Trends in Alternative Medicine Use in the United States, 1990-1997

Abstract & Commentary

This article reports a 1997 survey of a national randomized sample of households. The purpose of the questionnaire was to determine the rate of usage of alternative medicine by U.S. households, and to compare the results of the 1997 survey to a 1991 survey. There is a general impression that the use of complementary and alternative medicine (CAM) has increased during the past few years. Most medical schools now offer courses in CAM and the National Institutes of Health has developed a branch to study it.

The design of this type of study is complicated. In all such studies, there are compromises and great chances for the introduction of bias. Eisenberg and colleagues used random digit-dialing of a select sample of households throughout the United States. One household resident was interviewed. The household member must have been 18 years of age or older, and must have been able to use English to complete the questionnaire. Because it was recognized at the time of the survey that Americans are increasingly reluctant to answer telephone surveys, Eisenberg et al offered a financial incentive, though one was not offered at the time of the 1991 survey.

The initial sample included 9750 telephone numbers of which 52% were not working or were non-household numbers. An additional 5% were ineligible because the contact did not speak English. Forty-one percent of the remaining sample completed the interview at the time of the initial request. A subsample was recontacted, offered more money, and one-third of these individuals responded. It was known from a power calculation that approximately 2000 households would need to complete the interview for the results to be able to detect small significant differences.

Most of the information collected in the 1997 interview was similar to that collected in 1991. Care received from physicians (MD or DO degree) was distinguished from that received from any other practitioner. Participants in the questionnaire process were given a list of common medical conditions and asked whether they had any of these diseases. They were then asked about both their lifetime and past year usage of 16 alternative therapies. They were asked for which medical condition they used these therapies. Patients also were asked whether they discussed the use of CAM with their physician. Questions were asked concerning insurance coverage of CAM. The statistical analyses were appropriate for the type of study.

Eisenberg et al found that CAM was used by a wide array of societal members. However, usage was more common among women, non-African Americans, the 35-39 year age group, those with college education, and those with annual incomes of more than $50,000. There was a 65% increase in the use of CAM between 1990 and 1997, increasing from 577 therapies per 1000 to 953 per 1000. The use of herbal medicines, massage, megavitamins, self-help groups, folk remedies, energy healing, and homeopathy showed the biggest increases.

There was also an increase in the number of individuals who saw alternative medicine practitioners in 1997 (46.3% vs 36.3%). Massage, chiropractic, hypnosis, biofeedback, and acupuncture were the most used providers. Visits to alternative medicine therapists were estimated to exceed the number of visits to primary care physicians in 1997.

There was a wide array of diseases for which individuals sought CAM help. Back problems and allergies led the list but were followed closely by fatigue, arthritis, headache, neck problems, and high blood pressure. Many individuals saw both a physician and an alternative medicine provider.

Most of the costs of alternative therapy were self paid. Although there is a trend toward coverage of these therapies by insurance companies, approximately 58.3% of the patients paid for the entire alternative therapy themselves. In 1997, approximately $21.2 billion was spent on alternative therapy. This greatly exceeds out-of-pocket expenses for all hospitalizations. In their comment section, Eisenberg et al carefully point out the limitations of their study. The study was restricted to individuals who speak English, have telephones, and were willing to answer a questionnaire. Nonetheless, it is reasonable to estimate that nearly one of every two adults aged 35-49 years used at least one alternative therapy in 1997. (Eisenberg DM, et al. JAMA 1998;280:1569-1575.)

Comment by Kenneth Noller, MD

This is an important article. Despite what we, as physicians, might individually think of complementary and alternative therapy, the message is clear: The general public endorses and uses CAM to a great degree. I was raised in and received my education in the post-war years when science was king and nothing in medicine was effective unless it was proven in the laboratory. Alternative medicine was either ignored or laughed at. Obviously, such a one-sided view cannot be completely correct.

The pendulum is swinging more toward the middle and, I believe, it is incumbent upon us as physicians who care for the entire patient to be aware of alternative medicine and the good it can do. There are literally thousands of articles (many of them randomized clinical trials) that have shown the effectiveness of at least some of the alternative medicine measures. NIH has started a branch to investigate complementary and alternative medicine. They are finding a rich literature that "proves" effectiveness of many traditional folk medicines while, at the same time, they have also found some therapies not to be effective.

I see three major problems for which we, as physician guardians of our patients’ health, must take leadership. First, we must make it clear to our patients that it is important that we know of all medications they may be ingesting, whether these are prescription or nonprescription. Serious interactions occur between medications and we must strive to avoid them. However, patients will not freely admit to seeking CAM care unless we ask our questions in a nonthreatening manner and do not poke fun at these other treatment strategies.

Second, we must protect our patients from those practitioners of CAM who are clearly taking advantage of a distressed patient. Unfortunately, licensing of alternative medicine practitioners varies greatly, and, in many states, no license is necessary for some practices. While I have had many patients who have seen alternative providers and been happy, I cannot help but remember the recent patient who saw an "herbal immunologist" who took her history, talked to her for 20 minutes, and charged her $483. Obviously, he had figured out she could afford to pay his exorbitant fee.

Third, we must join the lobby that is pushing Congress to require content labeling of all "food supplements." These substances are not required to undergo testing for content. When bottles have been purchased off shelves in health food stores and pharmacies, there has been a wide variation in the amount of actual active ingredients in the pills from a tiny fraction of the labeled amount to many-fold greater amount.

CAM has always been here and is here to stay. We should learn what is good and reject what is bad. Most important, we must keep an open mind.