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A South Australian survey of more than 3000 people aged 15 or older found that 48.5% used at least one non-medically prescribed alternative medication annually (excluding calcium, iron and medically prescribed vitamins), and 20.3% of those in the survey had visited at least one alternative practitioner during the year.² Extrapolated to the Australian population, the overall out-of-pocket costs were almost three times the patient contributions for all classes of pharmaceutical drugs purchased during 1992-1993.² Our own smaller survey of the use of alternative medicine by people attending a Sydney teaching hospital emergency department revealed remarkably similar results in a predominantly white middle-class population.³ It is perhaps not surprising to learn of the high usage of alternative therapies in children⁴ and adults⁵ with cancer, or in people with chronic rheumatoid arthritis.⁶ However, the high usage in generally "healthy" populations cannot be attributed to desperation about an incurable disease or to reliance on traditional remedies by certain ethnic groups. Other reasons given in our study (apart from consultations for specific conditions) for consulting alternative therapists were to "feel better", "clean up the system", or other, general, reasons. In both the Sydney and the South Australian surveys, consumers of alternative medicine were more likely to be female, better educated and employed.^2,3 If these statistics are of concern to the medical profession, then the profession should be even more disturbed to learn that fewer than 50 per cent of both our study population³ and parents of children with cancer⁴ had informed their doctors of their use of alternative therapies -- yet many were simultaneously taking prescribed medications for the same indications.

The startling usage figures are for therapies for which there is, in most cases, no evidence of efficacy beyond "traditional use". Moreover, there are numerous documented problems with the safety of alternative preparations -- their content is uncontrolled, and hence very variable;⁷ they may be adulterated, as with the Chinese medicines for arthritis that contain corticosteroids;⁸ and the substances themselves may be intrinsically toxic.⁹ In Australia, there have been reports of acute hepatitis due to ingestion of chaparral,¹⁰ and deaths caused by anaphylactic reactions to royal jelly¹¹ (as summarised by Drew and Myers in this issue of the Journal). The popular perception that alternative medicines are harmless may be true of many preparations, but the more extensive their use, the greater the potential for toxicity.

It is unlikely that the Government will increase its vigilance. The recent review of the Therapeutic Goods Administration (TGA) included the investigation of "approval processes for alternative medicines with a view to ensuring any inappropriate existing impediments are removed."¹² The final report has been submitted and, while some recommendations have not been accepted, it is hard to see how these medicines can be any less restricted than they are at present. In his media release in response to the recent TGA review, Senator Christopher Ellison (Parliamentary Secretary to the Federal Minister for Health and Family Services) stated that, with a new range of initiatives, "the Federal Government has ensured that patients can have confidence that their [alternative] medicines will work in the way they are intended to". It is difficult to see how this can be the case when in the same document he states that the approval processes of the TGA should not prevent people obtaining alternative medicines "where the intrinsic safety of the product is not in doubt but the therapeutic effectiveness is unproven". These products should be scientifically assessed so that patients do not unwittingly delay their own access to proven effective therapy.

We believe it is up to doctors and other health professionals to address the situation as a matter of urgency. In our survey, the main reasons given for not telling medical practitioners about the use of alternative therapies were the perception that doctors would probably reject the therapies, and a belief that individuals were "in charge of their own health". If 50% of Australians are using alternative treatments each year, it is essential that doctors recognise this fact and be prepared to discuss such use with their patients in a non- judgemental manner.

As a minimum step, questions about alternative treatments must be included as a routine part of history-taking. Eliciting the reasons for their use might indicate where conventional medicine is perceived to be failing, and allow supportive discussion with patients. In addition, any unusual or unexplained symptom or sign should raise the possibility of an adverse reaction to, or interaction with, an alternative medication, and if there is a suggestive temporal association the event should be reported to the Australian Adverse Drug Reactions Advisory Committee (Commonwealth Department of Health and Family Services).

We need to acknowledge what is happening in the community. It has been suggested that the normal doctor-patient encounter lacks "time, empathy, personalisation, expectation of a cure in chronic disease states, counselling and a general emphasis on health rather than disease".² While this is not always the case, it is time for us to recognise that a complementary system for trying to achieve a state of well-being exists in Australia and is widely used by our patients. We cannot ignore it and should record and collect objective data about its use.

Gillian M Shenfield
Clinical Professor in Clinical Pharmacology

Philip A Atkin
Research Associate in Clinical Pharmacology

Sean S Kristoffersen
Honours Student, Department of Clinical Pharmacology, Royal North Shore Hospital, Sydney, NSW.

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3. Kristoffersen SS, Atkin PA, Shenfield GM. Uptake of alternative medicine [letter]. Lancet 1996; 347: 972.
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11. Harmless herbals? ADRAC Bull 1993; 12: 11.
12. KPMG Management Consulting. Review of Therapeutic Goods Administration on behalf of the Department of Health and Family Services. Canberra: AGPS, Jan 1997 p2.