In this issue of the Journal, Tonia Nicholson shows that more than one-third of patients presenting to her emergency department in Hamilton, New Zealand are using some type of oral remedy which we might call “alternative”. The survey concludes that the use of such medication is high.1 Should we be pleased that our patients take responsibility for their own health or should we be worried?

A glance at the most popular treatments is revealing; Arnica, Rescue Remedy, and St John’s wort are on top of the list. To many orthodox healthcare professionals, these names might sound like ‘Double Dutch’.

Arnica is a plant (Arnica montana) which is toxic when taken by mouth. But, in its highly dilute, homeopathic form it is largely free of adverse effects. For homeopaths, Arnica is the standard remedy to promote healing of various physical traumata. Therefore its appearance on the list is not surprising. But does it work? The short answer is no; a systematic review of the trial data failed to produce compelling evidence for its efficacy.2

The second on the list, Rescue Remedy, belongs to the family of ‘Flower Remedies’. These are highly dilute preparations invented about a century ago by E. Bach to normalise emotional imbalances, which he thought were at the root of all human illness. Flower remedies are devoid of pharmacological actions and all the available randomised clinical trials show that they have no clinical effects beyond placebo.3

By contrast, the third remedy, St John’s wort (Hypericum perforatum), is of proven benefit for mild to moderate depression.4 Self medication with this herbal antidepressant is, however, not unproblematic: it powerfully interacts with about 50% of all prescription drugs.5 Looking at the other remedies used by New Zealanders and checking this information against the hard evidence for (or against) efficacy and safety, I find little reason to be pleased—the majority of these treatments are not supported by efficacy data and several have the potential to do harm.6

To make matters worse, Nicholson also shows that 61% of users were not aware that “alternative” medicines might cause adverse effects and 57% did not report their remedy usage to their doctor.1 The lack of awareness of risk combined with the absence of communication must potentiate any danger that “alternative” medicines might entail.

We may well then ask, why do patients not tell us? The reasons are fairly obvious: they do not consider “natural” treatments as drugs and they fear that doctors will frown upon their love of these “alternatives”. But the much more poignant question is: why do doctors not routinely include these issues in their medical history taking? I predict that this failure will soon be considered negligent, simply because it can be detrimental to the health of our patients.

Of course, the bug does not stop here. Once we know that a patient uses this or that remedy, we need to advise responsibility to them. Most healthcare professionals know next to nothing about “alternative” medicine, and therefore they would not be able to issue much sensible advise (this is presumably why they do not ask their patients in the first place!). The conclusion is obvious and sounds simple: doctors need to learn the essentials about this area. At the same time it is, however, problematic because there is a lot to learn6 and doctors have little time to spare.

Nicholson’s data also suggest that 67% of users benefited from their choice of “alternative” medicines. This may seem surprising vis-à-vis my statement that most of the remedies are not supported by compelling evidence. I have to admit that I am not at all amazed. “Alternative” remedies are taken mostly for self-limiting conditions. Thus the natural history of the disease in combination with a placebo response (possibly enhanced by self-payment—“the more you pay the more it is worth”) are sufficient to explain the phenomenon, even in the absence of specific effects. And lastly we should remember one important principle: the absence of evidence is not evidence of absence of an effect. Some of these remedies might actually work—without the proper research we cannot tell.

So should we be concerned or pleased about our patients’ love affair with all things “alternative”? I think we should be encouraged to see that many patients are prepared to spend time and money on their own health. We might, however, consider ways of channelling their enthusiasm more wisely. What is needed, I believe, is reliable information6 (and the will to take it in) both for patients and healthcare professionals.

In the absence of sound knowledge, any treatment presents a risk. “Alternative” remedies are clearly no exception. Seeing how carelessly consumers self-administer potentially harmful medicines, noting how poorly these preparations are regulated, and observing how resiliently ignorant healthcare professionals have remained (despite the current boom in “alternative” medicine), I for one am troubled.

Author information: Edzard Ernst, Director, Complementary Medicine, Peninsula Medical School, Universities of Exeter and Plymouth, Exeter, UK

Correspondence: Professor Edzard Ernst, Complementary Medicine, Peninsula Medical School, Universities of Exeter and Plymouth, 25 Victoria Park Road, Exeter EX2 4NT, UK. Fax: +44 (0)1392 427562; email: Edzard.Ernst@pms.ac.uk