The growing presence of alternative medicine in health care

Americans are engaged in a massive movement toward healthier living, which includes disease prevention and maintenance of healthy lifestyle habits. This means we watch what we eat, frown upon smoking, limit alcohol consumption and, particularly during the past decade, encourage physical fitness through regular exercise.

But it also means we are cautious of the drugs we put in our bodies. And for a large number of Americans, this has led to increased use of herbals and other alternative medicines.

How is alternative medicine defined? And why should pharmaceutical representatives concern themselves with alternative medicines?

Define the universe

The term "alternative medicine" encompasses an extensive range of therapies. Everything from herbal remedies, chiropractic care, acupuncture, reflexology, guided imagery and biofeedback are covered under the umbrella of alternative medicine. It also includes less popular therapies such as magnetic therapy and other "energy" therapies.

Alternative medicine is sometimes referred to as "complementary medicine" because it is increasingly seen as a way to supplement conventional medicine, rather than replace it.

Alternative medicines, specifically herbal remedies, are often popular with consumers because they cost less than prescription medications and visits to physicians. But what many Americans who use herbal remedies don't realize is that there can be serious - sometimes even life-threatening - side effects to some of the potent natural remedies sold as dietary supplements in stores across the country.

Because the FDA does not regulate herbal remedies, many people mistakenly believe all herbal remedies are safe. But it is precisely this lack of regulation that makes numerous herbals unsafe. It also brings the importance of education about alternative medicines to the forefront of what pharmaceutical representatives should know when they visit their physicians.

Havarde Warner, R.Ph., the pharmacist-in-charge at Guardian Health Systems, a Richardson, TX-based pharmaceutical services provider, believes it is important for sales reps to be aware of herbal alternatives for a variety of reasons. Consider the following scenario, he urged: A pharmaceutical rep is cornered by a physician who claims the rep's prescription product has caused a serious side effect in a patient. This patient had taken this medication for months without incidence, but suddenly developed a cardiac arrhythmia. What this patient hadn't informed the physician is that he recently began using several herbal remedies, one of which may be the true culprit for the new and dangerous side effect.

Researching alternatives

Potential situations such as the one cited by Warner are causing federal regulators, health care professionals and the pharmaceutical industry to begin taking alternative medicines very seriously. In 1993, the National Institute of Health opened the Office of Alternative Medicine in Bethesda, MD. The office's mission is to identify and evaluate unconventional health care practices; support, coordinate and conduct research and research training on these practices; and disseminate information about these practices to the public.

The Office of Alternative Medicine is collaborating with the Atlanta-based Centers for Disease Control and Prevention to include questions about complimentary and alternative medicine in the next "National Health and Nutrition Examination Survey," and in other surveys.

It also provides funding for 10 specialty research centers to conduct various studies involving alternative medicines. Current studies address addictions, aging, asthma, allergy, immunology, cancer, HIV and AIDS, pain, stroke and women's health.

Last year, together with the National Institute of Mental Health and the Office of Dietary Supplements, the Office of Alternative Medicine awarded the largest grant to date for research of an herbal remedy. The office gave researchers at Duke University Medical Center $4.3 million to conduct a three-year clinical trial of hypericum perforatum, commonly known as St. John's wort.

The goal of the Duke study is to give definitive answers about whether St. John's wort works for clinical depression, according to Steven E. Hyman, M. D., director of the National Institute of Mental Health. It will be the first rigorous clinical trial of the herb large enough and long enough to fully assess whether its use produces a therapeutic effect.

The study is expected to enroll 336 psychiatric outpatients diagnosed with moderate depression. Participants will be divided into three groups, with some receiving St. John's wort, others a commonly prescribed antidepressant and the remaining receiving a placebo. After six months of treatment, results will be compared among the groups.

Providers and insurers

Accommodating patient demand for alternative medical therapies can be overwhelming for traditional health care professionals.

Physicians are presented with a professional challenge largely because the safety and efficacy of these therapies remains unknown. In the absence of professional medical or legal guidelines, physicians have begun their own dialogue on the subject. For example, David Eisenberg, M.D., wrote a management plan for the "Annals of Internal Medicine," which is published by the American College of Physicians. It advises physicians about patient safety, documentation of patient record and the importance of shared decision-making when it comes to advising patients who seek alternative medicine therapies.

Warner, the pharmacist-in-charge at Guardian Health Systems, sees varying degrees of interest among the medical community. Anecdotally, he noted that alternative therapies seem to be more accepted by younger physicians than middle-aged physicians. Surprisingly, though, he said older physicians, such as those age 60 and older, seem open-minded about alternative therapies as well. Could it be because they remember a time when natural remedies were listed alongside pharmaceutical medicines in the Physician's Desk Reference?

A few managed health care organizations now offer expanded benefit programs which cover these therapies as well. One of the first managed health care plans to provide alternative coverage in the United States was Oxford Health Plan, which began covering selected alternative therapies for members throughout New York, New Jersey, Pennsylvania, Connecticut and New Hampshire, as well as in Tampa and Chicago. Oxford developed a credentialed network of providers that included 1,800 providers as of July 1997. That number was expected to grow to 2,500 by January 1998.

The Beth Israel Deaconess Medical Center and Harvard Medical School will work with Oxford Health Plan to study alternative medicine treatments within managed care plans by following members of Oxford's plans.

Other health plans are beginning to see the benefit of providing coverage of alternative medicines to consumers as well. Blue Cross of California and Blue Cross of Colorado currently offer programs and Landmark Health Care of California is seriously considering offering such coverage to its plan members. And many providers, including Medicare and Medicaid, have covered at least a limited number of chiropractic visits for several years.

The market is greener

Although opinions vary on interest in the medical community about alternative medicines, one thing is clear: consumers are interested in herbal remedies, and pharmaceutical reps must become educated about the use and side effects of alternative therapies. PR