What’s the Harm
I have written often about ways in which complementary and alternative medicine (CAM) can be harmful. This is not because I believe CAM is necessarily always unsafe, or that I think conventional medicine doesn’t have significant risks as well. Any therapy that is doing anything at all is likely to have potential risks as well as benefits. It simply isn’t possible to tinker with as complex a system as a living organism without affecting elements of the system one does not intend as well as those one is targeting.
However, the advantage to science-based medicine is that the risks and benefits of individual therapies are often well understood. If we have sufficient information about what an intervention does and what the risks and benefits of it are, we can then make rational choices about using it. The problem with CAM is that there is often very little information about risks and benefits and yet strong claims are frequently made that these therapies work and are safe. The lack of real, scientific information, and beliefs about safety which are not founded on reliable evidence can generate harm.
The two types of harm that can be seen with CAM therapies are direct and indirect. Direct harm is injury or illness experienced by a patient from the treatment itself. This is similar to the side effects one can see with conventional treatment. Indirect harm is the harm that comes from acting on misinformation or false beliefs even when the treatment itself is not dangerous. This usually involves the harm experienced by patients who avoid conventional therapy in favor of unproven or clearly ineffective CAM remedies.
I have put together a list of articles from scientific journals and the news media illustrating both the direct and indirect harm of CAM therapies: What’s The Harm? The name is in honor of the web site What’s the Harm, which is a collection of anecdotes illustrating the dangers of all kinds of pseudoscientific and superstitious thinking, including that behind much of alternative medicine.
This post will be a collection of links to previous posts I’ve written and links to articles elsewhere illustrating the harm CAM can do.
General CAM Use:
Boström H, Rössner S. Quality of alternative medicine–complications and avoidable deaths. Qual Assur Health Care. 1990;2(2):111-7.
Yun YH, Lee MK, Park SM, Kim YA, Lee WJ, Lee KS, Choi JS, Jung KH, Do YR, Kim SY, Heo DS, Kim HT, Park SR. Effect of complementary and alternative medicine on the survival and health-related quality of life among terminally ill cancer patients: a prospective cohort study. Ann Oncol. 2013 Feb;24(2):489-94. doi: 10.1093/annonc/mds469. Epub 2012 Oct 30.
Johnson SB, Park HS, Gross CP, Yu JB. Complementary Medicine, Refusal of Conventional Cancer Therapy, and Survival Among Patients With Curable Cancers. JAMA Oncol. Published online July 19, 2018.
While generally safe if performed by a licensed, properly trained acupuncturist, acupuncture does pose direct risks, including side effects such as dizziness and nausea, infection from improper technique, and trauma from needles.
Cho YP, Jang HJ, Kim JS, Kim YH, Han MS, Lee SG. Retroperitoneal abscess complicated by acupuncture: case report. J Korean Med Sci. 2003 Oct;18(5):756-7.
Choo DC, Yue G Acute intracranial hemorrhage in the brain caused by acupuncture. Headache 2000 May;40(5):397-8.
Chung SJ, Kim JS, Kim JC, Lee SK, Kwon SU, Lee MC, Suh DC. Intracranial dural arteriovenous fistulas: analysis of 60 patients. Cerebrovasc Dis 2002 Feb;13(2):79-88
Ernst E, Sherman K. Is acupuncture a risk factor for hepatitis? Systematic review of epidemiological studies. J Gastroenterol Hepatol. 2003 Nov;18(11):1231-6.
Ernst E. Deaths after acupuncture: A sytematic review. Int J Risk and Safety in Med 2010;22(3):131-6.
Wenju He, Xue Zhao, Yanqi Li, Qiang Xi, and Yi Guo. Adverse Events Following Acupuncture: A Systematic Review of the Chinese Literature for the Years 1956–2010. The Journal of Alternative and Complementary Medicine. E-pub ahead of print. doi:10.1089/acm.2011.0825.
Iwadate K, Ito H, Katsumura S, Matsuyama N, Sato K, Yonemura I, Ito, Y. An autopsy case of bilateral tension pneumothorax after acupuncture. Leg Med (Tokyo). 2003 Sep;5(3):170-4.
Kirchgatterer A, Schwarz CD, Holler E, Punzengruber C, Hartl P, Eber B Cardiac Tamponade Following Acupuncture. Chest 2000 May;117(5):1510-1511
Laing AJ, Mullett H, Gilmore MF. Acupuncture-associated Arthritis in a Joint with an Orthopaedic Implant J Infect 2002 Feb;44(1):43-4
Nambiar P, Ratnatunga C. Prosthetic valve endocarditis in a patient with Marfan’s syndrome following acupuncture. J Heart Valve Dis 2001 Sep;10(5):689-90
Peuker E Case report of tension pneumothorax related to acupuncture. Acupunct Med. 2004 Mar;22(1):40-3.
Saw A, Kwan MK, Sengupta S. Necrotising fasciitis: a life-threatening complication of acupuncture in a patient with diabetes mellitus. Singapore Med J. 2004 Apr;45(4):180-2.
Sun CA, et al. Transmission of hepatitis C virus in taiwan: prevalence and risk factors based on a nationwide survey. Sun J Med Virol 1999 Nov;59(3):290-6
Jayne Wheway, Taofikat B. Agbabiaka, Edzard Ernst. Patient safety incidents from acupuncture treatments: A review of reports to the National Patient Safety Agency. The International Journal of Risk and Safety in Medicine. 2012;24(3):163-169.
Witt CM, Pach D, Brinkhaus B, Wruck K, Tag B, Mank S, Willich SN. Safety of acupuncture: results of a prospective observational study with 229,230 patients and introduction of a medical information and consent form. Forsch Komplementmed. 2009 Apr;16(2):91-7. Epub 2009 Apr 9
Woo PC, Leung KW, Wong SS, Chong KT, Cheung EY, Yuen KY. Relatively alcohol-resistant mycobacteria are emerging pathogens in patients receiving acupuncture treatment. J Clin Microbiol 2002 Apr;40(4):1219-24
Woo PC, Lin AW, Lau SK, Yuen KY. Acupuncture transmitted infections. British Medical Journal 2010;340:c1268.
Yamashita H, Tsukayama H, White AR, Tanno Y, Sugishita C, Ernst E. Systematic review of adverse events following acupuncture: the Japanese literature. Complement Ther Med 2001 Jun;9(2):98-104
There is little research on the risks of chiropractic treatment in dogs and cats (or on any possible benefits). However, there is clear evidence of harm in humans, particularly with manipulation of the neck. Given the limited evidence of benefit (for back pain) in humans and the absence of clear evidence of benefit in veterinary patients, significant caution is warranted.
Albuquerque FC, Hu YC, Dashti SR, Abla AA, Clark JC, Alkire B, Theodore N, McDougall CG. Craniocervical arterial dissections as sequelae of chiropractic manipulation: patterns of injury and management. J Neurosurg. 2011 Dec;115(6):1197-205. Epub 2011 Sep 16.
Herbs and Supplements
Herbs and dietary supplements are among the most plausible and likely to have real physiologic effects of all CAM therapies. This also means, they are the most likely to have potential risks. As things currently stand, most of these products, particularly herbal remedies, should be viewed as drugs that have not been rigorously tested for safety and efficacy (as pharmaceuticals are) and that are not regulated for quality to any meaningful extent (again, unlike pharmaceuticals). Under these circumstances, there are unknown but potentially significant risks to using these products.
GAO Acknowledges FDA Oversight of Dietary Supplements Inadequate
Vitamins & Supplements
Thomas LK, Elinder C, Tiselius H, Wolk A, Åkesson A. Ascorbic Acid Supplements and Kidney Stone Incidence Among Men: A Prospective Study. JAMA Intern Med. 2013;():1-2. doi:10.1001/jamainternmed.2013.2296.
Mursu J, et al. Dietary supplements and mortality rate in older women: The Iowa Women’s Health Study. Archives of Internal Medicine. 2011;17(18):1625-33.
Bashir Ahmad, Samina Ashiq, Arshad Hussainb, Shumaila Bashir, Mubbashir Hussain. Evaluation of mycotoxins, mycobiota, and toxigenic fungi in selected medicinal plants of Khyber Pakhtunkhwa, Pakistan. Fungal Biology. 2014;118(9–10):776–84.
Aliye Uc, MD, Warren P. Bishop, MD, and Kathleen D. Sanders, MD, Camphor hepatoxicity. South Med J 93(6):596-598, 2000,
Angers RC, Seward TS, Napier D, Green M, Hoover E, Spraker T, O’Rourke K, Balachandran A, Telling GC. Chronic wasting disease prions in elk antler velvet. Emerg Infect Dis. 2009 May;15(5):696-703.
Angkana R, Lurslurcharchai L, Halm E, Xiu-Min L, Leventhal H, et al. Use of herbal remedies and adherence to inhaled corticosteroids among inner-city asthmatic patients. Annal Allerg Asthma Immunol 2010:104(2);132-138.
Berberine. Inbaraj JJ, Kukielczak BM, Bilski P, Sandvik SL, Chignell CF. Photochemistry and photocytotoxicity of alkaloids from Goldenseal (Hydrastis canadensis L.) Chem Res Toxicol 2001 Nov;14(11):1529-34
Cheung E, Ng C, Foote J. A hot mess: A case of hyperemesis. Canadian Family Physician July 2014 vol. 60 no. 7 633-637.
Geller, A. et al. Emergency Department Visits for Adverse Events Related to Dietary Supplements. N Engl J Med 2015; 373:1531-1540
Lauren Blacksell, Roger W. Byard, Ian F. Musgrave. Forensic problems with the composition and content of herbal medicines. Journal of Forensic and Legal Medicine. Volume 23, March 2014, Pages 19–21
Booth JN 3rd, McGwin G. The association between self-reported cataracts and St. John’s Wort. Curr Eye Res. 2009 Oct;34(10):863-6.
Burkhard PR, Burkhardt K, Haenggeli CA, Landis T.Plant-induced seizures: reappearance of an old problem. J Neurol 1999 Aug;246(8):667-70
Chung-Hsin Chen, Kathleen G. Dickman, Masaaki Moriya, Jiri Zavadil, Viktoriya S. Sidorenko, Karen L. Edwards, Dmitri V. Gnatenko, Lin Wu, Robert J. Turesky, Xue-Ru Wu, Yeong-Shiau Pu, Arthur P. Grollman. Aristolochic acid-associated urothelial cancer in Taiwan. Proceedings National Academy of Sciences, April 2012. Panax ginseng: A Systematic Review of Adverse Effects and Drug Interactions. Drug Saf 2002;25(5):323-44 Drug Saf 2002;25(5):323-44
Cupp MJ Herbal remedies: adverse effects and drug interactions. Am Fam Physician 1999 Mar 1;59(5):1239-45
Debelle FD, Vanherweghem JL, Nortier JL.Aristolochic acid nephropathy: a worldwide problem. Kidney Int. 2008 Jul;74(2):158-69. Epub 2008 Apr 16.
Douros, A., Bronder, E., Andersohn, F., Klimpel, A., Thomae, M., Ockenga, J., Kreutz, R. and Garbe, E. (2013), Drug-induced acute pancreatitis: results from the hospital-based Berlin case–control surveillance study of 102 cases. Alimentary Pharmacology & Therapeutics.
Emery DP, Corban JG Camphor toxicity. J Paediatr Child Health 1999 Feb;35(1):105-6
Ernst E Adverse effects of herbal drugs in dermatology. Br J Dermatol 2000 Nov;143(5):923-
Fugh-Berman A Herb-drug interactions. Lancet 2000 Jan 8;355(9198):134-8
M.L. Hoang et al., “Mutational signature of aristolochic acid exposure as revealed by whole-exome sequencing,” Science Translational Medicine, 5: 197ra102, 2013.
Huang WF, Wen KC, Hsiao ML. Adulteration by synthetic therapeutic substances of traditional Chinese medicines in Taiwan. J Clin Pharmacol. 1997 Apr;37(4):344-50
Kutz GD. Herbal dietary supplements: Examples of Deceptive or questionable marketing practices and potentially dangerous advice. General Accounting Office. May 26, 2010.
Lai MN, Lai JN, Chen PC, Tseng WL, Chen YY, Hwang JS, Wang JD. Increased risks of chronic kidney disease associated with prescribed Chinese herbal products suspected to contain aristolochic acid. Nephrology (Carlton). 2009 Apr;14(2):227-34.
Lawrence JD. Potentiation of warfarin by dong quai. Page RL 2nd, Pharmacotherapy 1999 Jul;19(7):870-6
Mangala, P. Study of Lead Content in Ayurvedic and Homeopathic Medicines Commonly Used for the Treatment of Cold, Cough & Body Aches. IOSR Journal Of Environmental Science, Toxicology And Food Technology. 2014;5(3):8-12.
Means C. Selected herbal hazards.Vet Clin North Am Small Anim Pract 2002 Mar;32(2):367-82
National Toxicology Program. Technical Report on the Toxicology and Carcinogenesis Studies of Gingko Biloba extract in F344/N Rats and B6C3F1/N Mice. March, 2013.
Victor J. Navarro, Huiman Barnhart, Herbert L. Bonkovsky, Timothy Davern, Robert J. Fontana, Lafaine Grant, K. Rajender Reddy, Leonard B. Seeff, Jose Serrano, Averell H. Sherker, Andrew Stolz, Jayant Talwalkar, Maricruz Vega, Raj Vuppalanchi. Liver injury from Herbals and Dietary Supplements in the US Drug Induced Liver Injury Network. Hepatology; Article first published online: 25 AUG 2014 DOI: 10.1002/hep.27317
Steven G Newmaster, Meghan Grguric, Dhivya Shanmughanandhan, Sathishkumar Ramalingam, Subramanyam Ragupathy. DNA barcoding detects contamination and substitution in North American herbal products. BMC Medicine 2013, 11:222
Nizsly N, Grizlak B, Zimmerman M, Wallace R. Dietary Supplement Polypharmacy: An Unrecognized Public Health Problem? eCAM 2010 7(1):107-113
Norred CL, Finlayson CA Hemorrhage after the preoperative use of complementary and alternative medicines. AANA J 2000 Jun;68(3):217-20
O’Connor A, Horsley CA. Yates, KM “Herbal Ecstasy”: a case series of adverse reactions. N Z Med J 2000 Jul 28;113(1114):315-7 Pittler MH.
S.L. Poon et al., “Genome-wide mutational signatures of aristolochic acid and its application as a screening tool,” Science Translational Medicine, 5: 197ra101, 2013.
Ernst, E Risks associated with herbal medicinal products. Wien Med Wochenschr 2002;152(7-8):183-9
Poppenga RH.Risks associated with the use of herbs and other dietary supplements. Vet Clin North Am Equine Pract. 2001 Dec;17(3):455-77, vi-vii
Pies R Adverse neuropsychiatric reactions to herbal and over-the-counter “antidepressants”. J Clin Psychiatry 2000 Nov;61(11):815-20
Prakash S, Hernandez GT, Dujaili I, Bhalla V. Lead poisoning from an Ayurvedic herbal medicine in a patient with chronic kidney disease. Nat Rev Nephrol. 2009 May;5(5):297-300.
Raman P, Patino LC, Nair MG. Evaluation of metal and microbial contamination in botanical supplements. J Agric Food Chem. 2004 Dec 29;52(26):7822-7
Ruschitzka F, Meier PJ, Turina M, Luscher TF, Noll G Acute heart transplant rejection due to Saint John’s wort. Lancet 2000 Feb 12;355(9203):548-9
Saper RB, Phillips RS, Sehgal A, Khouri N, Davis RB, Paquin J, Thuppil V, Kales SN. Lead, mercury, and arsenic in US- and Indian-manufactured Ayurvedic medicines sold via the Internet. JAMA. 2008 Aug 27;300(8):915-23.
Tachjian A, Maria V, Jahangir A. Use of herbal products and potential interactions in patients with cardiovascular disease. J. Am. Coll. Cardiol. 2010 55: A32 ,
H.-H. Tsai, H.-W. Lin, A. Simon Pickard, H.-Y. Tsai, G. B. Mahady. Evaluation of documented drug interactions and contraindications associated with herbs and dietary supplements: a systematic literature review. International Journal of Clinical Practice, 2012; 66 (11):
Wang JD, Lo TC, Chen PC. Increased mortality risk for cancers of the kidney and other urinary organs among Chinese herbalists. J Epidemiol. 2009;19(1):17-23. Epub 2009 Jan 22.
Zhang SY, Robertson D. A study of tea tree oil ototoxicity. Audiol Neurootol 2000 Mar-Apr;5(2):64-8