Fabrizio Benedetti, M.D. 2014

How to safely and effectively incorporate alternative medicine into clinical practice.

Alternative medicine frequently does not work in the way it is advertised or for the conditions that it is advertised to treat. It can, nevertheless, affect physiology in a real and effective way. Most commonly it works by triggering compensatory brain mechanisms that involve neurotransmitters (brain chemicals). The trigger has more to do with how the brain is programmed than with the chemical composition of the medication. Communication from the treating professional and the therapeutic environment as well as expectations and prior conditioned responses of the patient can trigger a neurotransmitter mediated compensatory brain response. This is the placebo effect.

Here is an example. You tell a patient, “I will place needles in certain places on your body. They will disrupt the flow of your chi and the pain in your shoulder will be reduced.”

The location of needle placement does nothing physiologically. There is no disruption in the imaginary flow of the mythical substance chi. In fact, the needles could be placed anywhere on the body and any story could be made up and told to the patient as long as it is told in the proper way. The amazing thing is that their pain is actually reduced and this IS real. Suggestion and expectancy are carefully crafted to cause the brain to produce endogenous opioids and other pain relieving neurotransmitters that specifically target the location and kind of pain the patient is experiencing. (Accupuncture: What you need to know NCCIH)

Alternative medicine that is physiologically inert or any other placebo can not directly cure any physical illness but they can facilitate the brain to compensate for certain physical conditions such as pain, nausea, depression, anxiety, and OCDThey can not cure infection, malignancy, or anatomical defect but they may ameliorate any condition that can be made better by increasing or decreasing an endogenous (produced in the body) neurotransmitter such as dopamine. A potential example of this would be Parkinson’s disease which is caused by a specific nucleus in the brain failing to adequately produce dopamine. We have experimental evidence to suggest that an increase in dopamine can occur secondary to placebo. (Micheal J. Fox Foundation)

Alternative medicine can also have a positive effect on general health and well being. Theoretically, this would be mediated by bringing numerous neurotransmitters into homeostasis. If you are fighting cancer or heart disease the chronic stress might cause a compensatory imbalance or disruption in homeostasis of brain chemicals in order to defend from depression or anxiety. Serotonin, for example, might be way down or up which could help acutely but will be detrimental if the stress is chronic. When the stress is chronic you need all neurotransmitters to be returned to homeostasis to be maximally healthy. Thus, alternative medicine may lead to better outcomes when used alongside mainstream treatments.

Alternative medicine is often promoted by individuals who do not understand how mainstream medicine works. This leads to the very real danger of a patient not getting appropriate treatment because they believed something about the way an alternative treatment was presented to them that turned out to be false. That is not OK.

The ideal way to use alternative medicine is to first see an internist or family physician. They can provide assessments so that your infection or cancer can get the appropriate treatment. Then, you can be referred to a complementary or integrative provider who works in concert with the mainstream physician when providing an alternative intervention. A complementary or integrative provider, by definition, is someone who uses alternative treatments to complement or integrate with mainstream treatments.

For example, a family doctor might see a person who has Type II diabetes. The patient is prescribed Metformin® to help control their blood sugar but the doctor knows that how and what this patient eats and how this patient exercises and what kind of relationships this patient has will influence the long range outcome of this patient’s health. Therefore, the doctor sends the patient to a nutritionist, psychologist, exercise physiologist, massage therapist and to a homeopath. Many mainstream physicians will ask,

“Why the homeopath?”

The reason the homeopath was included is because the patient indicated a positive association with this type of therapy in the past or an open mind to trying this type of clinician. The homeopath may prescribe water that used to contain arsenic and tell the patient this will stabilize their blood sugar. Of course, it won’t directly stabilize their blood sugar in the same way that remembering to take insulin and to eat correctly will but it may help the patient remember to take insulin and eat correctly through the placebo effect.

The homeopath is an expert in having a doctor-patient relationship. This practitioner knows how to present an intervention in a way that maximizes the placebo effect. This person knows how to alter your brain chemicals in a therapeutic way with a non-pharmacologic and/or totally inert intervention.  

Mainstream doctors are not stupid. They know how to do this as well but it is often times the case that they are simply not focused on it as much. They are usually overwhelmed with the three or four trillion other things that doctors have to be thinking about. Wouldn’t it be great if doctors could farm out the excess doctor-patient relationship stuff to someone who is an expert at doing it?

As long as there is no deception involved a doctor could send a patient to a homeopath for the purpose of improving their emotional state just like when a patient is sent to a psychotherapist for the same thing. The intervention that either would provide is essentially the same.

There are several rules that are important for the complementary or integrative provider to follow. First, all treatments have the same cost and this cost is reasonable. Second, all therapies are safe and have minimal risk of negative medical outcomes. Third, there is no deception involved.

Wait a minute … isn’t deception an essential part of alternative medicine?

I am suggesting that you tell the patient something like, “The instructions from the homeopath may not be literally accurate but may still have a beneficial effect. Allow yourself to follow their instruction in a similar fashion as if you are following the instruction from a hypnotherapist. Just relax and go with it. Your brain may be guided by this instruction to produce endorphins that will reduce your pain.” (Note to reader: If you are inclined to do research on Placebo Medicine this would be a really good place to do it.)

Fourth, the complementary provider has some basic medical training and knows when to refer the patient back to the mainstream physician. (Making this happen is a challenge.)

Fifth, the mainstream physician follows up with the patient.

Finally, these providers have open lines of communication.

In addition to improving patient outcomes, this kind of relationship between practitioners of mainstream medicine and alternative medicine should result in the two differently oriented treatment professionals rubbing off on each other. The mainstream physician may be influenced to better appreciate the science of how to maximize the doctor-patient relationship. The alternative provider may learn from the mainstream provider when a patient has a condition that would be dangerous to treat without seeing an MD or DO.

I think that bringing medical professionals together like this can result in better patient care. However, I understand that the human brain is programmed to think in terms of dichotomous relationships. Most humans will want to take sides and perceive that either traditional medicine is good or alternative medicine is good but not that both can have benefits at the same time. Humans will want to stick to their previously held beliefs and think negatively of the identified out-group or other team. Humans think in terms of “us is good” and “them is bad.” There will always be traditional physicians who think anyone peddling a fake medicine is bad and there will always be alternative advocates who think traditional medicine is just pharmaceutical companies ripping people off for profit.  

Having a genuine desire to bring everyone together makes me an outlier. Being able to see things on a continuum is unusual for most humans. Nevertheless, this is my two cents worth.

-Morgan Levy, MD

(The AMA can’t fully endorse the clinical use of Placebo at this time because there is not enough research for us to know the safest and most effective way to incorporate it into clinical practice. This essay is meant to start a conversation that may lead to more research and a future AMA endorsement.)

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Dr. Levy does speaking engagements to both professional and non-professional groups on a sliding scale. Read his bio and contact him at: Morgan L. Levy, MD

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