Advising Patients Who Seek Alternative Medical Therapies

Advising Patients Who Seek
Alternative Medical Therapies

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:

FROM:   Annals of Internal Medicine 1997 (Jul 1);   127:   61-69 ~ FULL TEXT

David M. Eisenberg, MD

Beth Israel Deaconess Medical Center,
Boston, Massachusetts


Related Letters

Alternative medical therapies, such as chiropractic, acupuncture, homeopathy, and herbal remedies, are in great public demand. Some managed care organizations now offer these therapies as an "expanded benefit." Because the safety and efficacy of these practices remain largely unknown, advising patients who use or seek alternative treatments presents a professional challenge. A step-by-step strategy is proposed whereby conventionally trained medical providers and their patients can proactively discuss the use or avoidance of alternative therapies. This strategy involves a formal discussion of patients' preferences and expectations, the maintenance of symptom diaries, and follow-up visits to monitor for potentially harmful situations. In the absence of professional medical and legal guidelines, the proposed management plan emphasizes patient safety, the need for documentation in the patient record, and the importance of shared decision making.

Alternative therapies can be defined as medical interventions that are neither taught widely in U.S. medical schools nor generally available in U.S. hospitals (1). Examples include chiropractic, acupuncture, massage, and homeopathy. In 1993, my colleagues and I reported that an estimated 60 million Americans used alternative medical therapies in 1990 at an estimated cost of $13.7 billion, that the estimated number of annual visits to providers of alternative medicine (425 million) exceeded the number of visits to all U.S. primary care physicians (388 million), and that more than 70% of patients who acknowledged using alternative therapy never mention edit to their physicians (1). These data generated considerable attention and debate and suggest that an "invisible mainstream" exists within the U.S. health care system (2). Little is known, however, about the safety, efficacy, mechanism of action, and cost-effectiveness of individual alternative treatments.

In the past 3 years, the lay press has reported a national trend: third-party payers who provide alternative therapies in the form of "expanded benefits" (3-11). Most recently, the Oxford Health Plan began a program whereby chiropractic, acupuncture, and naturopathy became available to the Plan's 1.5 million subscribers as paid benefits (12, 13). This trend poses a predicament for physicians: how to responsibly advise patients who use or seek alternative therapies in the face of inconclusive evidence about the safety and effectiveness of these therapies.

This unavoidable challenge is not without risk. Questions of professional liability are valid. The reality is that no case law directly answers the question, "Will I be sued if I knowingly comanage a patient who sees an alternative therapy practitioner and experiences a bad outcome from that therapy?" Although physicians have been prosecuted for malpractice when they have personally delivered alternative treatments, no cases have involved conventionally trained physicians who have advised patients about alternative medical therapies.

The other extreme involves the risk of not asking about alternative therapies known to be dangerous. In 1996, the media reported deaths from overdoses of Herba ephedra (herbal ephedrine), known in Chinese herbal medicine as ma huang (14, 15). A death attributed to pennyroyal, an herb commonly available in health food stores, was recently reported in the medical literature (16). As more patients use over-the-counter herbs, botanicals, and supplements, physicians should discuss such practices with their patients, if only to safeguard their health.

Undoubtedly, talking with patients about alternative therapies requires additional skills and time. Yet, is this responsibility significantly different from exploring patients' use of alcohol or drugs, exposure to abuse, or preferences for cardiopulmonary resuscitation? Each is critically important to maintaining health and respecting patient values, and each takes time.

I propose a step-by-step approach whereby medical providers and patients can proactively discuss alternative medical treatments. These suggestions emphasize patient safety, the need for documentation in the patient record, and the importance of shared decision making.

      Asking the Unasked Question

I suggest that after completing routine questioning to identify patients' chief symptoms, medical providers begin a conversation about alternative therapies with some version of the following question: "Patients with (chief symptom) frequently use other kinds of therapy to find relief. For example, some patients use chiropractic, massage, herbs, vitamins, etc. Have you used or thought about using any of these or other therapies for your chief symptom, or for other reasons?"

Because one third of all alternative therapy use seems to be associated with health promotion and disease prevention (1), providers should also ask about a patient's use of alternative therapy in this context. This inquiry can be assimilated into questions about lifestyle and health risks.

The physician and patient must feel comfortable with how the question is asked. Two caveats are worth considering: 1) The neutrality with which this question is asked influences the honesty of the answer, and 2) there is no need to refer to the "other therapies" as "alternative," "complementary," or "unorthodox." Such labels may be perceived as judgmental, thereby inhibiting disclosure and discussion.

Patients who are interested in exploring alternative therapies do so for diverse reasons: 1) They seek health promotion and disease prevention; 2) conventional therapies have been exhausted ; 3) conventional therapies are of indeterminate effectiveness or are commonly associated with side effects or significant risk; 4) no conventional therapy is known to relieve the patient's condition; and 5) the conventional approach is perceived to be emotionally or spiritually without benefit. Whether or not patients use or seek advice about an alternative therapy, they are likely to be pleased when their physician cares enough to ask.


Detailed discussion about alternative therapy should not occur until the patient 1) has undergone a complete conventional medical evaluation, including diagnostic assessment and, where indicated, referral to consultants; 2) has been advised of conventional therapeutic options; and 3) has tried or exhausted conventional therapeutic options or refused these options for reasons documented in their record. Professional advice on the adjunctive or exclusive use of alternative therapy without a complete diagnostic evaluation is irresponsible and does not serve the patient's best interest.

      A Step-by-Step Strategy

Consider a patient with intermittent low back pain for whom nonsteroidal anti-inflammatory medications, physical therapy, regular exercise, and avoidance of heavy or improper lifting have not adequately reduced chronic or recurrent pain. The following approach (Figure 1), guided by the principle "do no harm" and its corollary, "monitor for unintentional side effects," can be considered:

1.   Ask the patient to identify the principal symptom.

Back pain is the principal symptom.

2.   Maintain a symptom diary.

Assist the patient with a daily symptom diary to be used for baseline assessment and evaluation of subsequent alternative (or conventional) therapeutic interventions. A scale from 0 ("no back pain") to 10 ("the worst pain imaginable") is recommended. Patients should be reminded that because accurate recall of discomfort, fatigue, and other symptoms is difficult, daily logs are essential.

3.   Discuss the patient's preferences and expectations.

Many patients come prepared to discuss opinions or powerful anecdotes from friends or family members. The discussion often focuses on the reasons patients seek alternative treatment or their desire to avoid conventional therapies. Patients with low back pain, for example, may incorrectly assume that surgery is their only conventional option.

If patients wish to pursue alternative therapy but lack strong preferences for specific therapies, encourage shared responsibility for investigating options further. Various texts are available to both patients and conventional medical providers. These offer information on multiple alternative therapies (17-32) or focus on single treatments (33-43). Conventional practitioners might consider attending continuing medical education courses on this topic (44-46). In our hypothetical example, the patient opts to pursue acupuncture.

4.   Review issues of safety and efficacy.

It is the conventional provider's professional obligation to monitor therapies with potential or documented toxicity, including herbal preparations (47-73), dietary regimens (74, 75) and supplements (76-79), medicinal agents delivered by injection (80), intravenous infusion (such as chelation therapy [81]), and certain forms of spinal manipulation (82-89). Advise patients that the absence of documented toxicity for herbs, supplements, or chemical preparations does not equal safety. Notions that "natural" substances are inherently safe are false (90). Snake venom is "natural" but deadly (91); poison oak and ivy contain "natural" urushiols that cause severe contact dermatitis (92). Examples of potentially toxic herbs include sassafras (55), chaparral (69), and germander (73). Reference books (93-95) and online resources (96) (Appendix 1) are available to investigate the relative safety of individual herbs and supplements.

Reviewing the current medical literature fails to provide unequivocal documentation of the safety or efficacy of the overwhelming majority of alternative therapies (85, 87, 89, 97-102). Notable exceptions include spinal manipulation for acute low back pain (103), acupuncture for nausea (104), and behavioral and relaxation techniques for chronic pain and insomnia (105). Adverse events attributable to acupuncture have been reported (106, 107) but are rare (108-112). The risk for transmission of infectious organisms can be reduced to almost zero by using disposable needles.

Risk is also associated with manipulation of the cervical spine (82, 83, 87-89). Other treatments with potential significant risks include some single herbs; some Chinese "patent" remedies manufactured overseas that routinely include various herbs and are occasionally adulterated with steroids or lead (68); high-dose vitamins and minerals, radical diets, certain deep-tissue massage; and any substance administered intravenously.

Relatively low-risk therapies include homeopathy, most forms of massage, prayer, guided imagery, spiritual healing, hypnosis, and relaxation techniques. Two caveats are worth noting: 1) Any therapy can cause "indirect toxicity" if it results in a delay of a proven treatment, and 2) there is a risk for perceived blame and failure among patients who, expecting a "cure" as a result of mental or spiritual exercises, do not experience the desired result (113). Thus, thinking of alternative therapies in terms of relative risk or benefit is reasonable.

Indirect toxicity is exemplified by documented drug-drug interactions. Examples include the potentiation of calcium channel blockers by grapefruit juice (63) and decrease in the bioavailability of digoxin in the presence of guar gum consumption (48). Given the potential for unintended drug-drug interactions, patients who take prescription medications, especially drugs with known toxicity to the liver or kidneys (such as chemotherapeutic agents), should be cautioned about, if not dissuaded from, simultaneously using herbs, supplements, and other substances with poorly studied pharmacologic activities. Perhaps the most common, vexing example involves the patient who is receiving chemotherapy or radiation therapy and considers the consumption of herbs, high-dose vitamins, or supplements before or during treatment. These substances may, hypothetically, inhibit or potentiate the activity of conventional therapeutic agents. Physicians must warn patients about unintended drug-drug interactions and the prospect of not knowing which substance is responsible. In general, a strategy that uses one therapeutic intervention at a time, at least until a therapeutic plateau is reached or a reasonable period of monitoring elapses, should be discussed and documented in the record.

5.   Identify a suitable licensed provider.

Patients may have already identified a provider by word of mouth or informal referral. Physicians should emphasize that alternative therapy providers are licensed by state governments and commonly maintain professional malpractice insurance. Licensure laws and the scope of practice guidelines regulating individual practices vary by state (114) (Figure 2) and are subject to frequent change. Patients should review the professional credentials of any prospective alternative provider. Ideally, this information should be documented in the patient's record.

6.   Provide key questions for the alternative therapy provider during initial consultation.

When patients are being counseled about use of alternative therapy, providing the following questions to ask the alternative medical provider is helpful: 1) Is the provider's belief in the effectiveness of the therapy (for example, acupuncture) based on clinical experience with similar patients? If so, is it possible to speak to such a patient? 2) Of what will the therapy consist? What is the recommended frequency of therapy? 3) How many weeks will pass before the patient and provider can decide that the therapy is or is not beneficial? 4) What is the cost per session, with or without medication, and the anticipated total cost for the specified time period? Is third-party reimbursement available? 5) Are there potential side effects? 6) Is the provider willing to communicate diagnostic findings, therapeutic plans, and follow-up with the patient's primary care provider or subspecialist? Are there any limitations to this communication?

Ideally, the physician should obtain patients' permission to release relevant information (including information on the use of prescription medications) to the alternative therapy provider in order to offer accurate historical information and avoid conflicting recommendations.

7.   Schedule a follow-up visit (or telephone call) to review treatment plan.

Topics to be addressed during this session include 1) the alternative practitioner's responses to the questions outlined above; 2) potential risks or toxicity, particularly those involving therapies taken orally, intramuscularly, or intravenously; and 3) recommendations that directly conflict with those of the conventional provider. An extreme example is the recommendation that a patient delay or forego surgery, chemotherapy, or radiation therapy for a potentially treatable malignant condition.

8.   Follow up to review the response to treatment.

This should occur after a "reasonable" period (usually 4 to 8 weeks). By the time this follow-up session takes place, patients usually have decided whether or not to continue the alternative therapy. If the therapy was effective, the patient's positive experience constitutes a beneficial clinical outcome and provides anecdotal evidence that this therapy (or, one might argue, the provider of this therapy) may be helpful to others with similar problems. If the therapy was ineffective, the patient and physician together can review other alternative and conventional therapeutic options. Regardless of the perceived efficacy o r lack thereof, patients who pursue an alternative therapy while being monitored by their physician tend to feel "listened to" and enjoy a degree of perceived safety that they might otherwise be denied.

9. Provide documentation.

Conventional providers are encouraged to build a record of the clinical encounters, conversations, and advice that lead to all treatment decisions.

      Patients Who Already Use Alternative Therapies

Such patients may not wish to discuss these alternative practices; this should be recorded in their medical records. For patients who welcome this conversation, the physician's challenge is to explore whether the patient and alternative provider are willing to follow the steps discussed above. Refusal on the part of either party should be documented in the patient's record.

      Patients Who Reject Conventional Diagnosis or Therapy

A more challenging situation involves the new patient who currently uses an alternative therapy (or wants a referral) but refuses conventional evaluation. Patients have the right to forego conventional treatment, but this choice does not constitute a right to obtain a referral or tacit medical approval for alternative therapy in the absence of a diagnosis.

Physicians might convince such patients that an "integrated" approach is in their best interest. If patients refuse this advice, they are best served by the unequivocal message that requests for referral to an alternative provider are unreasonable and cannot be met. Physicians facing this predicament should follow accepted professional guidelines for referring patients to another physician. Under no circumstances should a conventional medical provider feel professionally obligated to make or support referrals to alternative therapy providers in the absence of a thorough medical evaluation.


Discussions about the use of alternative medicine are primarily influenced by patient preference, perceived need for alternative interventions, and anecdotal evidence that the therapy may provide relief and long-term benefit or be toxic. Together, patients and providers must acknowledge that as long as information on the efficacy and toxicity of alternative therapies remains inadequate, advice will remain imperfect and a matter of judgment.

As with all good care, the patient's wishes should not override a physician's professional judgment. If the physician believes that an alternative therapy is unsafe or inappropriate, patient requests for it should not be endorsed. Perhaps the question each clinician must ask is, "Would I let a family member follow this course of action?" Patients, I believe, want their physician's opinion, even if it is a blunt "I wouldn't be comfortable watching a family member do this. " If, however, little evidence suggests that risks outweigh potential benefits and the physician is willing to monitor the patient, it is often appropriate to pursue alternative treatment.

By implementing the proposed strategy, physicians and patients may disagree about which alternative therapy is safe and potentially effective. I believe that this kind of disagreement is extremely valuable. Kassirer (115) commented that

the patient should be given the benefit of the doubt when important decisions are contemplated. The physician initially should assume that the patient is capable of becoming a full partner in the decision-making process and encourage active participation. This means the patient will have to assume more responsibility for outcomes of medical decisions and the physician will have to relinquish some....

Kassirer concludes that

when discussing details with the patient, physicians should disclose whatever uncertainties exist. Most patients are not horrified to learn that a considerable body of medical information is fuzzy and uncertain. Neither do they fail to comprehend that some tests and treatments are risky, that some treatments are not always efficacious, and that on occasion the treatment may turn out to be worse than the disease.

Physicians and patients should dare to disagree, especially about therapies for which scientific support is anecdotal, equivocal, or preliminary. Often, the most sensitive barometer of a relationship is the ability to resolve disagreement. A rabbi commented that when providing premarital counseling, she always asks the couple, "Tell me how you disagree. I'm not interested in what you disagree about, but rather how you work through your disagreement." The manner in which the patient and physician wrestle with disagreements about therapeutic choices helps define their relationship and its value to each party.

We as a profession must address the challenge of discussing alternative therapies with our patients and put an end to the "don't ask, don't tell" approach that characterizes communication in this area. These discussions are opportunities for shared decision making and "relationship-centered care" (116). No patient should feel that their medical journey is to be taken alone or according to some stealth trajectory, invisible to their conventional providers. The delivery of medical care, like the experience of illness, is best viewed as a journey shared.

Appendix 1. Selected Information Resources on Herbs and Supplements

Research Databases

U.S. Department of Agriculture
Agricultural Genome Information System

Free access to 80 000 records on herb taxonomy and the use of herbs worldwide, developed by Dr. James Duke. Other available databases include a WAIS (wide-area information server)-based subset of Agricola.


College of Pharmacy
The University of Illinois at Chicago
Contact: Mary Lou Quinn
Phone: 312-996-2246
Fax: 312-996-7107

Contains 124 000 scientific articles on the chemical constituents and pharmacology of plants (75% were published after 1975). Requires annual subscription fee for mediated searching plus a fee for each record retrieved.

Research Journals

Journal of Natural Products
American Society of Pharmacognosy
555 31st Street
Downers Grove, IL 60515
Phone: 708-971-6417

Journal of Ethnopharmacy
Elsevier Science Ireland, Ltd.
Madison Square Station, Box 882
New York, NY 10159
Phone: 212-989-5800

International Journal of Pharmacognosy
Swets & Zeilinger
400 Creamery Way, Suite A
Exton, PA 19341
Phone: 800-447-9387

HerbalGram, HerbClip
American Botanical Council
PO Box 201660
Austin, TX 78720
Fax: 512-331-1924

Mediated Searching

Herb Research Foundation
1007 Pearl Street, Suite 200
Boulder, CO 80302
Phone: 303-449-2265
Fax: 303-449-7849

Hand searching of private library composed of 125 000 papers that cover a full range of botanical issues. Hourly fee for searching plus a per-page charge.

U.S. Department of Agriculture National Agricultural Library
Food and Nutrition Information Center
Phone: 301-504-5719

National Institutes of Health Office of Dietary Supplements' public information service. No charge for telephone requests. Reference service hours are Monday through Friday, 12:30 to 4:30 p.m. Eastern Standard Time.

Lloyd Library
917 Plum Street
Cincinnati, OH 45202
Phone: 513-721-3707

One of the largest comprehensive collections of books and serials on natural pharmaceuticals in North America. Searches are free, but a copy fee is charged for materials retrieved.

List of Associations


Extensive annotated listing of commercial, nonprofit, national, and regional organizations dedicated to the support of herbal medicine. Other resources available through Herbnet include recent news and publications.

Appendix 2. Information Resources for State Licensing


Federation of Chiropractic Licensing Boards
901 54th Avenue, Suite 101
Greeley, CO 80634
Phone: 970-356-3500


National Center for Homeopathy
801 North Fairfax Street, Suite 306
Alexandria, VA 22314
Phone: 703-548-7790

Homeopathy is licensed in three states. Contact state licensing boards for general information.

Massage Therapy

National Certification Board for Therapeutic Massage and Bodywork
8201 Greensboro Drive, Suite 300
McLean, VA 22102
Phone: 800-296-0664

Provides detailed information on state licensing and regulatory requirements and on individual certified practitioners. Certification is not consistently required for licensure. Not all massage therapists are nationally certified.


No single acupuncture organization can provide information by telephone on a state-by-state basis. State boards of registration in medicine should be contacted for further information.

National Certification Commission for Acupuncture and Oriental Medicine (NCCA)
1424 16th Street NW
Suite 501
Washington, DC 20036
Phone: 202-232-1404

Book (cost, $7.00) available that provides each state's licensing and regulatory requirements.

American Academy of Medical Acupuncture
5820 Wilshire Boulevard, Suite 500
Los Angeles, CA 90036
Phone: 213-937-5514

Membership limited to allopathic and osteopathic physicians who have had 200 hours of acupuncture training.


American Association of Naturopathic Physicians (AANP)
601 Valley Street, Suite 105
Seattle, WA 98109
Phone: 206-328-8510

Naturopathy is licensed in 12 states and the District of Columbia (Figure 2). The AANP provides contacts for local licensing and regulatory boards and general information on naturopathy.

Acknowledgments: The author thanks Ellen Meisels, JD, MPH, Janis Claflin, PhD, and Rabbi Elaine Zecher for their contributions; Janet Walzer, MEd, Christopher Tuttle, Thomas Delbanco, MD, Thomas Inui, MD, and Debi Arcarese for editorial suggestions; and Debora Fischer for technical assistance.

Grant Support: In part by National Institutes of Health grant U24 AR43441, the John E. Fetzer Institute, the Waletzky Charitable Trust, the Friends of Beth Israel Hospital, and the Kenneth J. Germeshausen Foundation.

Requests for Reprints: David M. Eisenberg, MD, the Center for Alternative Medicine Research, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215.


1. Eisenberg DM, Kessler RC, Foster C, Morlock FE, Calkins DR, Delbanco TL.
Unconventional Medicine in the United States: Prevalence, Costs, and Patterns of Use
New England Journal of Medicine 1993 (Jan 28); 328 (4): 246252

2. Eisenberg DM.
The invisible mainstream.
Harvard Medical Alumni Bulletin. 1996;70:20-5.

3. Phalon R.
New support for old therapies.
Forbes. 20 December 1993:254-55.

4. Neff R.
They fly through the air with the greatest of... ki?
Business Week. 23 January 1995:60.

5. Carton B.
Health insurers embrace eye-of-newt therapy.
Wall Street Journal. 30 January 1995:B1.

6. Scheck A.
Alternative medicine is next health trend.
Investor's Business Daily. 20 June 1995.

7. Dunkin A.
"Complementary" medicine: is it good for what ails you?
Business Week. 27 November 1995:134.

8. Hilts PJ.
Health maintenance organizations turn to spiritual healing.
The New York Times. 27 December 1995:B10.

9. Egan T.
Seattle officials seeking to establish a subsidized natural medicine clinic.
The New York Times. 3 January 1996:A6.

10. Jackson C. Alternative medicine goes mainstream. The Tampa Tribune. 8 January 1996:8.

11. Russell S. HMOs try dose of alternative medicine. San Francisco Chronicle. 22 January 1996:A1.

12. Bloomberg Business News. Oxford Health plans to cover alternative care. The New York Times. 9 October 1996:A11.

13. Lagnado L. Oxford to create alternative-medicine network. Wall Street Journal. 7 October 1996:B9.

14. Krauss C. Pataki outlaws herbal stimulant linked to deaths. The New York Times. 24 May 1996:B1.

15. Cowley G. Herbal warning. Newsweek. 6 May 1996:60.

16. Anderson IB, Mullen WH, Meeker JE, Khojasteh-Bakht SC, Oishi S, Nelson SD, et al. Pennyroyal toxicity: measurement of toxic metabolite levels in two cases and review of the literature. Ann Intern Med. 1996;124:726-34.

17. National Institutes of Health. Office of Alternative Medicine. Alternative Medicine: Expanding Medical Horizons. Washington, DC: US Gov Pr Office; 1994.

18. Zwicky JF. American Medical Association. Reader's Guide to Alternative Health Methods. Chicago: American Med Assoc; 1993.

19. Collinge W. Complete Guide to Alternative Medicine. New York: Warner Books; 1996.

20. Micozzi MS, ed. Fundamentals of Complementary and Alternative Medicine. New York: Churchill Livingstone; 1996.

21. Fugh-Berman A. Alternative Medicine: What Works. Tucson, AZ: Odonian Pr; 1996.

22. Burton Goldberg Group. Alternative Medicine: The Definitive Guide. Puyallup, WA: Future Medicine; 1993.

23. Marti JE, Hines A. The Alternative Health and Medicine Encyclopedia. New York: Gale Research; 1995.

24. Lerner M. Choices in Healing: Integrating the Best of Conventional and Complementary Approaches to Cancer. Cambridge, MA: MIT Pr; 1994.

25. U.S. Congress Office of Technology Assessment. Unconventional Cancer Treatments. OTA-H-405. Washington, DC: US Gov Pr Office; 1990.

26. Goleman D, Gurin J. Mind/Body Medicine: How to Use Your Mind for Better Health. Yonkers, NY: Consumer Reports Books; 1993.

27. Stalker D, Glymour C, eds. Examining Holistic Medicine. Buffalo, NY: Prometheus Books; 1989.

28. Butler K, Barrett S. A Consumer's Guide to Alternative Medicine: A Close Look at Homeopathy, Acupuncture, Faith-Healing, and Other Unconventional Treatments. Buffalo, NY: Prometheus Books; 1992.

29. Barrett S. Health Schemes, Scams, and Frauds. Mt. Vernon, NY: Consumers Union; 1990.

30. Raso J, Barrett S, eds. Mystical Diets: Paranormal, Spiritual, and Occult Nutrition Practices. Buffalo, NY: Prometheus Books; 1993.

31. Gevitz N. Other Healers: Unorthodox Medicine in America. Baltimore: Johns Hopkins Univ Pr; 1988.

32. O'Connor BB. Healing Traditions: Alternative Medicine and the Health Professions. Philadelphia: Univ of Pennsylvania Pr; 1995.

33. Kaptchuk T. The Web That Has No Weaver: Understanding Chinese Medicine. New York: Congdon & Weed; 1983.

34. Pizzorno JE, Murray MT. A Textbook of Natural Medicine. Seattle, WA: John Bastyr College Publications; 1993.

35. Bellavite P, Signorini A. Homeopathy: A Frontier in Medical Science. Berkeley, CA: North Atlantic Books; 1995.

36. Vithoulkas G. The Science of Homeopathy. New York: Grove Pr; 1980.

37. Weiner M, Goss K. The Complete Book of Homeopathy. New York: Bantam Books; 1982.

38. Wardwell WI. Chiropractic: History and Evolution of a New Profession. St. Louis: Mosby-Year Book; 1992.

39. Moore JS. Chiropractic in America. The History of a Medical Alternative. Baltimore: Johns Hopkins Univ P r; 1993.

40. Tyler VE. Herbs of Choice: The Therapeutic Use of Phytomedicinals. Binghamton, NY: Haworth Pr; 1994.

41. Tyler VE. The Honest Herbal: A Sensible Guide to the Use of Herbs and Related Remedies. 3d ed. Binghamton, NY: Haworth Pr; 1993.

42. Weiss RF. Herbal Medicine. Beaconsfield, United Kingdom: Beaconsfield Publishers; 1988.

43. Werbach MR, Murray MT. Botanical Influences on Illness: A Sourcebook of Clinical Research. Tarzana, CA: Third Line Pr; 1994.

44. Conference calendar. Alternative Therapies in Health and Medicine. Aliso Viejo, CA: Innovision Communications. 1997;3:125.

45. Upcoming conferences and training seminars. Alternative & Complementary Therapies. Larchmont, NY: Mary Ann Liebert. 1997;3:72.

46. Forthcoming meetings of interest. Advances: The Journal of Mind-Body Health. Kalamazoo, MI: John E. Fetzer Institute. 1997;13:79.

47. Huxtable RJ.The harmful potential of herbal and other plant products. Drug Saf. 1990;5(Suppl 1):126-36.

48. de Smet PA. Health risks of herbal remedies. Drug Saf. 1995;13:81-93.

49. de Smet PA, Dukes MN, eds. Drugs used in non-orthodox medicine. In: Dukes MN, ed. Meyler's Side Effects of Drugs. 12th ed. Amsterdam: Elsevier; 1992:1209-32.

50. de Smet PA, Keller K, Hansel R, Chander RF, eds. Toxicological Outlook on the Quality Assurance of Herbal Remedies: Adverse Effects of Herbal Drugs. Berlin: Springer-Verlag; 1992:1-72.

51. de Smet PA. Is there any danger in using traditional remedies? J Ethnopharmacol. 1991;32:43-50.

52. D'Arcy PF. Adverse reactions and interactions with herbal medicines. Part 1. Adverse reactions. Adverse Drug React Toxicol Rev. 1991;10:189-208.

53. D'Arcy PF. Adverse reactions and interactions with herbal medicines. Part 2-Drug interactions. Adverse Drug React Toxicol Rev. 1993;12:147-62.

54. Woolf GM, Petrovic LM, Rojter SE, Wainwright S, Villamil FG, Katkov WN, et al. Acute hepatitis associated with the Chinese herbal product jin bu huan. Ann Intern Med. 1994;121:729-35.

55. Segelman AB, Segelman FP, Karliner J, Sofia RD. Sassafras and herb tea. Potential health hazards. JAMA. 1976;236:477

56. Ridker PM, McDermott WV. Comfrey herb tea and hepatic veno-occlusive disease. Lancet. 1989;1:657-8.

57. Tai YT, But PP, Young K, Lau CP. Cardiotoxicity after accidental herb-induced aconite poisoning. Lancet. 1992;340:1254-6.

58. Vanherweghem JL, Depierreux M, Tielemans C, Abramowicz D, Dratwa M, Jadoul M, et al. Rapidly progressive interstitial renal fibrosis in young women: association with slimming regimen including Chinese herbs. Lancet. 1993;341:387-91.

59. World Health Organization. Herbal Medicines Containing Germander Withdrawn. PHA Informati on Exchange Service. Geneva: World Health Organization; 1992.

60. Jimson weed poisoning-Texas, New York, and California, 1994. MMWR Morb Mortal Wkly Rep. 1995;44:41-4.

61. Lead poisoning associated with use of traditional ethnic remedies-California, 1991-1992. MMWR Morb Mortal Wkly Rep. 1993;42:521-4.

62. Smith GW, Chalmers TM, Nuki G. Vasculitis associated with herbal preparation containing Passiflora extract [Letter]. Br J Rheumatol. 1993;32:87-8.

63. Bailey DG, Arnold JM, Spence JD. Grapefruit juice and drugs. How significant is the interaction? Clin Pharmacokinet. 1994;26:91-8.

64. Chan TY, Chan JC, Tomlinson B, Critchley JA. Chinese herbal medicines revisited: a Hong Kong perspective. Lancet. 1993;342:1532-4.

65. Conn JW, Rovner DR, Cohen EL. Licorice-induced pseudoaldosteronism. Hypertension, hypokalemia, aldosteronopenia, and suppressed plasma renin activity. JAMA. 19 68;205:492-6.

66. Dandekar UP, Chandra RS, Dalvi SS, Joshi MV, Gokhale PC, Sharma AV, et al. Analysis of a clinically important interaction between phenytoin and Shankhapushpi, an Ayurvedic preparation. J Ethnopharmacol. 1992;35:285-8.

67. Fushimi R, Tachi J, Amino N, Miyai K. Chinese medicine interfering with digoxin immunoassays [Letter]. Lancet. 1989;1:339.

68. Goldman JA, Myerson G. Chinese herbal medicine: camouflaged prescription antiinflammatory drugs, corticosteroids, and lead. Arthritis Rheum. 1991;34:1207.

69. Gordon DW, Rosenthal G, Hart J, Sirota R, Baker AL. Chaparral ingestion. The broadening spectrum of liver injury caused by herbal medications. JAMA. 1995;273:489-90.

70. Hogan RP 3d. Hemorrhagic diathesis caused by drinking an herbal tea. JAMA. 1983;249:2679-80.

71. Kane JA, Kane SP, Jain S. Hepatitis induced by traditional Chinese herbs: possible toxic components. Gut. 1995;36:146-7.

72. Kempin SJ. Warfarin resistance caused by broccoli [Letter]. N Engl J Med. 1983;308:1229-30.

73. Larrey D, Vial T, Pauwels A, Castot A, Biour M, David M, et al. Hepatitis after germander (Teucrium chamaedrys) administration: another instance of herbal medicine hepatotoxicity. Ann Intern Med. 1992;117:129-32.

74. Roberts IF, West RJ, Ogilvie D, Dillon MJ. Malnutrition in infants receiving cult diets: a form of child abuse. Br Med J. 1979;1:296-8.

75. Sherlock P, Rothschild EO. Scurvy produced by a Zen macrobiotic diet. JAMA. 1967;199:794-8.

76. Kamb ML, Murphy JJ, Jones JL, Caston JC, Nederlof K, Horney LF, et al. Eosinophilia-myalgia syndrome in L-tryptophan-exposed patients. JAMA. 1992;267:77-82.

77. Hertzman PA, Blevins WL, Mayer J, Greenfield B, Ting M, Gleich GJ. Association of the eosinophilia-myalgia syndrome with the ingestion of tryptophan. N Engl J Med. 1990;322:869-73.

78. Vitamin preparations as dietary supplements and as therapeutic agents. Council on Scientific Affairs. JAMA. 1987;257:1929-36.

79. Megavitamin and megamineral therapy in childhood. Nutrition Committee, Canadian Paediatric Society. Can Med Assoc J. 1990;143:1009-13.

80. Taylor GD, Turner AR. Cutaneous abscess due to Nocardia after "alternative" therapy for lymphoma. Can Med Assoc J. 1985;133:767

81. Oliver LD, Mehta R, Sarles HE. Acute renal failure following administration of ethylenediamine-tetraacetic acid (EDTA). Tex Med. 1984;80:40-2.

82. Powell FC, Hanigan WC, Olivero WC. A risk/benefit analysis of spinal manipulation therapy for relief of lumbar or cervical pain. Neurosurgery. 1993;33:73-9.

83. Fast A, Zinicola DF, Marin EL. Vertebral artery damage complicating cervical manipulation. Spine. 1987;12:840-2.

84. Lee KP, Carlini WG, McCormick GF, Albers GW. Neurologic complications following chiropractic manipulation: a survey of California neurologists. Neurology. 1995;45:1213-5.

85. Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH. Spinal manipulation for low-back pain. Ann Intern Med. 1992;117:590-8.

86. Haldeman S, Rubinstein SM. Cauda equina syndrome in patients undergoing manipulation of the lumbar spine. Spine. 1992;17:1469-73.

87. Assendelft WJ, Koes BW, van der Heijden GJ, Bouter LM. The efficacy of chiropractic manipulation for back pain: blinded review of relevant randomized clinical trials. J Manipulative Physiol Ther. 1992;15:487-94.

88. Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG. Manipulation and mobilization of the cervical spine. A systematic review of the literature. Spine. 1996;21:1746-59.

89. Coulter I, Hurwitz E, Adams A, Meeker W. The Appropriateness of Spinal Manipulation and Mobilization of the Cervical Spine: Literature Review, Indications and Ratings by a Multidisciplinary Expert Panel. Santa Monica, CA: RAND; 1995.

90. Friedman RA. "Natural" doesn't mean safe [Editorial]. The New York Times. 19 April 1996:A29.

91. Russell FE, Carlson RW, Wainschel J, Osborne AH. Snake venom poisoning in the United States. Experiences with 550 cases. JAMA. 1975;233:341-4.

92. Epstein WL. Plant-induced dermatitis. Ann Emerg Med. 1987;16:950-5.

93. de Smet PA, Keller K, Hansel R, Chander RF, eds. Adverse Effects of Herbal Drugs. Berlin: Springer-Verlag; 1993.

94. Newall CA, Anderson LA, Phillipson JD. Herbal Medicines: A Guide for Health-Care Professionals. London: Pharmaceutical Pr; 1996.

95. Blumenthal M, Hall T, Rister R, Gruenwald J, Riggins C, eds. Klein S, Gruenwald J, Rister R, translators. Commission E Monographs. Austin, TX: American Botanical Council; 1996.

96. Wilkinson JA. The internet as a research and information tool for herbal medicine. British Journal of Phytotherapy. 1995;4:34-45.

97. ter Riet G, Kleijnen J, Knipschild P. Acupuncture and chronic pain: a criteria-based meta-analysis. J Clin Epidemiol. 1990;43:1191-9.

98. Patel M, Gutzwiller F, Paccaud F, Marazzi A. A meta-analysis of acupuncture for chronic pain. Int J Epidemiol. 1989;18:900-6.

99. Kleijnen J, ter Riet G, Knipschild P. Acupuncture and asthma: a review of controlled trials. Thorax. 1991;46:799-802.

100. ter Riet G, Kleijnen J, Knipschild P. A meta-analysis of studies into the effect of acupuncture on addiction. Br J Gen Pract. 1990;40:379-82.

101. Kleijnen J, Knipschild P, ter Riet G. Trials of homoeopathy [Letter]. BMJ. 1991;302:316-23.

102. Reilly D, Taylor MA, Beattie NG, Campbell JH, McSharry C, Aitchison TC, et al. Is evidence for homoeopathy reproducible? Lancet. 1994;344:1601-6.

103. Bigos SJ, Bowyer OR, Braen RG, et al. Clinical Practice Guideline. Number 14. Rockville, MD: Agency for Health Care Policy and Research, U.S. Department of Health and Human Services; 1994.

104. Vickers AJ. Can acupuncture have specific effects on health? A systematic review of acupuncture antiemesis trials. J R Soc Med. 1996;89:303-11.

105. Glock M, Friedman R, Myers P. National Institutes of Health Technology Assessment Statement. Integration of Behavioral and Relaxation Approaches into the Treatment of Chronic Pain and Insomnia. Bethesda, MD: National Institutes of Health; 1995; NIH publication no. PB96113964.

106. Carron H, Epstein BS, Grand B. Complications of acupuncture. JAMA. 1974;228:1552-4.

107. Rampes H, James R. Complications of acupuncture. Acupuncture in Medicine. 1995;13:26-33.

108. Cheng TO. Acupuncture and acquired immunodeficiency syndrome [Letter]. Am J Med. 1989;87:489.

109. Kent GP, Brondum J, Keenlyside RA, LaFazia LM, Scott HD. A large outbreak of acupuncture-associated hepatitis B. Am J Epidemiol. 1988;127:591-8.

110. Slater PE, Ben-Ishai P, Leventhal A, Zahger D, Bashary A, Moses A, et al. An acupuncture-associated outbreak of hepatitis B in Jerusalem. Eur J Epidemiol. 1988;4:322-5.

111. Stryker WS, Gunn RA, Francis DP. Outbreak of hepatitis B associated with acupuncture. J Fam Pract. 1986;22:155-8.

112. Vittecoq D, Mettetal JF, Rouzioux C, Bach JF, Bouchon JP. Acute HIV infection after acupuncture treatments [Letter]. N Engl J Med. 1989;320:250-1.

113. Angell M. Disease as a reflection of the psyche [Editorial]. N Engl J Med. 1985;312:1570-2.

114. Sale JD. Overview of Legislative Developments Concerning Alternative Health Care in the United States. Kalamazoo, MI: John E. Fetzer Institute; 1994.

115. Kassirer JP. Adding insult to injury. Usurping patients' prerogatives. N Engl J Med. 1983;308:898-901.

116. Tresolini CP. Health Education and Relationship-Centered Care. San Francisco: Pew Health Professions Committee; 1994

Return to the ALT-MED/CAM ABSTRACTS Page

                  © 19952023 ~ The Chiropractic Resource Organization ~ All Rights Reserved