Integrated medicine revisited

Edzard Ernst

In the early days of FACT, relatively few people talked about the subject of integrated (or integrative) medicine. Today it is the buzzword in the field. It is interesting therefore to read what the early FACT team wrote about this topic – here is an excerpt of an editorial from 1998:¹ ‘Why then should we scrutinise the moves towards the integration of complementary medicine? The answer is seemingly simple and straightforward. As for every other medical treatment provided by national healthcare systems, a set of reasonable preconditions has to be met. The most fundamental are that therapies ought to be safe, effective and cost-effective. These preconditions are intimately interconnected and ensure that a treatment does more good than harm.

What is the evidence then for complementary medicine regarding these criteria? Overall, it is inconclusive. Take for instance acupuncture as a treatment for pain. It is widely believed that this is supported by a large body of evidence. In fact, all systematic reviews on the subject conclude that the evidence for its clinical effectiveness is not fully convincing. As for the potential risks and actual costs of acupuncture, compared with those of other treatment options, our knowledge is similarly incomplete. With some degree of variation, this applies to virtually all complementary therapies. Uncertainty about whether a given treatment is efficacious renders a risk–benefit assessment and a cost-effectiveness analysis problematic. It is, therefore, largely unknown whether a given complementary treatment does more good than harm and whether the same effect (if any) can be achieved at lower costs. If safety, effectiveness and cost-effectiveness are not established beyond reasonable doubt the integration of any therapy, whether complementary or mainstream may be premature.’

Meanwhile thousands more research papers have been published and, as a consequence, the situation has changed considerably. Our latest summary of the hard evidence reveals that, for many indications, CAM treatments are now proven to be effective beyond reasonable doubt – here is the complete list of solidly evidence-based CAM from our recently published Oxford Handbook of Complementary Medicine.²

This list is, I think, impressive and raises a number of intriguing points:

• The majority of these interventions relate to herbal or other supplements.
• Only for few indications do we have more than one evidence-based CAM treatment.
• The range of indications for which evidence-based CAM treatments exists is long and covers both acute and chronic conditions in many clinical areas.

My position on integrated medicine has remained unchanged. If the term truly means the integration in routine healthcare of those CAM interventions that are proven by the accepted standards of medicine, it becomes redundant because it is synonymous with EBM. But this logic only works if conventional medicine begins to consider adopting the treatments listed above. Currently this does not seem to be the case. My pledge therefore is that those CAM interventions that are demonstrably effective and safe should be used in routine healthcare. Everything else would mean perpetuating double standards to the detriment of our patients.

References

1. Ernst E, Barnes J, Abbot NC et al. The integration of complementary medicine – a constructive criticism. Focus Altern Complement Ther 1998; 3: 47.
2. Ernst E, Pittler MH, Wider B, Boddy K. Oxford Handbook on Complementary Medicine. Oxford: Oxford University Press , 2008.