The NHS state that Complementary and alternative medicine (CAM) is treatment that falls outside of mainstream healthcare; these treatments range from acupuncture and homeopathy to aromatherapy. Although “complementary and alternative” is often used as a single category, it can be useful to make a distinction between the terms.
The US National Center for Complementary and Integrative Health (NCCIH) uses this distinction:
- When a non-mainstream practice is used together with conventional medicine, it’s considered “complementary”.
- When a non-mainstream practice is used instead of conventional medicine, it’s considered “alternative”.
But is it actually good for pets – or their owners?
Table of contents
Complementary medicine in veterinary
In 2017 the RCVS – our regulator – issued a position statement on Complementary and Alternative Medicines. The statement, which does not contradict BSAVA’s statement, supports the evidence-base and sound scientific foundation on which the veterinary profession operates and reiterates its members commitment to animal health and welfare.
The RCVS states:
“In order to protect animal welfare, we regard such treatments as being complementary rather than alternative to treatments for which there is a recognised evidence base or which are based in sound scientific principles. It is vital to protect the welfare of animals committed to the care of the veterinary profession and the public’s confidence in the profession that any treatments not underpinned by a recognised evidence base or sound scientific principles do not delay or replace those that do.”
Positives
Can provide additional support to pets and owners
Where a therapy has some evidence base behind it then they may act as a great adjunct to treatment plans.
CAM is such a diverse term and can cover a huge variety of treatments and interventions. Some have no evidence base; but others such as some herbal remedies and some manual therapies have got evidence emerging, or low-quality evidence for their potential benefits, or a good plausible mechanism for their mode of action.
When used alongside conventional medicine, some pets can really benefit from additional support. Furthermore, use of other therapies that involve the owner can help significantly with the human-animal bond; making owners feel involved and integrated into their pet’s treatment plan. The owner may also feel empowered to have some involvement in their pet’s treatment plan; especially with therapies that allow them to carry on at home with exercises.
Negatives
Does it cause greater mistrust?
There have been links made between those that believe in alternative medicine and other beliefs in misinformation. In humans, the belief in complementary and alternative medicine (CAM) was strongly associated with paranormal beliefs.
One article in The Skeptic explored that whether through fear, lack of education, social factors, inability to critically analyze misinformation online or mistrust of motives, we have seen a worrying group of people who passionately and convincingly spread misleading information about the very people who are educated and trained to protect. A sad corollary to this ideology is the idea that doctors prescribe, sell or suggest treatments that are meant to harm; and as such the fallacy of ‘natural is best’ gains momentum.
The article believes that proponents of ‘natural’ practices (be that herbal treatments, homeopathy, reiki healing, or something else) often form social media groups that become toxic echo chambers and a ‘blizzard of misinformation’, reinforcing their mantra: medicine is bad and natural is good. The accessibility of these social media groups exacerbates the spread of misinformation. Proponents of these ideologies are highly convincing, resolute in their beliefs, and they tend toward categorical thinking and conspiratorial worldviews, bouncing off each other and sinking deeper into their belief system.
The link between medical skepticism and the natural fallacy has been the subject of recent research; which found strong correlations between vaccine skepticism and adherence to complementary and alternative medicine and conspiracy ideation. The results of a study by Cuevas et al. suggest that mistrust toward healthcare may unfavorably affect patient-clinician interactions and patients’ health-related outcomes.
Many lack evidence
In one review for most therapies, the authors found few or no scientific articles describing the clinical efficacy for 24 separate complementary/alternative therapies in the species cat, dog, or horse. Of the publications that met the inclusion criteria, the majority did not have scientific documentation of sufficient quality to draw conclusions regarding their effect. 63% of therapies had no scientific documentation that was even capable of addressing the question “does it work”!
Even in the four studies identified within scientific publications with a lower risk of bias, which indicates that the study result can be considered more reliable over time, no significant difference between treated and control group was reported.
The studies also had drawbacks to drawing clinically applicable conclusions from the included articles because of poor study design. Less than half of the studies were randomized controlled trials; the minority used similar treatment protocols; and the main outcome variables were either subjective or measures that are easily influenced by other factors than the treatment; such as owner questionnaires, visual lameness examinations, or clinical examinations assessing heart or respiratory rates. Another problem is the small sample sizes with low statistical power.
People may think it works when it doesn’t
Some people, including owners, therapists and veterinary surgeons, may perceive that the therapies work because of belief in the therapy (placebo effect); anecdotal evidence (extrapolation from hearsay or personal experience of a single or small number of cases) or errors in inference (cognitive bias).
One article explains about ‘caregiver placebo’:
The placebo effect is the improvement experienced when taking a placebo drug or treatment, which is not attributable to the properties of the treatment itself, and is often claimed to be due to the patient’s belief in that treatment. As our pets likely do not have a preconceived belief in the treatment, their owners will claim they cannot experience this psychological phenomenon – however, while pets may not have a preexisting bias towards treatments, there is a significant placebo effect seen on the owners, called the ‘caregiver placebo’.
The caregiver placebo essentially means that, as the owners have faith in a treatment, they see a notable benefit in their pets, even if the animal is not clinically any better. This effect works in combination with a number of other factors, such as behavioral changes the owner displays in giving their pet more attention after administering the medication, and the concept of ‘regression to the mean’ in chronic conditions.
They may waste or redirect finances
Of course, owners can use their finances as they see fit. However a recent report showed many owners are worried about veterinary costs. It is possible that the National Health Service in the UK has left many people ignorant as to the expense involved in health care. It is noteworthy that veterinary professionals are often subject to extensive abuse about the cost of veterinary services; yet the practitioners of alternative medicine also charge, quite substantially, for their service. If treatment and finances are directed towards non-evidence-based therapies this could mean that effective treatment is delayed. This leaves the patient to deteriorate further, which in turn means more care and more expense. Sadly, in some cases, the owner may have spent precious finances on treatment that does not work; leaving little left for evidence-based treatment options.
It may delay evidence-based treatment
The RCVS states that homeopathy (and other non-evidence-based therapies) should only be used alongside conventional treatment. Many ask what the harm of using CAM is if it is used alongside other conventional medicine. Indeed, if this is the case then the negative impacts, other than the additional financial burden, would be less. However, evidence seems to suggest that those using CAM may be less likely to accept and use conventional medicine. And this is where the problems occur.
One article discussed that in human medicine, those who have used alternative medicine instead of conventional treatment are slightly less likely to have a primary care provider, or to have had a preventive care in the past year. A study found that the use of ‘alternative’ treatment was associated with the delay of seeking cancer treatment, and decreased survival.
The BSAVA statement
In making decisions about the use of complementary and alternative therapies it is important to consider their safety and efficacy. Many people assume that all complementary and alternative therapies are natural and therefore safe, but this is not always the case. All therapies may produce unwanted side effects or may interact with other therapies. In the case of alternative therapies it is also important to consider the welfare implications of withholding conventional treatments.
This article discusses the known fact that often human health tends to filter into veterinary medicine. Although, especially in the case of homeopathy, UK veterinary professionals are obliged to only ever dispense it when used alongside conventional treatment; this does not mitigate the implications associated with the belief system in homeopathy. The ‘natural is best’ fallacy, misinformation, and fear mongering amplify medical anxiety and the distrust of conventional treatment, which can lead to evidence-based treatment being delayed or declined. In an informal poll run on Veterinary Voices UK, 87% of participants had experienced issues in the use of non-evidence-based therapies that could have impacted animal health and welfare.
To conclude
In line with the BVA’s position, where complementary medicines or treatments are offered, they should be complementary to conventional medicine and not offered as an alternative; they shouldn’t delay or prevent the use of conventional medicine, to avoid any potential health and welfare harms.
The veterinary surgeon has a legal duty to animal welfare and the client; as well as the integrity of the profession, to disclose the evidence base to support the efficacy of the complementary medicine or treatment, and any side effects and human and animal safety concerns, such that the owner can make an informed choice. Furthermore, the veterinary surgeon has a duty to ensure that the complementary medicine or treatment is safe; does not interact negatively with conventional medication or treatment; and does not compromise animal health and welfare.
Discussion