly, for
hypercholesterolemia. But osteoarthritis is dubious. Wearing my public health hat,
I’d say, look, this guy, 55 or so, perhaps it’s time he stopped
playing tennis. I mean,
that’s pretty stressful on joints. What about swimming? What about walking? There are easier things to do.
I mean, you’re not young all your life. GERALDINE: That’s right. And adding to that is
Quality Use of Medicines actually suggests that we need to always ask the question about whether we should be prescribing medicines
in the first place. Are there non-pharmacological
approaches? And if Trevor’s investigations
demonstrate that he does have osteoarthritis, then acupuncture might be
a very successful therapy and there’s some very good evidence
about the role of acupuncture… KEN: Sham acupuncture
or genuine acupuncture? No, genuine acupuncture. I saw a study recently
of a meta-analysis of 18,000 patients which, I think,
has proven beyond a doubt that acupuncture is very effective for pain management
in musculoskeletal problems. So, you know,
there are other things to look at. Interestingly, a number of these things
may have ancillary benefits. You know, I’ve published,
from my research group, on the benefits of fish oil
in occupational stress which this guy suffers from. So, as Trevor said, if he finds that the
fish oil is benefiting his arthritis, it may be actually having other benefits
because it has systemic action. But you hit on
a very important point there that’s people… sometimes employ some… let’s say, justifications
for their purchase of remedies, partly because it’s a way of not having
to spend the time going to the doctor but also it’s a safe plan B that you can take these remedies
and, even if it doesn’t work, it’s got some additional benefits
and it’s sort of ‘healthy’. I mean, do you have a comment on that,
Stephen? Well, look, at the end of the day, I think, you know, there’s an issue
between theory and practice. I believe, in theory, that we should be
able to get everything from our diet and the environment that we live in. In practice, I don’t think
that actually works out. I live in the country, I came down
to Sydney for this program. I find the idea of breathing this air in to be pretty intolerable
on a long-term basis. You know, I know a lot about diet. I know that I err when I’m travelling, when I’m under significant stress. All of the dietary studies
in this country have shown that there are at-risk groups
with nutrient deficiencies. So I think that there’s probably
a good place for supplementation and it’s part of that,
you know, the practice of us all living the good life
doesn’t actually happen out there. We have to differentiate between
nutritional supplements and remedies that are more
pharmacologically active substances. This guy won’t be suffering
from a glucosamine deficiency or a fish oil deficiency and if he were, then a lower dose
would surely be employed. I’ve heard it argued by James Duke
from… X, the Department of Agriculture
in the United States that maybe some of these people are suffering from
phytonutrient deficiencies. I mean, really, if you summed up
the whole last 50 years of nutritional research, it’s eat more
fruits and vegetables. If we all did that, we’d actually be
significantly healthier. So I think there’s a place
if people aren’t having all of the stuff that they need to have
to actually be healthy to provide some of those supplements that might give them some of those
phytonutrients that they need. JON: I think that was an interesting
point you were making as well that the thing that really stands out, regimen in naturopathic medicine
has a very different meaning to what’s used here,
it’s actually diet and lifestyle. What we’re really seeing here
is the extension of drug therapy. They’re natural drugs
but they’re just drugs. There’s no, I guess… That is a big thing
in complementary medicine, without the complementary medicine
practice, they really are just extra drugs. They may have lower side effects, but they’re using that same
biomedical reactionary model and that’s generally probably causing a
lot of that problem with effectiveness. There are many myths and misconceptions
associated with complementary medicine, one of which you just alluded to,
people think ‘natural’ equals safe. I think we all understand
the weakness of that argument. But there are some other ones like,
you know, ‘I can give it a go
because there’s no potential harm.’ I mean, Ken, would you like to talk
about some of the potential harms associated with the use
of complementary medicines? Clearly, they are lower risk medicines and that’s how they’re regulated by the
Therapeutic Goods Administration. Having said that, that doesn’t mean
they’re without risk. Some of them have
their own side effects. Certainly, many of them interact
with conventional medicines which is why it’s so important
to take a comprehensive history and make sure you know
what the patients are taking. And, equally, well, they can have quite
an impact on the patient’s hip pocket. These are quite expensive and if they’re
not actually providing a useful benefit, then that’s a problem, especially
as often patients can’t afford all their conventional medicines
sometimes. Last but not least,
and a particular worry, is that sometimes, they’re used
by practitioners and patients as an alternative to a conventional,
more evidence-based approach. That’s where we’ve seen some patients
get into really dire straits where they reject conventional medicine and use these alternatives instead. – Or a delay of more effective therapy.
KEN: Yes, exactly. One of the misconceptions, Stephen, I just thought you might want
to elaborate on the idea that traditional evidence
is… What’s the usual saying? Something like 3,000 years
of Ayurvedic medicine can’t be wrong. What are some of the weaknesses
in that argument? I think one of the things we have to
appreciate right from the word jump is that there’s a difference between
an anecdote and empiricism. An anecdote is
that I caught a train today. It’s a part of a personal narrative
and is generally a single incident. Empiricism is people actually
using observation to be able to determine outcomes. And I would argue and have argued to my
medical colleagues on many occasions that herbal medicine, for instance,
is an empirical science. It’s the result of trial and error of literally probably millions
of herbalists over billions of hours of usage over trillions of trillions of patients. Now, as a medical scientist, I’d actually say it’s not the highest
level of evidence. There are cultural biases,
there are social biases, there are observational biases,
but it is a form of science. And to back that up, we did experiments
at Southern Cross University where… we took plants
that were used in China and plants used in Australia
by Indigenous Australians that we believe, because of the way
that they were used, were anti-inflammatory. The same plant in both countries used by different populations
for primarily the same purpose. Um, the pharmaceutical industry
would tell us that there’s one hit in 1,000 plants
in random bio-prospecting. We got 24 hits out of 30, which is an 800% increase in random bio-prospecting. So traditional medicine
has actually got a value from a scientific perspective
as a repository of knowledge. Yeah, but it’s still observational data
and, Jon, didn’t you allude to this in some of your reports that you’ve
written for the regulatory agencies that we have to remember the weaknesses
of observational data. Well, there are weaknesses
but I think there are strengths as well. It doesn’t mean that we should stop
at observational data but I think that observational data does
give us somewhere to jump off from and I was just talking
with Ken outside – the Indian Government, for example, have actually developed what they call
the traditional knowledge database which is essentially digitising
old texts from traditional medicine as a tool for researchers, so they can
actually see what was used traditionally so they can do the research from that –
it shouldn’t be discarded entirely. Especially the World Health Organisation
is really pushing traditional medicines and over 80% of the world’s population
is using traditional medicine so we definitely can’t dissuade… Clearly, there’s been good Western drugs that have come out
of traditional medicine. Aspirin out of willow bark,
digitalis out of foxglove, artemisinin derivatives out of Chinese
herbal medicines for malaria, malarial parasites. But equally, well,
there’s been big problems. I mean, we used,
in traditional medicine, uh… bloodletting for 300 years. Now, we still use bloodletting
occasionally for haemochromatosis and a few areas where it works but that was, again,
found by controlled clinical trials when you counted the bodies
after bloodletting compared to no bloodletting,
that, in fact, it was very harmful. So the essence is we’ve got to put this
traditional knowledge to clinical trial. I don’t think any of us
would dispute that. We should also remember that the TGA
allows traditional use evidence and I think that is one part
which a lot of practitioners don’t know and I think that is important.
It’s defined in the regulation. GERALDINE: We need to move on
to our second case study. Our second case study is Sharn,
a 52-year-old woman who presents to the local pharmacy
wanting something to alleviate her menopausal symptoms which include frequent
day and night sweats, sleeplessness at night, excessive
tiredness during the day, mood swings and increasing anxiety. She says that she’s heard that valerian
and black cohosh are helpful. She’s clear she does not want HRT
and intends to visit a local naturopath. So, Evelin, what would you suggest
for this woman? Well, as a pharmacist,
I look at the evidence and for black cohosh,
the overwhelming evidence, – there’s some controversial as well, as of almost every
complementary medicine – but for black cohosh, it says that
mostly there is evidence for decreasing menopausal symptoms,
especially hot flushes. So black cohosh is definitely
a possibility and valerian is not used in menopausal
or hasn’t been tried in menopause of women
but it is used for insomnia. There’s enough evidence out there
that it helps with insomnia. So I would clearly say to that lady that
it is a possibility to use black cohosh to help with hot flushes and try valerian for insomnia. But there are obviously risks associated
with complementary medicines as well and so I would point out, for example,
with black cohosh, although it’s a relatively safe herb, there have been reports on
hepatotoxicity with black cohosh, and I would allude to the fact that if
she has a pre-existing liver condition that she shouldn’t use it, for example. Although, it’s controversial again
whether it is really that bad, if there’s a really close relationship between the reported cases
and black cohosh. Can you quantify the degree of benefit
for this woman’s hot flushes? You say that the black cohosh
is particularly beneficial for that. So say she normally
gets 20 hot flushes a day, can you tell a person how much
that might be reduced by? I wouldn’t be able to quantify it because no studies
have really shown that, but apparently, it is the amount
of the number of hot flushes a day and the severity is decreased
from what we’ve heard and what we’ve seen
in the clinical trials. And with valerian, it helps you to
fall asleep, for example, and easier… GERALDINE: Ken? Again, I think going back to Trevor’s
concerns about asking the patient. I’d be interested in why she doesn’t
want hormone replacement therapy. Clearly, there’s been concerns about
the long-term use of that but, uh… current thought is that
short-term use is very effective in terms of relieving symptoms and unlikely to be particularly harmful. Again, it’s just something
that could be explored. It may be that she’s got some
misconceptions about this. There’s been a lot of bad
media publicity. It may be it’s a reasonably held belief. GERALDINE: Do you agree, Trevor? Well, there’s a couple of points
I’d like to make. One is although Evelin can’t say
how many hot flushes the black cohosh will reduce, I couldn’t say the same thing
about Estalis patches either. I can’t tell the woman that will reduce
the flushes by ten per day. Really, all I can say is that this is
the amount of evidence I’ve got and… you can try this, it’s a medicine
I think would be beneficial for you if the diagnosis had been properly made. But I will take your feedback. The critical question here is she said she has heard of valerian
and black cohosh are helpful. What I would like to say is,
‘So have I.’ I’ve heard they’re helpful. I actually don’t know about valerian,
so I’m not going to presume to know, but let’s agree that we’re going
to look into this together. That’s right, surely you’d go look it
up, which we’ll talk about later. And the thing is, if she’s come saying,
‘I don’t want HRT’, and if I stand up there and say, ‘Well,
you bloody well should have HRT,’ we’ve lost the battle. If I can say,
‘Yeah, I’ll hear about it. The symptoms you’ve described
could actually be HIV, could be hepatic liver…
alcoholic liver disease, or it could be hepatitis.’ Again, she’s not necessarily
just a walking symptom. – You have to have a diagnosis.
TREVOR: Right. If that’s what she’s going to do,
that’s fine, but we’ll have the conversation later
if you need help. There’s a critical issue that I think
is important to emphasise – the fact is that there are
a range of therapies and I think part of our responsibility
as health professionals is to communicate to people
what their range of choices are. As Ken pointed out,
short-term HRT is effective. You know… black cohosh is effective. We’re currently doing a study,
looking at acupuncture in menopause and there’s good evidence to suggest that acupuncture
is an effective treatment. One of the things we need to do
is to let people know what their range of choices are and support them taking those effective
sorts of therapies. I think that’s why it’s so relevant
to talk about this in the setting of rural and remote practitioners
and patients because not all the choices
are available so you can talk till you’re blue in the
face about going to have acupuncture but there might not be
an acupuncturist around. But the beauty of
a lot of complementary medicines is that you can order them
over the internet! In fact, we have had a question
from a GP in the Northern Territory who asks, ‘What do I say
to some of my patients who tell me that they can buy CMs
from overseas on the internet. Can’t really get them in Australia,
is there a quality issue even for products like evening primrose
oil for menstrual pain? – The answer is don’t do it!
– (All laugh) Just be very clear to your patients,
don’t do it. The reason for that is there’s at least
a sort of 30-50% probability that those products purchased
over the internet are substandard, counterfeit,
have no active ingredient, or are adulterated
with things that shouldn’t be. Again the Therapeutic Goods
Administration has been quite good at picking up those sorts of things but
the message again, I’ll just reiterate, do not purchase products
from the internet overseas. Trevor, I believe you’re absolutely
frightened of remedies from overseas. – Is that correct?
– Yes. I think I’ve seen too many stories
and cases about, as was mentioned, counterfeit medications. And we do not have any control
over stuff that has come through
that sort of a source and anybody who gets on their emails – all the advertisements for Viagra and
Viagra equivalents would know that! How much marketing
there is in that stuff. I think that’s what we have to… For all its faults, the TGA does
a fantastic job in some things and is world-leading in many respects and one of the things that you can be
guaranteed of in Australia is that if an Australian product
says it has something in there, it has a TGA standard name
so it actually has that in there. When you’re looking at interactions, you can be pretty sure that’s going
to interact with that. In American products,
they don’t have standard names. You may have the one substance
listed there four times if it’s even on the label at all, so there are safeguards
that exist in Australia that just don’t exist anywhere else. Don’t buy Australian products
over the internet because a lot of them
are also counterfeit, so that’s another problem. For example, it was highlighted by a
Blackmores CEO at an industry meeting that eBay has lots of range
of Blackmores products and they doubt whether those ones
are particularly… They can’t tell you whether they are
actually made in Australia or not. So, again, there’s an issue
with buying Australian products over the internet from
God knows which sources. I think we need to be clear that there are reputable Australian
internet pharmacies that do produce Australian regulated
products of good quality. What we’re talking about here
is overseas internet, which, as Evelin said, can mimic
and counterfeit Australian products but, again,
the message is don’t buy them. I think, getting back to this case, I think it’s very important
for us to also emphasise that, in talking with patients about
their complementary medicine use or intention to use,
we need to take an adequate history. So partly, I think I’d like to know,
Trevor, what you think if this lady had a history
of breast cancer and also what should we teach those
watching the program tonight about taking a history of the people’s
complementary medicines themselves. One of the first things
is not to be shocked and frightened to ask the question
and to hear what people say. They will say, ‘You’re one of those
doctors that’s going to lecture me.’ Whereas if you can say,
as I said, ‘Valerian, I don’t know. I understand what valerian
is, um, but we’ll look at that and the black cohosh, I have some
information, some knowledge on that.’ Once you start saying, yeah,
let’s talk about this, you’ve actually got a chance
to work through whatever the best option’s going to be
and actually protect the patient from some of the scams
that are being talked about here. But that takes time and you can’t do it
in a six-minute consultation. Evelin, what do you teach your pharmacy
students at Griffith University about taking a history
of complementary medicines? We actually say… we teach that they
should actually take a record of what patients are purchasing
including complementary medicines and that’s actually what we found when
we did a national survey of consumers. We found that consumers
actually expect pharmacists to take a record on those products. And they have to document
the actual brand, don’t they? Exactly, because obviously not every
complementary medicine product is the same so you need to really
distinguish between products and, um, look at the active ingredients
and extracts for herbal medicines. And the dose. Yes. EVELIN: Treat them like medicines,
basically. GERALDINE: Exactly!
Like any other medicine. But prescription drugs, because often
we have generics that will be more or less equivalent, people would
just put down the active ingredient, but you just can’t do that
with comp meds, can you? No. But that’s why, if you work
in a pharmacy, you are the owner, if you stock products
where you know the evidence and you know
they are good quality products, then you’re already one step ahead. If you have regulars coming in,
you get to the point where they’re purchasing those products
which you know are quality products, and that’s where we want to get to. That’s right. We’ll talk some more
about products in a second. We’ll just get on
to our third case study which brings up some of these issues. So this case is Marjorie. She’s a 65-year-old woman
with rheumatoid arthritis. She’s currently taking
hydroxychloroquine, she’s also on alendronate
for her osteoporosis and a bit of prednisone. She’s begun taking a digestive enzyme
product that contains minerals as well which she ordered online
from the United States. The thing is,
there are some interactions here and also issues of product quality. So, Jon, could you please comment
on how should someone assess the risk of taking
a complementary medicine product with their prescription drugs? Well, as I said, I would just consider complementary medicines
to be natural drugs. Some of them aren’t even that natural but you should just treat them
exactly the same there. They’re usually pharmacologically active
substances with a risk profile
and a benefit profile and, hopefully,
the benefit outweighs the risk profile. So I would not think of them
any differently and it is really something
that GPs should be cognitive of and actually learn how a lot of these, particularly the common ones,
actually do work pharmacologically. In this being a real case, the problem was she actually hadn’t
noticed the minerals. When they were…
If minerals were presented to her as substances from a doctor
or a pharmacist, she would’ve thought
about drug interactions but because they were lumped
into this… And this raises that point of purchasing
something not with that TGA safety because in the US,
you don’t actually, um… The labelling laws that exist there don’t necessarily come anywhere near
the Australian ones. So even knowing what was in there,
even if you actually had it, the only way to be sure,
you’d have to send it off for analysis, which you can’t obviously do. If you bought an Australian product,
you would know what was in there and whether it was interacting
with your medicines. I think that’s a critical issue
that we need to just acknowledge. I mean, it’s one of the areas
that I think the TGA has done… made major mileage
in comparison to other countries. Back in 1985, they actually mandated that all companies manufacture
therapeutic goods in this country to pharmaceutical grade standards, to pharmaceutical good manufacturing
practice or GMP. A lot of small companies that weren’t
able to do that went out of business at that particular point in time and the industry now, I think,
is actually rightfully proud of the fact that, you know,
certainly the majority of the industry actually follow those standards,
I think, with pride. In comparison, in the United States, complementary medicines
are made at food grade standard. Now, it’s not that there wouldn’t be
some companies who up the ante and play a higher game but there are products in the US market that, you know, I wouldn’t feed to a pet
animal, let alone actually consider taking myself or giving them
to anyone that I actually cared for and certainly would never consider
giving them to a patient. One of the critical issues is
pick up any complementary medicine in this country,
pick up any pharmaceutical drug and it’ll have an AustL number
if it’s a complementary medicine and an AustR number
if it’s a pharmaceutical drug. And they mean that it’s part
of the therapeutic goods regulation in this country,
it’s either listed or regulated, and one of the things that the TGA does
is to actually determine how medicines are actually regulated based on a risk
framework – from low risk to high risk. That risk framework actually starts
to set the standard for how complementary medicines
should be regulated internationally. They’re the only way that someone
can bring in a therapeutic good into Australia
and legally market it, isn’t it? If there’s no AustL or AustR,
is that right to say it’s illegal? It’s illegal, yes. If you go to a shop somewhere in… in, uh, an area of the city and there are products
on the market for sale and they look like therapeutic goods and, you know, I think there’s a saying
among my colleagues at the TGA is ‘if it looks like a duck
and it quacks like a duck, it’s a duck’ so if it’s a bottle and it’s got tablets
in it, it’s a therapeutic good and therefore, it must actually be part of the Australian Register
of Therapeutic Goods and if there’s no AustL or AustR number
on it, it’s an illegal product. Perhaps I could add also that people
can explore the ARTG themselves. You can go online and search the
Australian Register of Therapeutic Goods and if a Hunger Buster,
I’m just making that up, any brand of a substance that you see
as a possible therapeutic good isn’t there, that’s bingo, isn’t it?
Means it’s illegal. Well, it’s not quite as simple as that. I mean, basically, Stephen is right,
but there are exempt products. Some homeopathic products,
for example, are exempt. Again, there’s concern about this and I think the regulations are going
to be changed but at the moment, although that’s 99% right what Stephen
says, it’s not 100% right. Equally well, the fact that you can go
to the TGA website and look at the register
and see products there, complementaries, that’s a problem too. Because although there’s information
on the public record about complementary medicines, it’s put there by the sponsor,
it’s not checked by the TGA and a lot of that information
is quite incorrect and wrong. Outrageous claims are being made,
for example, by the sponsors and we have the same problems
in promotion too. But I think we’re going to come to that
later when we talk more. Ken, just briefly, if this product,
this digestive enzyme product from the United States
had actually been recommended to this lady by a pharmacist or a doctor or a complementary medicine
practitioner and sold, even though it’s not
on the ARTG, is that also illegal? KEN: Yes, it is. It is.
– I think that’s an important point. Oh, yes, it is,
and it is very important. Safety and measure,
as Stephen has highlighted, a customer should look at the label to
see if it’s got an AustR or AustL and if it hasn’t got that,
it certainly raises questions. It’s especially important in regard
to herbal products. One of the things that the TGA mandated
a number of years ago because of issues associated
with potential substitution of one plant for another and it might be done inadvertently
at point source where they’re actually getting
the raw materials, is that if you put a herb in a product
in this country, you have to send it off
to an independent laboratory to have it botanically identified
so the herb that’s on the label is the herb that’s in the product and I think that’s one of the guarantees
we have in Australia. Again, it’s not quite as good as that. We’ve had the problem of adulteration
of herbal products. For example, people may well remember
melamine and milk, which is not a herbal product, but it was an example of people
contaminating milk with melamine to fool chemical tests. Now, the same thing, regrettably,
is happening with herbal products. In particular, one example in Australia
was ginkgo biloba a couple of years ago which looked fine on the basic test
but was actually adulterated with buckwheat so it really didn’t
contain the ginkgo that it was meant to but it fooled chemical tests. Again, to give credit
where credit’s due, the TGA has actually upped
the testing on that. But there’s an ongoing problem here
with adulteration and, uh, these sorts of things. I think it’s important
to actually acknowledge that people who actually adulterate
medicines are criminals. And one of the things that probably is
one of the biggest growing parts of organised crime internationally is
the production of adulterated medicines. There’ve even been some people
from the WHO that have estimated that up to 50% of medicines
reaching the developing world may be actually adulterated. KEN: Counterfeit.
They had no active ingredient. And if people experience adverse effects
from these adulterated ingredients, it’s really important to report
those adverse events, isn’t it? So we might just remind the audience also that we need to hear from the community about adverse events and safety to identify these problems. The Therapeutic Goods Administration will take calls directly. There’s the Adverse Medicine Events Line that members of the general public can ring up. KEN: Health practitioners have access to the TGA’s blue form, now it’s internet based. Again, if they’re getting a history
of complementary medicines and other medicines and getting some
concerns about adverse reactions, then fill out those forms,
go on the internet. It’s the only way
we’ll know about those. It’s very important
that they’re asking the patient what exact product it was, so they’ll be
able to specify that on the form and the patient stays anonymous, which
is also important to tell the patient. GERALDINE: Names don’t go on the form.
– Exactly. Now, we must move on
to our next case study – one of those heart-sink situations where we often see complementary medicines used because the person
is faced with a mortal illness. So this patient is Mrs Goodwin
who lives in a small coastal town, recently diagnosed with colon cancer, and has had one round of chemotherapy and was very ill throughout
and in post-treatment. She approached a complementary medicine
practitioner who promised miraculous results using certain herbal remedies. After taking these for two weeks, she began to feel better, the practitioner was not registered
with any authority and insisted that Mrs Goodwin trust him and not take any further part in orthodox medicine or treatment. So she stops the chemotherapy and continues with herbal medicines and, after six months or so, Mrs Goodwin begins to seriously deteriorate
and is in pain. She continues the herbal treatment
but her husband is very concerned and wants their GP to do something. Now, Trevor, I understand you’ve been
faced with similar patients. Tell us what we can do. Yeah, we’ve actually had to deal
with very similar circumstances and, ahem, there’s a couple
of hard lessons in here. Firstly, we are not our patients’ keeper and, unfortunately, people make
bad choices, bad decisions, and we… if we can keep engaged
in the conversation, sometimes we can protect them
from those decisions and balance the information better
and interpret it better. Sometimes we can’t, in which case,
the case that’s presented, she’s come back after six months
and things are looking bad. I still… even when she’s made
a bad decision, I’m not going to judge her because,
at the end of those six months, she’s going to come back, I’m still
going to say, ‘I still care for you. I still respect you as a human, and this hasn’t turned out as well
as you might have wanted it to but I’ve still got a lot of therapy
I can offer you to support you and most of that
will be conventional therapy.’ But she’s not supposed to engage
any of your therapies. So now we need,
if we’ve had that conversation – and we’ve had this with a patient
in our own practice – we’ve got the opportunity to say,
‘Is this working for you? Is this alternative therapy working?’ There comes a time
when it’s actually not working and so, ‘Will you now talk to me?’ I’ll be blunt and I’ll be honest and
open, I need to be honest and open and say what I can do. The big problem with the case
as it was originally presented was that it didn’t work
and her disease progressed but what if she was also
engaging in therapies that were downright dangerous
to her health – say, vigorous colonic lavage
and enemas galore. What would you do?
Would you step in? Well, I have to be careful
how much I can step in because, again, if I actually walked
over to her house and held her and said, ‘No, you can’t do this,’
that’s an assault. So, again, if I can keep
the communication going, I can actually be honest,
maintain the respect and say, ‘This is doing you harm.
Look at what’s happened now.’ If she refuses my advice,
I have to live with that, and, in fact, I probably will need the help of some of my colleagues
to work through that. Other members of the panel,
how would you feel, how would you act if this patient faced
with a mortal illness was actually a ten-year-old child and was being taken to
the complementary medicine practitioner, who we’re presenting as someone
who’s not registered and perhaps engaging in questionable
practices, by the parents. I mean, what do we do? Well, in theory,
that’s assault on the child and there are legal remedies. But, obviously, as Trevor has said, the first thing is to try
to get good communication going and to try to sort it out. Having said all that,
if that absolutely fails, you have got a duty of care
to the child and there are authorities
that you can and must go to if that child
is ultimately going to be abused. But, again, I’d go back
to what Trevor has said – good communication,
keeping the lines open, is terribly important. There are important communication
principles here, aren’t there, about respecting the patient and so on? We have to respect
the patient’s autonomy, that doesn’t mean
I’d like what’s happening to her. And, in fact, this ‘therapist’
who’s pretending to be a therapist, as has been said,
there needs to be some legal control over that sort of behaviour and bring on regulation
of, um, complementary therapies because there are a lot of charlatans
out there doing crazy stuff. But, hey… my colleagues, who I know do terrible things to patients
in six-minute medicine. JON: And the communication
is particularly important, too, because, nine times out of ten,
if you give a patient a choice between a CAM practitioner and a GP,
they’ll choose the CAM based solely on the fact that they get
to see their GP for 15 minutes max, they get to see their CAM practitioner
for an hour, there’s a greater therapeutic
relationship built on communication. So if you improve communication,
you build trust and then the patient can actually
trust you to take your advice. I was actually once put on the spot
on a radio program where somebody asked me, ‘How do you
tell a good complementary therapist?’ One of the things I actually realised from my own training
and what I actually teach students, is that they have to know the limits
of their practice. I’d say that that’s a critical issue
for any therapist is basically, if you go and see
any therapist, from a surgeon
right through to an acupuncturist and you actually say to them,
‘What are the limits of your practice?’ If they don’t know any or they believe
that their therapy can cure everything, then get out of your chair
and run for your life because no therapy is perfect. In this case of Mrs Goodwin,
what advice would you give the husband who’s so concerned? Well, I think one of the issues I’d
probably be discussing with the husband is trying to actually expose Mrs Goodwin
to what her full options are. You know, I’d probably be trying
to get her to see somebody who can actually explain everything
from the herbal medicine she is taking right through to her
options in chemotherapy and radiotherapy and talking through
what they’d actually do. You know, sometimes,
I say to patients, ‘I’ve done 14 years
of university education and if I was in your body
with what I know, this is what I’d do.’ As a health practitioner,
it might be worthwhile also trying to talk to the complementary
medicine practitioner, you know, if the patient gives
their permission to do so to maybe come up with a combined effort
to maybe compromise. Maybe even, you know, suggest a second
opinion from another naturopath or another acupuncturist
or whatever that CAM practitioner is because… I’ve edited the textbook
for naturopathy. We actually teach students
how to work with chemotherapy and the acupuncturists do the same,
the chiro… This isn’t standard complementary
medicine practice, so finding a complementary medicine
practitioner that will work with conventional
treatment is an option that you can talk
to her husband about. We have received a question from Linda
who’s a nurse in North Queensland about a medicine
I’ve not actually heard of so I’d be interested to know
whether any of you have. ‘How can I intervene
on behalf of a child who’s being given homeopathic A-P-I-S?’ JON: Apis.
– Apis. What is Apis? EVELIN: Bees. GERALDINE: So bee sting? TREVOR: Homeopathic…
EVELIN: Yeah, from bees. ‘How can I intervene
on behalf of a child who’s being given homeopathic apis
for bee stings regularly who is allergic to bee stings?’
Trevor, a response? Keep communicating is one thing because you can say,
you can report her to DoCS, which I’ve been told to
by a specialist before. Then you will actually lose
all communication with the family, it’ll be a catastrophe. Or you can keep saying,
‘Hang on a minute, we need to keep discussing this,
this is not working. Can we actually engage some tests to see
if it actually has worked?’ There are ways you can do that. And keep
putting the evidence in front of them. The question is
why would you want to interfere? Has the child been having an allergic
reaction to this homeopathic medicine, which raises the question
why would that be? If it’s a high dilution,
it would work in a different way. So it’s a question
of whether she’s observing an adverse reaction
to that homeopathic medicine. Perhaps you can guide this nurse
asking the question about what to look for on the product,
maybe see how diluted it really is? Yeah, it goes into a big discussion
about what homeopathic medicines are and, you know, that the diluted ones
are more potentiated. It’s a completely different paradigm. It’s too difficult to discuss
in this short period of time. – It raises the issue about resources.
EVELIN: Yes. This is an important issue
we need to spend time on – where to go for information. And that was a question
we have had from Dr Craig Brown. ‘Which complementary medicines
have good evidence base and where can I find this information?’ So, for example, Evelin, if we were
going to look up homeopathic apis, where would you go to look that up? Well, I… the first look would be
at the review from the NPS which was conducted in 2009
and the review on the quality of complementary medicine
information resources. And if you go to the NPS website, you actually can download the PDF file and, um… in that review, they were looking at all sorts
of different resources and the Natural Medicines Comprehensive
Database was, for example, one of the ones
which they classified as very good to get information from. The one which is listed there,
the fourth one, the Natural Standard database
was another one. Those ones are subscription databases. However, the subscription, for example,
for the first one is relatively low. For a three-year subscription,
you’re paying less than $200. So, really,
as a healthcare practitioner, you should look at this NPS review and every pharmacy in the country should have access to those databases. And some of the other databases
mentioned there are the general ones we go to – Cochrane and PubMed,
which are databases which also contain information
on conventional medicines and we should, as health practitioners,
be familiar with those anyway. There was another one
which was an American-based one which is quite good for giving
complementary medicine information too and I’m sure she would find some
information on homeopathic medicines in those databases as well. – Even Google is useful, isn’t it?
EVELIN: It depends. – (All laugh)
– Depends. Maybe not Wikipedia. Before Google and Wikipedia, you’d
just sit there going, ‘What’s that?’ and hopefully look up
a lot of pharmacopoeias but now you can search the world! KEN: Well, you’ve got to be very
careful, haven’t you? Because there’s an enormous amount
of rubbish on Google and the key thing is to sort out
what are the good resources and again, Evelin’s made the point that the National Prescribing Service
has done a lot of work on this. There are good resources. I subscribed to at least one of those. It’s essential, I think, to be able to
get that evidence-based resource. I think it’s actually important
to acknowledge and I think one of the things
that has a tendency when you get a group
of health professionals together discussing complementary medicine is that we get into this rhetoric
of danger. One of my doctoral students
did her thesis looking at this rhetoric of danger, in a media analysis on herbal medicines. And we talk about these interactions and the various, you know,
negative things that can occur and I don’t, uh, disagree
that those things are possible but we also need to look at the fact that there’s a wide range of benefits
that happen and generally, this is a low-risk
field of medicine. There are not piles of bodies out there
in the streets. Um, you know, there are a lot
of complementary medicines that have actually got first-class scientific level of evidence
for their usage and I think that’s the thing that health
practitioners need to be aware of. GERALDINE: Trevor, what sort
of resources would you use? We have a number of resources
in our practice and I use the Australian College of
Nutrition and Environmental Medicine. Do you have to be a member
to access their resources? It doesn’t take much to be a member. GERALDINE: Jump up and down? But they do run a lot of courses that, for somebody who’s, again,
scientifically trained and is saying, ‘What are these things?’ it’s a fantastic way
to actually start understanding at least what people are talking about and then to decide whether you can
incorporate it into your practice. What do you have to do
to access their resources? Contact the college office in Melbourne. GERALDINE: Do you have to pay money? They’re usually pretty helpful
to start with. If people want to do a course,
yes, you have to pay money. I think the bottom line is, most of
these resources are huge, aren’t they? TREVOR: Yes.
– We have to consult multiple ones. Jon, do you have any other favourites
you’d like to mention? I would recommend maybe, there’s bound to be
some CAM practitioners in the area. Some bad ones, but also some good ones. CAM practitioner training
in Australia now does have a lot of critical analysis
and research skills in there. They can actually help you,
guide you to the evidence as well, and I think that GPs and pharmacists, all conventional health practitioners
could benefit from actually, you know,
interacting with CAM practitioners and I think the CAM practitioners
could actually benefit from learning from the GPs, nurses
and pharmacists as well. I also just want to point out that
some of the professional literature which a lot of pharmacists,
for example, are using, they don’t actually contain
enough evidence-based complementary medicine information. So there has to be
awareness amongst us to tell pharmacists
that they have to be careful and go to the MH
or the therapeutic guidelines or the MIMS or AusDI
for complementary medicine information. It’s just not enough what’s in there and it’s not as actual
as we would like it to be. – Or as detailed?
EVELIN: Yes. Yes. None of those resources which are
excellent for conventional medicine were recommended by the
National Prescribing Service review. EVELIN: For complementary medicines. There is a need to go
to specific resources. Wouldn’t you say, not to forget your
basic training in pharmacokinetics and pharmacology and remember to think
of things from first principles which, again, you might not have
spoonfed from a resource, you might have to think about it
and go back to looking things up. I think, critically, in regard to that, there are two resources that I would
recommend people think about. If somebody comes in
and they’re talking about a therapy that they actually don’t know, maybe not Google but Google Scholar which actually looks at
the international scientific literature and also PubMed. Both two free resources and I’m constantly using them
as an academic. When somebody asks a question
such as this program, you know, ‘Does soy have an influence
in breast cancer?’ I spent half an hour on PubMed
this afternoon to delineate the fact that it’s only
in HER2-positive individuals that soy is a problem. So you can get very specific information
very rapidly from those sources. That’s right. And, um, Jon,
can you tell us a little bit… You alluded to this before, about complementary medicine
practitioners being regulated. Is there any regulation at the moment? Some of them are quite well regulated, the osteopaths, I think,
do a very good job. Chinese medicine,
probably do the next best. There’s some groups
that are statutorily regulated but have a lot of professional problems
like the chiropractors. There’s variability there. Unfortunately, most CAM practitioners
are completely, virtually unregulated. I mean, looking at a profession
like naturopathy, you’ve got 28 associations
that are recognised by the TGA. You’ve got… When naturopaths
got GST-free status, kinesiologists, homeopaths,
everyone started calling themselves naturopaths overnight because
there was no protection of title. So it can be very difficult to find
a qualified practitioner but there are qualified practitioners
out there. Usually, I’d recommend that you find
someone who is recognised by multiple health providers,
health benefit associations. – Health benefit associations?
– Private health insurers, sorry. Not just one but multiple ones, because
some actually have quite lax standards. And, uh… ideally, someone
who’s university trained or at least has a four-year
degree training would be the other thing I’d look at. What should consumers do
if they find that the practitioner is not complying
with expected standards? What would the process be? I think a lot of people give a bit of misplaced loyalty
to their practitioner sometimes. Just as you’d go
for a GP second opinion, you should go for a second naturopath
opinion, a second chiropractor opinion. If you’re going to see a chiropractor
who wants to sign you up for $5,000 worth of treatment straight
away, run away as quickly as you can. It’s about finding someone that actually
is treating you like an individual. If you’ve got a chiropractor that’s
potentially financially exploiting you, a naturopath, some doctors do it
as well, some physiotherapists, don’t feel like you have to stay
with them. There are other choices in
the complementary medicine field, just as there are in the medical field
as well. We recently had that controversy with the Blackmores ‘Coke and fries’ issues
with the Companion sales. I don’t think that’s gone away but would
anyone like to make a comment about what that reflected in terms of
the complementary medicine environment? Look, there’s a big problem out there
with complementary medicines and although I’m the first to admit that
there are good evidence-based products, there’s an awful lot of scams
and problems out there, products that are over-hyped
and over-promoted. To some extent, the Blackmores deal
was a sort of example of this. They were suggesting that for conditions
with prescription products, that one should automatically consider, a pharmacist should consider
recommending a ‘companion’ complementary medicine. Although there is some evidence
that in some people, that might be appropriate, it certainly
wasn’t appropriate as a routine and it raises again the real questions of was this just commercial promotion
to make a buck? Even more concerning
to many health practitioners – we know that people have problems of forwarding the co-payments
on conventional medicines, to have added on an extra
for complementaries would almost certainly mean that some patients would be foregoing
necessary medicines. So this is an example of where
the commerce really is overcoming… GERALDINE: Potential conflict
of interest. Very much a conflict of interest. The pharmacist can make you really upset
thinking about it because you’d push
for a specific brand rather than evaluating the evidence
for all products out there and taking into consideration the
individual circumstances of a patient, which we should, and that wouldn’t have
really been the case in this regard. For me personally, when I saw this, it feels like it gives the ‘ready to go’
for all pharmacists to just push any complementary medicine, even those who have maybe little or no
knowledge of complementary medicines and those pharmacists still exist and that’s just really not
a good practice. Great comment. Thank you. I wonder if we can go to each of you now
to get your take-home message for our audience, please.
Jon, can we start with you? OK, well, the take-home message
I’d like to put across is we certainly have to be aware
of the potential risks of complementary medicine
because there’s quite a few of them. But we should also remember
the potential benefit and take the measured approach. As a health professional, get educated and know where
to find evidence-based information. GERALDINE: Stephen? I think my take-home message is that
there are two bodies of knowledge – one is the rigorously scientifically
defined knowledge and there are a lot
of complementary medicines that have got very good
scientific evidence, and then there’s the traditional
knowledge which I believe we need to respect. I believe we need to translate that
into research but it may take hundreds of years
of effort by people like myself to make that happen. In the meantime, we have to acknowledge
there’s this traditional evidence that does have real value to it. GERALDINE: Ken? Look, I agree there is good
complementary medicines out there, evidence-based, but there’s also
an awful lot of hype and really rubbish type products. And the challenge is sorting them out, for which some of the resources
we’ve mentioned on this program and critical appraisal skills will help. GERALDINE: And, finally, Trevor? Basically, to be open to learn
with your patients that complementary therapies, especially
for me in nutritional therapies, provide an extra set of tools
that may be of benefit but you have to start learning
and it takes a long while to learn. It’s not an easy way out,
it’s an extra lot of knowledge. Be sceptical, as the panellists said,
about some of the hype but apply that to both sides
of your training. I’m just as sceptical
about my orthodox training as I am about nutritional medicines. And at the end of the day, remember
that arrogance equals ignorance and the bottom line is that we’re here
to help our patients get well or to do as best as we can
for their health and what works for that
is what I’m looking for. Very wise. Well, thank you, everyone. I hope you’ve enjoyed this program on Complementary Medicines –
The Best Advice. Our thanks to the Department
of Health and Ageing for making the program possible and thanks to you
for taking the time to attend. If you’re interested
in obtaining more information about the issues raised in the program, there are a number
of resources available on the Rural Health Education
Foundation’s website at rhef.com.au. Don’t forget to complete and send in your evaluation forms to register for CPD points. I’m Geraldine Moses, goodnight. Captions by
Captioning & Subtitling International Funded by the Australian Government
Department of Families, Housing, Community Services
and Indigenous Affairs�

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