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| Journal of the New Zealand Medical Association,
05-May-2006, Vol 119 No 1233
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Complementary
and alternative medicines (including traditional Māori treatments) used by
presenters to an emergency department in New Zealand: a survey of prevalence and
toxicity
Tonia Nicholson
Complementary and alternative medicines (CAM) is a widely
used term, but it has no commonly accepted definition. For the purposes of this
paper, the definition of CAM chosen is
any product including herbal remedies,
vitamins, minerals, and natural products that can be purchased without a
prescription at a health food store, supermarket, or from alternative medical
magazines and catalogues, with the purpose of self treatment.1
The use of CAM is known to be widespread in many Western
countries, with billions of dollars being spent on treatments each year. Factors
believed to contribute to the popularity of CAM include the perception of
treatments as “natural and therefore safe”, the goal of treating the
individual not the illness, and the requirement of the patient to take
responsibility for their healing process.
However, these beliefs may result in problems for CAM users.
Indeed, herbal therapies may produce adverse effects, cause toxicity, or
interact with conventional medicines. Moreover, in the majority of countries
(with the notable exceptions of Germany, France, and Sweden) herbal products are
marketed without proof of testing for efficacy or safety. They are sold as food
and dietary supplements under regulations for Current Good Manufacturing
Practice, which ensures that they are produced under sanitary conditions but
provides no guarantee of purity or efficacy.
Recent studies have reported that CAM have been used by up
to 68.1% of ED presenters in Australia2 and 24% of ED presenters in the USA.3
Studies in New Zealand have looked at the prevalence of use in certain subgroups
of patients4–7 but none has looked at the use in ED presenters.
Therefore,
this project was designed with the primary aim of assessing the prevalence of
use of CAM (including use of traditional Māori treatments) among
presenters to a tertiary hospital ED in New Zealand. Secondary aims were to
determine if any patient subgroups are more likely to use CAM, and what types of
CAM are used.
Additionally it was hoped to determine where people get
their information about CAM from, where they purchase the products from, how
many inform their medical practitioner of their use of CAM, how effective they
believe the treatments are, and how many suffer adverse effects or
toxicity.
MethodThe study was an analytical, cross-sectional
convenience sample of all patients (regardless of their presenting complaint)
and their relatives who presented to an ED. It was undertaken between December
2004 and January 2005 at Waikato Hospital in Hamilton, New Zealand. This is a
tertiary referral and trauma centre, which sees approximately 49,000
presentations per year. The study was approved by the Waikato Ethics
Committee.
The survey forms were self explanatory, anonymous, and
required short written answers or a tick response to the questions. They were
handed out to patients and their relatives either upon presentation to ED by
clerical staff or the triage nurse, or at some point during their stay in the
department by their primary nurse.
Children less than 14 years of age were excluded from
the survey, although the parents of paediatric patients were asked to complete
the survey for themselves. Any patients who either were too ill, had dementia,
or could not read English well were also excluded.
Those patients who presented with a condition that
needed emergent treatment were also initially excluded, but could be
reconsidered later for participation once their condition had improved. The
forms were available for distribution 24 hours a day for 7 days of the week.
People who did not wish to participate in the survey where asked to tick the
“No” box in the consent section, and return the form to their
primary nurse.
Sample size calculation was difficult due to the
paucity of systematic review of this topic in the literature in New Zealand.
However, it was decided that a pilot sample of 1000 patients would be able to
provide indicative results.
The questionnaire first collected data relating to the
patient’s age, sex, and ethnicity. It was subsequently divided into two
parts. The first part enquired about the use of complementary and alternative
medicines, which will be discussed here. The second part asked about the use of
herbal party pills, and this information is the subject of a separate paper
published in the April 2006 issue of Emergency Medicine Australasia (Vol. 18,
Issue 2).
Most of the results are reported descriptively with 95%
confidence intervals fitted around simple proportions. However, ordinal logistic
regression was used to investigate the effect of age, sex, and ethnicity on the
use of CAM. Frequency of use was used as the ordinal outcome variable, with age,
sex, and ethnicity used as the explanatory variables.
Ordinal logistic regression was also used to
investigate the relationship between the source of information about CAM (used
as the ordinal outcome variable), and knowledge of the contents of the CAM and
possible adverse effects (used as the explanatory variables).
ResultsDuring the period of the study, 5880 patients were seen in
the Emergency Department at Waikato Hospital. Of these patients, a convenience
sample of 1073 were invited to participate in the survey, and only 30 declined
(thus a participation rate of 97.2%). The mean patient age was 40.6 years with a
range of 14–97years.
616 of the responders (59%, CI 56.0–62.0) were female
and 412 (39.5%, CI 36.6–42.5) were male (15 people, or 1.4%, did not state
their sex). Table 1 below describes the ethnicity of the study sample.
Table 1. Ethnicity or citizenship of respondents to the
questionnaire (N=1043)
†Europeans were
distinguished from New Zealander Europeans in terms of their country of
birth.
Since vitamin and mineral supplements are generally
considered free of significant adverse effects when not taken in excess, people
were asked not to give information regarding these products, and if information
was given then it was not analysed. The data that was analysed, however,
revealed that the use of CAM was common, with approximately one in three
responders reporting CAM use.
Table 2 compares the sex and
ethnicity of CAM users with non-users.
Eighty-seven of the 397 people who had used CAM (21.9%, CI
18.1–26.3) reported use of only one course. 199 (50.1%, CI 45.2–55)
reported occasional CAM use, whilst 70 (17.6%, CI 14.2–21.7) reported use
on a regular basis. (Forty-one people didn’t answer.)
There was strong evidence of an association of age
(p<0.0001), sex (p<0.001), and ethnicity (p=0.01) with the use of CAM.
Specifically, females were more likely to use CAM than males; Europeans (NZ- and
Europe-born) were most likely (and those of “Other” ethnicity least
likely) to use CAM; and those aged 20–60 years were more likely to use CAM
than younger (<20 years) or older (>60 years) people.
Respondents
reported the use of a total of 75 different types of CAM. Table 3 describes the
21 most commonly used treatments and/or their indication, excluding Māori
therapies. Arnica was the most commonly used CAM (77 people or 19.4%),
with Rescue Remedy and St John’s wort next most used, respectively.
Together these therapies were used by 38% of users (either alone or with other
treatments). Many CAM were used by only a few people, and 23 were used by only 1
person. Five people (1.3%) considered marijuana to be a CAM.
Table
3. The top 21 commonest complementary and alternative therapies (CAM) used by ED
presenters to Waikato Hospital during December 2004 and January 2005 (excluding
Māori therapies) [N=397]
Of those who had used CAM, 29
(7.3%, CI
5.1–10.3) had used traditional Māori therapies. Of these, 24 people
(82.8%, CI 64.8–92.7) were of Māori ethnicity, whilst 3 (10.3%, CI
2.9–27.4) were New Zealand Europeans. (The remaining 2 people didn’t
state their ethnicity).
The total number
of Māori
responding to the questionnaire was 223. Thus, in this population sample, 10.7%
(CI 7.3–15.5) of Māori presenting to ED used traditional Māori
therapies. The total number of Māori responders that had used CAM was 75.
Of these, 17 (22.7%, CI
14.6–33.5)
reported use of only traditional Māori therapies, whilst 7 (9.3%, CI
4.4–18.4) also reported use of non-Māori CAM.
Interestingly,
more Māori used non-Māori CAM (51 or 68% of those reporting use, CI
56.7–77.4) than used traditional Māori therapies (29 or 13.1% of
those reporting use, CI 9.2–18.1). The majority of people grew or
collected the plants needed, and then made the Māori therapy themselves (15
people or 51.7%, CI 34.5–68.6).
Table
4 describes the different traditional Māori therapies used with
their indication where known.
Table
4. Types of traditional Māori treatment used by the ED
presenters
†Rongoa
is not a specific treatment but is the Māori word for all traditional
medicines; ‡Only the Mamaku Ponga is used; §Harakeke is the
Māori word for flax plant.
Note:
Traditionally, plants must be blessed by a Māori elder before use, and the
residue must be returned to the earth (buried) after use.
Seven main sources of CAM were reported. Most people (170 or
42.8%, CI 38.0–47.7) reported buying products from health shops. 118
(29.7%, CI 25.4–34.4) people reported buying products from a specialist in
alternative therapy (such as a herbalist or homeopathist). Sixty-six people
(16.6%, CI 13.3–20.6) reported buying products from a pharmacy, whilst 23
(5.8%, CI 3.9–8.6) reported growing and/or making the treatment
themselves. Ten people (2.5%, CI 1.3–4.7) reported buying CAM from a
supermarket. A small number reported using either a mail order company (5 or
1.3%, CI 0.5–3.0) or a company representative (four or 1%, CI
0.3–2.7) as their source. Seven people (1.8%, CI 0.8–3.7) reported a
different, unspecified source to those above, and 120 (30.2%, CI
25.9–34.9) reported multiple sources.
Table 5 describes the origins of information about CAM that
were reported. The commonest source reported was friends and family, followed by
specialists in alternative medicine and shop assistants. Eighteen people (4.5%)
reported receiving their information from their midwife.
Table 5. Origin of information about complementary and
alternative medicines (CAM)
Only 129 people (32.5%, CI 28.1–37.3) reported that
they knew what the CAM they had used contained; hence 245 (61.7%, CI
56.8–66.4) reported that they did not know the contents (23 people
didn’t answer the question). There was no evidence that receiving
information about CAM from a specialist in alternative therapy had any influence
on the knowledge of the content of CAM (p=0.25).
132 people (33.2%, CI 28.8–38.0) reported that they
were aware that the use of CAM could be associated with adverse effects; hence
243 (61.2%, CI 56.3–65.9) were unaware of this at the time of use (16
didn’t answer the question). There was no evidence that receiving
information from a specialist in alternative therapy had an influence on the
knowledge of possible adverse effects (p=0.48).
Just over a quarter of users (103 or 25.9%, CI
21.9–30.5) reported that they were taking conventional medicines when they
used CAM; hence 276 (69.5%, CI 64.8–73.8) reported that they weren’t
using conventional medicines at the same time (12 didn’t answer the
question).
Only 148 people (37.3%, CI 32.7–42.1) reported that
they had told their medical practitioner of their use of CAM; hence 227 people
(57.21%, CI 52.3–61.9) reported not telling them (16 didn't answer the
question).
The majority of people (266 or 67%, CI 62.2–71.4)
reported that CAM had helped them. Only 92 people (23.2%, CI 19.3–27.6)
reported that CAM had been ineffective, whilst 12 (3.0%, CI 1.7–5.3)
reported being unsure if there had been any benefit (21 didn’t answer the
question).
The majority of people (349 or 87.9%, CI 84.3–90.8)
reported no adverse effects from CAM. Sixteen people (4.0%, CI 2.5–6.5)
reported that they had suffered an adverse effect (26 didn’t answer the
question). The effects reported were generally non-specific and included
abdominal pain, poor appetite, indigestion, constipation, diarrhoea, and skin
rash. The two most serious reactions reported were serotonin syndrome (when
paroxetine was prescribed to a person already taking St John’s wort), and
excessive post-surgical bleeding (in a patient taking
Gingko biloba preoperatively).
Of those suffering an adverse effect, only one (6.2%, CI
–0.6–30.6) person reported telling their general medical
practitioner about it, whilst 6 (37.5%, CI 18.5–61.5) had not told them (9
did not answer the question). For both of the most serious cases, the diagnosis
of an adverse effect from a CAM was made by the responders’ medical
practitioner.
DiscussionThis study demonstrates that the use of CAM is common in
people presenting to EDs in New Zealand. This is consistent with reports from
Australia2,8 and the USA.3,9–11 Use in this study was significantly more
likely in females aged 20–60 years, and in those of European ethnicity.
This sex and age bias is also consistent with previous studies.12–15
CAM were primarily used either for general health promotion,
or for the treatment of minor complaints and chronic conditions. Arnica (used to
treat soft tissue injuries), Rescue Remedy, and St John’s wort (used to
treat anxiety, stress, and depression) were the commonest CAM used. Comparison
with the recent study by Taylor et al from Melbourne2 reveals a similar
prevalence of use of St John’s wort (in this study 6.1%, and in theirs
4.5%). However, Arnica and Rescue Remedy do not feature in the top 26 CAM
reported in the Melbourne study.
Not
surprisingly, traditional Māori therapies were most likely to be used by
Māori and the majority were homegrown/made. As with most CAM, Māori
treatments are generally used for non-specific conditions. They primarily
consist of poultices made from the leaves of plants, or tonics made from
boiling part (s) of the fresh plant.
Many people reported obtaining information about CAM from
multiple sources, but the commonest used was family and friends. The percentage
for this source (47.3%, CI 42.5–52.3) was similar to findings in other
studies in the USA (62.5%)16 and Turkey (43.5% for family and 57.5% for
friends).17
Additionally, the US study 16 reported a similar percentage
of people receiving information from specialists in CAM (32.5% from herbalists
and 27.5% from naturopaths, compared with the total percentage for all
specialists in CAM of 35.5% in this study.) However, in the US study,16 more
people cited the Internet as a source of information than in this study (25%
compared with 4%).
In this study, 4.5% of people reported their midwife as a
source of information about CAM. In all cases, as might be expected, this was
information about therapies that could be used to help with morning sickness,
child birth, and lactation. However, few people stated the name of the CAM used,
with most only describing its indication.
There is little evidence available regarding the safety of
CAM during pregnancy and lactation, and many would recommend avoidance of CAM
during these times. However, a few studies have looked for evidence of adverse
effects on the offspring, and beneficial effects in mothers suffering from
nausea and vomiting of pregnancy (NVP), using vitamin B6,18,19 multivitamins,20
and ginger;21 and these have been reassuring. In general, however, the use of
CAM during pregnancy and lactation should be cautioned, since there is little
evidence of safety.
The lack of knowledge of the contents of CAM, and the
possibility of adverse effects from treatments revealed in this study, is
perhaps not surprising—but it is concerning, particularly as over a
quarter of users were concurrently using conventional medicines. The Slone
Survey in the USA 24 also assessed this issue and found that 16% of prescription
drug users also used CAM. In comparison, 25.9% of CAM users in our study were
also using conventional medicines.
Reporting of the use of CAM to medical practitioners in this
study was moderate and consistent with other studies.3,6,23–25 Reported
effectiveness of CAM was very high, and this is also consistent with other
studies.2,6,17 Several studies have directly compared the effects of CAM against
placebo and/or conventional therapies and shown a beneficial
effect.18–21,36–38 However, rigorous evidence for the efficacy of
many CAM is lacking, and some degree of placebo effect and/or variation in
symptom intensity of chronic conditions with time may also influence the
perceived effect.
Previous studies have looked at the incidence of adverse
effects or toxicity associated with the use of CAM in ED presenters and our
findings were very similar to those of Taylor et al.2 Firstly the incidence of
adverse effects was not high (4.0% here compared with 4.5% in their study), and
secondly, most effects were non-specific. Additionally, during the relatively
short period over which this study was conducted (7 weeks) there were no
presentations to the Emergency Department with adverse effects associated with
the use of CAM.
The two most serious adverse effects described were
serotonin syndrome from the use of St John’s wort in combination with
paroxetine, and postoperative bleeding associated with the use of Ginkgo biloba.
St John’s wort (Hypericum
perforatum) has been compared in studies both against placebo and against
commonly used antidepressants.36–38 It has been shown to be effective in
mild to moderate depression and has relatively few adverse effects.36–41
Though its exact mechanism of action remains unclear, it is thought to involve
some inhibition of serotonin reuptake. Indeed, there have been at least three
case reports in the literature of symptoms consistent with serotonin syndrome
occurring in people taking St John’s wort.42–44.
Two meta-analyses have suggested that
Gingko biloba has a positive effect
over placebo in the treatment of “cerebral insufficiency without
dementia”45,46 and a systematic review of its use in the treatment of
dementia has also shown a suggested a positive effect.47 An increased risk of
bleeding is a recognised association with the use of
Gingko, and is thought to be caused by
Ginkgolide B, which is a terpenoid that inhibits platelet activating factor.
There have been several case reports of intracerebral bleeds associated with the
use of Gingko,48–51 one of bleeding into the eye,52 and one of
postoperative bleeding after a laparoscopic cholecystectomy.53.
This study has several limitations. Firstly, it used a
convenience sample, and it excluded the sickest patients and those who did not
speak English. In the area of New Zealand where the study was conducted, very
few patients would have been excluded because of poor English, and this is
unlikely to have had a significant effect on the results. However, excluding the
sickest patients may have underestimated the number of severe adverse effects or
drug interactions associated with the use of CAM. Also, the survey was completed
by patients and their relatives/friends. It may be that more relatives/friends
completed the questionnaires than patients, again resulting in an
underestimation of adverse effects and toxicity from CAM in ED patients. Another
confounding factor is that the survey was retrospective, and thus may have been
influenced by recall bias.
Finally, the survey did not ask specifically when the
responders had used CAM, so it was not possible to determine how many had used
CAM on the day of presentation. It would have been useful to ask this and also
how many had used CAM within the past year.
Despite the limitations of this study, it can still be
concluded that the use of CAM is common in people presenting to emergency
departments in New Zealand. In addition, people’s knowledge about possible
adverse effects from CAM and/or interactions with conventional medicines is
limited, and few people volunteer the information that they are using CAM to
their regular medical practitioner. Therefore, doctors should routinely enquire
specifically about the use of CAM in all patients presenting to the emergency
department.
Additionally, doctors should also be aware that CAM may
cause non-specific adverse effects, which might be the reason for presentation,
and conventional medicines might interact with CAM, which must be considered
before they prescribe any treatment. The incidence of such effects appears to be
low, and therefore diagnosis may be difficult. Thus all emergency departments
should have a source of information about CAM readily available, and in
addition, teaching about CAM should be included in continuing medical education
(CME) sessions.
Author information:
Tonia C Nicholson, Emergency Physician, Department of Emergency Medicine,
Waikato Hospital, Hamilton
Acknowledgements: I
acknowledge the help of the nursing staff in the Emergency Department at Waikato
Hospital for their help in the distribution and collection of the survey forms.
Particular thanks go to Vi Taha for her help with
information on
Māori therapies, and for organising appropriate blessing of the information
before inclusion in this paper. I also thank Steve Holmes for his technical
advice during the data analysis, Joanna Stewart for her statistical advice, and
Martyn Harvey for his advice during the preparation of this paper.
Correspondence: Dr
Tonia Nicholson, Emergency Physician, Department of Emergency Medicine, Waikato
Hospital, Private Bag 3200, Hamilton. Email: NicholsT@waikatodhb.govt.nz
References:
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