Full text of DOI:10.1111/j.1553-2712.2001.tb00548.x

ACADEMIC EMERGENCY MEDICINE • January 2001, Volume 8, Number 1
41
CLINICAL PRACTICE
Use, Understanding, and Beliefs about Complementary
and Alternative Medicines among Emergency
Department Patients
STEVEN J. WEISS, MD, KEVIN M. TAKAKUWA, MD, AMY A. ERNST, MD
Abstract. Objectives: To describe the extent of com- at some time and 24% were presently using CAMs.
plementary and alternative medicine (CAM) use The most commonly used CAMs were ginseng (13%),
among emergency department (ED) patients, to eval- St. John’s wort (6%), and ginkgo biloba (9%). All
uate patients’ understanding of CAMs, and to deter- CAMs were considered to be safe by 16% of the pa-
mine gender differences in beliefs about CAMs. Meth- tients. Only 67% would tell their doctors they were
ods: This study was a convenience sampling of using CAMs. Females were more likely than males to
patients seen in an urban ED. Patient demographics believe that CAMs do not interact with other medi-
were recorded. A questionnaire was administered cations (15% vs 7%, difference 8%, 95% CI = 2% to
that assessed patients’ knowledge and use of CAMs. 15%). Conclusions: Complementary and alternative
Patients were also asked about their beliefs on safety, medicines are familiar to most patients and used by
medication interactions, and conveying information many of them. Despite this, a large percentage of pa-
about these substances to their physicians. Results: tients would not tell their physicians about their use
A total of 350 ED patients were included in the study; of alternative medications. Emergency medicine pro-
87% had heard of at least one of the CAMs. There viders should be aware of the commonly used CAMs,
was no difference between genders or races concern- and questions about their use should be routinely in-
ing knowledge about CAMs. The most commonly cluded in ED exams. Key words: alternative medi-
known CAMs were ginseng (75%), ginkgo biloba cations; emergency department. ACADEMIC EMER-
(
55%), eucalyptus (58%), and St. John’s wort (57%). GENCY MEDICINE 2001; 8:41–47
Forty-three percent of the responders had used CAMs
NE IN three Americans is using some form For the purpose of this paper, we restrict the use
of complementary and alternative medicine of the term CAM to apply to the medications that
CAM). Physicians prescribe 54% of CAMs, and in are considered as alternatives to prescription med-
990, there were 425 million visits to providers of ications.
O
(
1
unconventional medicine. Complementary and al- Complementary and alternative medicines
ternative medicines are seen as ‘‘natural’’ and are have been the subject of numerous textbooks. Re-
not controlled by the Food and Drug Administra- cently, randomized, double-blind studies have been
tion (FDA). The CAM industry is now a 1.5 billion performed comparing CAMs with other drugs.
dollar industry and growing at a rate of more than These trials have looked at alternative medication
1
,2
15% per year.
for various pathologies, such as saw palmetto for
In the literature, the term ‘‘CAM’’ applies both prostate problems, St. John’s wort for depression,
4
–7
to actual medications and to the providers of alter- feverfew for migraines, and Echinacea for colds.
native medical therapies. Other authors have ad3- Despite the fact that CAMs generally appear safe,
dressed the use of various alternative providers. case reports of side effects and drug interactions
8
–15
continue to appear.
The importance of CAM use to emergency med-
icine (EM) is just beginning to become apparent.
Received April 18, 2000; revision received July 5, 2000; ac- Gulla and Singer looked at all alternative thera-
cepted July 14, 2000. Presented at the ACEP Research Forum, pies among ED patients and found that herbal
From the UC Davis Medical Center, Sacramento, CA (SJW,
KMT, AAE).
Las Vegas, NV, October 1999.
remedy use was third in popularity, just behind
Address for correspondence and reprints: Steven Weiss, MD,
massage therapy and chiropractic with about a
Division of Emergency Medicine, 2315 Stockton Boulevard,
fourth of all ED patients using them. They also
PSSB 2100, Sacramento, CA 95817. Fax: 916-734-7950; e-mail:
sjweiss@ucdavis.edu
A related commentary appears on page 65.
found that most patients did not inform their phy-
sicians of their use of alternative therapies and

42
ALTERNATE MEDICINES
Weiss et al. • ALTERNATE MEDICATIONS AMONG ED PATIENTS
suggested that emergency physicians (EPs) should
routinely question their patients on alternative
therapies, particularly herbal preparations. They
M
ETHODS
3
Study Design. This study was a survey of pa-
tients presenting to an urban ED. Based on the
survey design, the university institutional review
board determined that the study was exempt from
informed consent.
did not, however, study the various herbal reme-
dies individually. Another ED study of CAM use,
among a small sample in a Dominican Republic
1
6
ED, came to the same conclusion.
Differences in attitudes and uses of CAMs may
be important when targeting populations for ques- Study Setting and Population. All adult En-
tioning and education. Complementary and alter- glish-speaking walk-in patients presenting to our
native medicine use has previously been linked ED during a convenience sampling of shifts were
with younger age, female gender, Catholic religion, included in the study. We excluded patients who
1
7–19
and more education.
These differences in dem- were in extremis, those who were unable to partic-
ographic variables could help determine which ipate due to psychiatric, medical, or traumatic ill-
subgroups of the population might be at risk for ness, drug overdose, or alcohol intoxication, incar-
adverse events related to the use of CAM, such as cerated patients, or those with a language barrier.
drug–herb interactions.
Determination of ability to participate was based
The objectives of this study were to evaluate pa- on disease acuity determined solely by judgment of
tients’ understanding and use of CAMs, to describe the interviewer.
the extent of CAM use among ED patients, and to
determine whether there are race and gender dif- tan area with a total population of 500,000. The
ferences in beliefs related to CAMs. ED does a mix of primary and tertiary care for the
The study was conducted in a large metropoli-
TABLE 1. The Alternative Medicines that Were Evaluated in the Study
Purported Use
Reported Problems in the Literature
Black cohosh
Comfrey
To relieve symptoms of menopause.
Intense headaches, dizziness, slow pulse, nausea, and vom-
44
iting. Possible risk for breast cancer or its recurrence. *
Serious liver damage. In large quantities, it causes hepatic
veno-occlusive disease. In combination with pepsin, it in-
For wound healing, and as a diges-
tive aid.
55,56
creases the risk of hepatic disease up to 200 times.
5
7,58
DHEA†
Echinacea
Ephedra (Ma-huang)
Eucalyptus
Feverfew
Building muscles.
Mania.
Anaphylaxis.
Hypersensitivity myocarditis and acute hepatitis.
1
0
Boosts the immune system.
For colds and wheezing.
For colds and flu.
11,48
4
5
Seizures.
Headaches.
None reported.
Subarachnoid hemorrhage.
1
3
Ginkgo biloba
Increases blood flow to the brain
and improves cognitive decline.
For fatigue and stress.
Ginseng
A case of hypertension, reversed by withdrawal from ginseng,
is also well documented. Gynecomastia due to estrogenic
effect. Interaction to decrease blood warfarin levels. Diu-
1
2,59–62
retic resistance. Ginseng abuse syndrome.
None reported.
Hawthorne
Jin Bu Huan
Improves coronary circulation.
As a sedative.
Acute and chronic hepatitis. Caused life-threatening neuro-
49,63,64
logic and cardiovascular manifestations in children.
Kava dermopathy. Coma in combination with benzodiaze-
Kava kava
For mild to moderate anxiety.
4
6,65
pines. (Piper methysticum)
6
6
51
Melatonin
Pennyroyal oil
Sleep disorders.
An abortifacient.
Optic neuropathy and autoimmune hepatitis.
It may deplete glutathione stores in a manner similar to acet-
aminophen toxicity. It has also been described as causing
4
5,67
renal failure, seizures, and abdominal pain.
St John’s wort
Depression.
Serotonin syndrome in combination with other serotonergic
medications and decreased levels of anti-retroviral medi-
1
9,68
cations.
Also acute heart transplant rejection and
1
4,15
mania.
Saw palmetto
Valerian
For benign prostatic hypertrophy.
For anxiety.
None reported.
Has been associated with hepatotoxicity, cardiac complica-
4
7,69
tions, and delirium.
Hypertensive crisis, angina, and agranulocytosis.
7
0–72
Yohimbine
A vitalizing agent for men, particu-
larly for the treatment of male
impotence.
*
†
For complete reference citations, see the reference list.
DHEA = dehydroepiandrosterone.

ACADEMIC EMERGENCY MEDICINE • January 2001, Volume 8, Number 1
43
Figure 1. The survey instrument. DHEA = dehydroepiandrosterone.
city, and has an annual volume of 60,000 patients. knowledge of CAMs; and 4) patient’s use of indi-
The hospital is a large urban inner-city ED with a vidual CAMs. The survey is presented in Figure 1.
patient population that is 51% males and has a Table 1 lists the alternative medications that were
mean (ϮSD) age of 42 (Ϯ20) years.
evaluated in this survey, along with their sug-
gested use and some of the problems that have
been associated with them.
Study Protocol. The survey was developed and
pilot-tested on a group of 26 physicians at our hos-
pital. The CAMs chosen were based on the most
commonly found CAMs at our local health food
stores. Suggestions for additional CAMs were
added based on the feedback received.
Data Analysis. Descriptive statistics were used
to analyze survey results. Chi-squared was used to
compare discrete variables with confidence inter-
vals calculated for all significant differences. SPSS,
version 9 (SPSS Inc., Chicago, IL), was used for all
calculations.
Surveys were presented to ED patients during
the six-month period from July 1999 to December
1
999. Four research assistants distributed the sur-
veys. The researchers explained the survey and
then gave it to the patient to complete on his or
RESULTS
her own. The researchers did not intervene during A total of 350 (48% female) patients completed the
the patient’s completion of the form. Patients were survey. The mean (ϮSD) age was 37 (Ϯ13) years,
assured that questionnaires were confidential. The with 62 subjects aged 18–24 years, 98 subjects
following four sets of information were recorded: 1) aged 25–35, 137 subjects aged 36–50, 42 subjects
patient demographics; 2) beliefs about CAMs and aged 51–64, and 11 subjects 65 or over. The racial
their safety, medication interactions, and convey- breakdown was 4% Asian, 13% African American,
ing information to their physicians; 3) patient’s 17% Hispanic, 60% white, and 6% other. Six per-

44
ALTERNATE MEDICINES
Weiss et al. • ALTERNATE MEDICATIONS AMONG ED PATIENTS
cent of the patients stated that they saw a provider For instance, St. John’s wort causes a significant
19
of alternative medicines.
decrease in indinavir concentration, which could
Eighty-seven percent (305/350) of the subjects lead to the development of drug resistance and
had heard of at least one of the herbal remedies treatment failure.
presented in the survey. Two-thirds (241/350)
Many patients do not volunteer information
stated that they would tell their physicians about about their CAM use. In our study, 33% of the pa-
any herbal remedy use, while 8% (29/350) believed tients stated they would not tell their doctors they
there was no need to tell their physicians. Only a are using CAMs. This could lead to delay in diag-
small percentage of the population thought that nosis of medication problems or interactions. Since
herbal remedies were safe (16%, 56/350), that they practically none of the charts that we reviewed
did not interact with medications (6%, 21/350), or during this study reflected the patient’s use of
that they were more effective than medicines (17%, CAMs, we suspect that the answer to this question
6
1/350). Women were significantly more likely to referred to the patient’s private physician and that
believe that the herbal remedies do not interact even fewer believed they needed to tell an EP.
with other medications (19% vs 2%; p < 0.05, 95% The use of CAMs has been on the rise in recent
CI = 4% to 29%); there were no other gender or years. Studies have suggested CAM use in patients
2
0–23
racial differences found. Those who were presently with such diverse problems as cancer, Parkin-
taking CAMs were significantly more likely than son’s disease, arthritis,
those not taking CAMs to believe that they do not fection,
2
4
25–28
25–29
asthma,
HIV in-
30,31
30–33
and inflammatory bowel disease.
interact with other medications (10/85, 12% vs 11/ Therefore, few patients are immune from the pres-
65, 4%, diff 8%, 95% CI = 0.4% to 15%) and were sures placed on them by the lay press to try over-
significantly more likely to trust herbal remedies the-counter remedies for serious ailments.
2
to be more effective than medicine (24/85, 28% vs
Moreover, CAM use is becoming a part of
medical practice. Use of CAMs has been investi-
3
7/265, 14%, diff 14%, 95% CI = 4% to 25%).
Table 2 summarizes the number of patients gated in the ED
3,18,34–36
and the family practice
3
7–39
sampled who had heard of the product (column 1), clinic.
could identify the product’s use (column 2), had by neurologists, psychiatrists, pediatricians,
ever used the product (column 3), and were pres- and surgeons. This would suggest that CAM use
ently using the product (column 4). Eighty-seven may be not only secondary to lay press, but also
percent of the subjects had heard of at least one related to suggestions by medical practitioners.
There are also reports about CAM use
40 41 42
43
CAM product, 53% could identify the correct sug-
Increasing CAM use has led to increased re-
gested use of at least one product, 43% had used ports of toxic side effects. Neurologic symptoms
at least one of these products, and 24% were pres- and hepatitis are the two main categories of side
ently taking at least one of these products. The effects with these substances. Reported neurologic
most commonly known CAMs were ginseng (75%), symptoms include headache and dizziness with
ginkgo biloba (55%), eucalyptus (58%), St. John’s black cohosh; subarachnoid hemorrhages with
wort (57%), Echinacea (42%), and melatonin (44%). ginkgo biloba; coma, delirium, or mania with kava
The most commonly used CAMs were ginseng kava, valerian, DHEA (dehydroepiandrosterone),
(
13%), St. John’s wort (6%), ginkgo biloba (9%), or St. John’s wort; and seizures with eucalyptus
13,44–47
Echinacea (7%), and eucalyptus (4%).
and pennyroyal oils.
Hepatitis has been as-
sociated with Jin Bu Huan, Ephedra (ma-Huang),
4
8–51
DISCUSSION
melatonin, and valerian.
Emergency physi-
cians caring for patients taking these medications
Our study suggests that CAM use among ED pa- must understand the effects of substances, their
tients is high and that a large number of patients possible interactions with other medications, and
believe that CAMs are safe. Some patients believe their side effects. These are summarized in Table
that CAMs do not interact with other medication, 1.
and informing the EP of CAM use is not common.
To the best of our knowledge, CAM use in the
We found that the most commonly used CAMs are ED setting has been addressed in only two other
3
ginkgo biloba and ginseng, both of which have sig- published reports. Both also reported a large
nificant potential adverse effects. Ginkgo has been number of patients with experience with CAMs. A
1
3
linked to subarachnoid hemorrhages, and gin- brief report of a survey of 139 patients in New York
seng has been shown to affect warfarin blood lev- found that herbal use was third to chiropractic and
1
2
els.
massage therapy among the various alternative
A small percentage of our study population (6%) approaches. This report did not look at the indi-
believe that CAMs do not interact with other med- vidual CAMs that are available on the U.S. mar-
ications. This belief could lead to unsuspected in- ket. A smaller survey (n = 50) did a more compre-
teractions with currently prescribed medications. hensive evaluation of available CAMs but looked

ACADEMIC EMERGENCY MEDICINE • January 2001, Volume 8, Number 1
45
TABLE 2. Knowledge of Herbal Remedies (n = 350)
Heard of the Product
Can Identify the Purpose
Use Ever
Use Now
Ginseng
264 (75%)
204 (58%)
200 (57%)
194 (55%)
155 (44%)
148 (42%)
107 (31%)
101 (31%)
106 (31%)
97 (28%)
95 (27%)
98 (27%)
94 (27%)
86 (25%)
88 (25%)
86 (25%)
65 (19%)
64 (19%)
305 (87%)
126 (36%)
66 (20%)
89 (25%)
88 (25%)
52 (15%)
69 (20%)
21 (6%)
13 (4%)
14 (4%)
27 (8%)
31 (9%)
83 (24%)
50 (14%)
51 (15%)
44 (13%)
39 (11%)
45 (13%)
22 (6%)
19 (6%)
17 (5%)
27 (8%)
23 (6%)
11 (3%)
27 (8%)
11 (3%)
43 (13%)
15 (4%)
23 (6%)
31 (9%)
13 (4%)
25 (7%)
Eucalyptus
St. John’s wort
Ginkgo biloba
Melatonin
Echinacea
DHEA
Feverfew
Saw palmetto
Valerian
Ephedra (Ma-huang)
Hawthorne
Kava kava
Yohimbine
Pennyroyal oil
Comfrey
Black cohosh
Jin Bu Huan
Any of the above
9
4
4
7
6
8
(3%)
(1%)
(1%)
(2%)
(2%)
(3%)
8
(3%)
26 (7%)
10 (3%)
10 (3%)
3
3
5
5
2
(1%)
(1%)
(1%)
(1%)
(1%)
3
(1%)
9 (3%)
18 (5%)
12 (4%)
20 (6%)
9
0
(3%)
(0%)
7
(2%)
185 (53%)
151 (43%)
85 (24%)
at those that were used in the Dominican Repub- the generalizability of our results. Additionally,
1
8
lic. None of the CAMs addressed in this previous studies should be directed toward noting toxicities
study are among the primary CAMs available in and possible drug interactions of alternate medi-
the United States. Our study expands on the find- cations in ED populations.
ings of the previous work, and provides additional
information on use of CAMs in a U.S. ED.
C
ONCLUSIONS
Teaching EPs about CAMs has lagged behind
the widespread use of these substances. There
have been suggestions for incorporating the infor-
The use and public acceptance of CAM in our study
population were high. Because of potential side ef-
fects and drug interactions, patients should be rou-
tinely questioned about CAM use. Emergency
medicine providers should be aware of CAMs and
education about CAMs should be included in med-
ical training.
5
2
mation in both medical school and family practice
5
3,54
residencies.
No literature addresses whether
EM practitioners should receive training in CAM
use, toxicity, and drug interactions.
LIMITATIONS AND FUTURE QUESTIONS
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