Complementary medicine for pain
Complementary approaches to pain control are extremely
numerous and popular. There is reliable evidence that some are effective
and that some do not work, but for many there is insufficient evidence
to draw any conclusion.
Complementary medicine encompasses a confusing array of therapies
(Table 1). It is often defined by what it is not (e.g. not based on science,
not taught in medical schools, etc.) rather than by what it is. A 'positive'
definition states that complementary medicine is:
diagnosis, treatment and/or prevention which complements
mainstream medicine by contributing to a common whole, by satisfying a
demand not met by orthodoxy or by diversifying the conceptual frameworks
Complementary medicine has become an important topic, not least because
of its popularity in the general population and its prevalent
use for pain control. Between 20 per cent and 75 per cent of all adults
in industrialized countries have used at least one type of complementary
medicine within the past year. Almost all patients suffering from chronic
pain try some form of complementary medicine.
Reasons for popularity
The reasons for the popularity of complementary medicine are varied and
complex; they change with time, space, and from one therapy to another.
They also differ from one individual to the next - for example, a pain
patient will have different motives from someone who is 'worried well'.
Thus no single determinant exists but a broad range of interacting positive
and negative motivations can be identified (Table 2). Some of these amount
to a biting criticism of our modern healthcare system.
Obstacles to research
Many providers of complementary medicine are convinced that their therapy
defies scientific research. They argue that it is individualized,
holistic, intuitive, and so on, and therefore not amenable to study by
standard approaches of medical appraisal. There have been many calls call
for a 'paradigm shift' in research.
Usually these arguments are based on a series of misunderstandings, and
often the problems can be resolved by clearly defining the research
question and subsequently identifying the optimal research tool.
If this question relates to testing the effectiveness of a treatment,
randomized controlled trials usually provide the least
biased method for finding a reliable answer.
Why then is there so little research into complementary medicine? A particular
problem is that the area lacks both a research tradition and a research
infrastructure. Research career opportunities are limited and the field
does not attract experienced researchers. Most importantly perhaps, the
orthodox attitude remains sceptical and, as a consequence, the funding
of complementary medicine research is pitiful.
Is there any evidence at all?
Opinions dominate complementary medicine, and they can be dangerously
misleading. The best way to establish the true value of any therapy is
through rigorous research. Moreover, each of the numerous techniques has
to be evaluated on its own merits; simple answers or broad generalizations
are not possible. Some forms of complementary medicine are safe while
others are burdened with risks; some are effective while others may be
Unfortunately, with so little investment in research, very few studies
have examined the role of complementary medicine in pain control. For
only a few treatments is our knowledge sufficiently advanced to allow
preliminary conclusions to be drawn (Table 1). In some
cases (for example, herbal medicine) the evidence is positive;
in other instances (for example, chelation therapy) it is negative.
The confusing array of treatments makes it obvious that there cannot be
one single mode of action. Only with some therapies are we anywhere near
to understanding how they work.
For instance, herbal medicine acts through the pharmacological
actions of the plant constituents - much like conventional drugs.
Acupuncture might work through several complicated neurophysiological
pathways. Treatments such as aromatherapy or massage might be effective
via a relaxation response.
For the majority of treatments, however, no plausible mode of action has
yet been identified.
Complementary medicine is not cheap. The UK's annual total expenditure
on complementary medicine is around £1.6 billion, and practitioners' fees
can be considerable.
This level of spending has significant implications not only for the nation's
healthcare system but also for our economy in general. The ultimate question
is whether the use of complementary medicine increases or decreases overall
expenditure in our healthcare system. Self-treatment, it has been argued,
may ease the burden on the public NHS. To answer it, one would require
reliable data. The most rigorous studies to date show no evidence that
the use of complementary medicine reduced overall expenditure.
The power of placebo
Some forms of complementary medicine could be 'ineffective' (in the sense
of not being better than a placebo) and still alleviate pain through a
placebo response. Some argue that, in such instances, complementary medicine
should be used regardless, particularly when its use is not associated
with serious risks.
Rigorous research could even be seen as counterproductive. We might, for
instance, find little 'hard' evidence in favour of homoeopathy and its
availability would thus decrease. Patients who previously benefited from
it might in turn no longer do so.
On the other hand, if research really showed that homeopathy helps people
through powerful non-specific (placebo) effects, the medical community
should start seriously considering the power of placebos. The research
question then shifts to how placebo effects might be optimized so that
more patients can reliably profit from them.
Complementary medicine is frequently used by patients to alleviate pain.
Several forms are beginning to be backed up by good evidence. In many
instances, however, it is unclear whether complementary approaches are
truly effective, harmful or just a waste of time and money. To fill the
considerable gaps in our current knowledge, we urgently require more research
- and sufficient funds to adequately perform this work.
Professor Edzard Ernst is Director of Complementary
Medicine, Peninsula Medical School, Universities of Exeter and Plymouth,
Exeter EX2 4NT, UK.
Ernst E, Pittler M H, Stevinson C, White A R (2001) The desktop guide
to complementary and alternative medicine. Edinburgh: Mosby.