About 12.5% of Canadians are using complementary and alternative medicine (CAM)…or are they?
CAM practitioners have been making gains in the Canadian Health System (for example, naturopaths in Ontario were last year given the right to prescribe certain medications) and homeopathic, herbal, and other CAM products line pharmacy shelves with questionable approval from Health Canada. Alt med practitioners sometimes claim rising numbers of users (or at least make an argument ad populum) to justify and promote CAM. But how many Canadians are actually accessing CAM services and what are they using it for?
A recent study was published in BMC Complementary and Alternative Medicine that looked at the use of CAM by Canadians with chronic disease and in the general population. Data was gathered from the Canadian Community Health Survey (CCHS) which was completed by over 400,000 people over the age of 12 between 2001 and 2005. The analysis focused on asthma, diabetes, epilepsy, and migraine as…
…they are conditions that can affect individuals throughout the life span and they are all chronic conditions that can be associated with episodic exacerbations that may require periodic acute treatment.
This was not a study of efficacy, just usage. So we’ll set aside discussions of CAM efficacy for now. This is merely a study of Canadians’ self-reported access to CAM services according to various demographic variables.
Here’s a summary of the results:
Weighted estimates show that 12.4% of Canadians visited a CAM practitioner in the year they were surveyed; this rate was significantly higher for those with asthma 15.1% and migraine 19.0%, and significantly lower for those with diabetes 8.0% while the rate in those with epilepsy (10.3%) was not significantly different from the general population.
Now let’s dig a little deeper to see what those numbers actually mean.
Is it CAM?
I’m going to take their tables and figures a bit out of order, starting with Figure 2. [For all figures: click to enlarge, mouseover for caption.]
Note that there were fewer people with epilepsy than the other conditions, by an order of magnitude (the prevalence of epilepsy is quite low), so the variance in this group was much higher than the other groups.
As we can see, the majority of CAM use was massage therapy (~ 65% of CAM users in this study had tried massage), by a wide margin. The next most popular treatments were, in order: acupuncture, homeopathy, chiropractic, herbalism, reflexology, and “spiritual healing”. So right off the bat we can see that the 12.5% figure may be an overestimate, as massage is not necessarily considered CAM.
Who uses what?
In the general population, Crich (almost 25% out of 5 categories) and educated (almost 50% out of 4 categories) people were more likely to use CAM, suggesting that people are more likely to try these treatments if they have a bit more disposable income — though there were some differences among the chronic conditions. Richer and more educated Canadians were more likely to use CAM for asthma and migraine and poorer and less-educated people were more likely to use CAM for diabetes and epilepsy, according to this data.
Despite the presence of a chiropractic clinic on seemingly every corner of my rural neck of the woods, CAM use is far more common in urban areas (80%). Also, perhaps perplexingly, CAM use is associated with both very high and very low education, though the educated were still twice as likely to use CAM. Other groups more likely to have used CAM in the last 12 months were those in the 25-44 year age group, women, and individuals who were single/divorced/widowed.
So we can see that, in some ways, this study confirms what has been found previously. However, this study isn’t designed to fully answer why these patterns are present or whether these groups may have had different reasons for using (or not using) CAM. I’d be interested in seeing other research with those specific questions in mind so that these patterns get more attention in the research discussion.
A partial answer to the why question?
People with migraine (a pain condition) were the most likely to have seen a CAM practitioner in the last 12 months, as seen in Figure 1.
CAM treatments for pain are ubiquitous compared to conditions with more specific physiological symptoms like diabetes and epilepsy. Also relatively high was asthma and it’s notable that chiropractic treatment for asthma had been promoted in recent years (though less recently, particularly in the UK) along with other popular treatments. Could there be differences related to prevalence and advertising?
There were notable differences in CAM use among the specific health conditions. People with diabetes were more likely to try acupuncture and reflexology and people with migraine and asthma were more likely to use chiropractic, compared to the general population. Given the proposed mechanisms of these particular modalities and the respective symptoms of these conditions, this pattern is relatively unsurprising.
The authors of this study propose that there is a potential pattern related to the the progression of chronic disease, in that CAM use is less likely for stable conditions (e.g., diabetes) than for conditions prone to flare-ups (e.g., asthma, migraine). In their conclusion the authors note that once adequate control of a condition is achieved, one would not need to seek out alternative treatments.
But thought of another way, it seems likely that for a stable condition for which CAM may not be effective, people are more likely to give up on CAM, whereas a variable condition may present greater likelihood of opportunities for false-positives (for example, taking CAM during a “bad” phase” and then feeling better may be attributed to the treatment when this pattern may have been due to the natural progression of the disease). This seems at least somewhat taken advantage of considering the greater presence of CAM advertising to people with less well-defined disease progression and symptoms (e.g., fibromyalgia, headache, insomnia, etc).
I would be interested to see further analysis of the survey data, if possible, analysing more health conditions. CAM seems mostly used for conditions that are painful, have less concretely-defined symptoms and presentation, and/or for which CAM products are well-advertised. For example, consider CAM treatments for illnesses that have undesirable or expensive mainstream treatments (e.g., cancer). That people who happen to have diabetes, for example, occasionally access CAM services for unknown reasons isn’t terribly informative on its own. I would also be interested to see which CAM treatments have grown in use/access vs. others in recent years.
This study provides some insight into CAM use in Canada, however the main drawback is that it is a self-report study and there is no indication that the people with these conditions were actually seeking treatment for that condition. Also, they only collected data on the access of CAM services, not the specific use of CAM products – it is possible that some people access these services without having participated in the treatment or they might be “prescribed” herbal medicine or other remedies to take at home. Furthermore, there is no analysis of cross-over access or even cross-over conditions (for example, someone can have both diabetes and asthma) and how that affects access to CAM.
The authors reassure the reader that Canadians are using CAM in conjunction with, not instead of, conventional care. However, I don’t think they can reasonably determine this from the data that is presented. In fact, the authors also mention that people do not discuss their CAM treatments with their doctors but they discuss prescription medication with their naturopaths. This suggests, that even if people are using CAM “in conjunction” with mainstream medicine, they are treating them as separate entities despite, for example, the potential for drug interaction with some herbal remedies or low dilutions of homeopathy that may still contain active ingredients.
I also find this sentence puzzling:
Since scientific evidence has shown the benefits of some types of CAM, greater emphasis needs to be placed on how to better assess the use and impact of CAM services in those with chronic conditions.
I do not see how they could draw this particular conclusion. Which types of CAM are shown to be beneficial? Are these the types that are more or less accessed in the general population? Are any types shown to be effective for the specific chronic conditions analysed in this study? If so, are these the ones being accessed by those groups? Etc… This conclusion seems out of scope with their data and reads as uncritically promotional of CAM, perhaps calling into question the overall objectivity of the study.
CAM use in the general population is relatively low and access seems to be mostly for massage therapy, though perhaps not necessarily for the treatment of associated symptoms. Many people seek massage for general relaxation and the same can still be true regardless of having a chronic health condition.
CAM is potentially being sought by people with specific conditions for which there is no evidence that any CAM modality can treat directly. However, as stated above, this study does not conclusively show that people are seeking CAM treatment for those particular illnesses as opposed to an unrelated (and possibly less serious or acute) condition.
This analysis does not make access patterns clear and therefore is not useful in determining CAM use specifically for the symptoms of chronic disease, though the data does provide some interesting information on the general access of CAM by people who happen to have a chronic disease.