Finding of fewer antibiotic prescriptions from integrative doctors urges new research priorities

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Global medical news channels blew up three weeks ago with the report of potentially positive public health outcomes associated with expanding care from general practitioners whose practices include integrative modalities.

In the UK Huffington Post: “GPs with complementary medicine training less likely to prescribe antibiotics.” In the Times of London: “Alternative GPs Use Fewer Antibiotics.”  At a blog at BMJ Open: “Surgeries employing GPs with additional training in complementary medicine appear less likely to prescribe antibiotics.” And finally, to note just one other, a doctor blog from Australia: “Don’t diss GPs that stretch the boundaries.”

When was the discipline of “integrative medical doctors” ever given such congratulatory attention?

The research, published in BMJ Open, was a health services exploration focused on the impact of the practitioners themselves, rather than on parsing the value of any one specific natural health modality – acupuncture, diet change, herbs, homeopathic medicines, etc. -  used in their treatment scheme.

The study raises multiple questions relative to the potential impact of integrative practice on all manner of drug prescriptions. What might be found if practices of integrative professionals who have access to prescribing rights - MDs, Dos, NPs, NDs - are compared to usual care across an array of conditions where sometimes problematic pharmaceuticals are widely-prescribed? Might we see a broad reduction of the burdens of adverse effects?

Until this research, associations between the knowledge and use of integrative practices by general practitioners and their patterns of antibiotic prescribing were not widely explored.

The results are compelling. GPs who offer homeopathy, acupuncture or herbal remedies, for instance, prescribe 22 per cent fewer antibiotics. The biggest decline was 24% for chest infections. No differences, however, were found between the integrative-savvy and regular practitioners when it came to antibiotic prescriptions for urinary tract infections. Overall “surgeries employing GPs with additional training in complementary medicine appear less likely to prescribe antibiotics.”

The lead researcher was Esther van der Werf-Kok, PhD, a lecturer in the epidemiology of primary infectious disease at the University of Bristol. She is quoted in The Times suggesting that, given her findings, one or more specific integrative modalities might merit exploration as a treatment for infection: “There may be some room to see whether herbal medicines or homeopathy or acupuncture could be used as a non-antibiotic treatment.”

To follow Werf-Kok’s suggested course may miss a more fruitful direction for future research on the value of the integrative model of care. And this goes for antibiotics and many other commonly over-prescribed pharmaceuticals.

Werf-Kok is suggesting the usual trip down biomedicine’s reductive rabbit hole. Instead, why not train researchers’ sights on what happens to a general practitioner’s relationship to pharmaceuticals when they have something else – integrative perspectives and modalities - to offer. What happens when the story practitioners impart to patients about the need for antibiotics -or other drugs – shifts?

The Times article references a recent study that found that roughly 20% of antibiotic prescriptions aren’t necessary. The 22% reduction in antibiotic use found by Werf-Kok and her team is a pretty good z

Interesting coincidence – and a source of further questions. This success of integrative practices to support the public health campaign to limit the explosion of superbugs may be due to using a specific modality such as acupuncture or herbs or homeopathy. At the same time, these public health benefits might be due in part at least to the confidence of the integrative practitioner in trying something else before pulling the trigger on an antibiotic prescription.                                                                                                                

The general proposition that a doctor trained in integrative practices will limit antibiotic prescriptions gets even more interesting if one extrapolates across the myriad of pills in general medicine that are both overprescribed and can, like antibiotics, be associated with high harm.

What are the relative patterns among integrative medical doctors, holistic nurse practitioners and naturopathic doctors - in states where they have prescribing rights - regarding a dozen of the top drugs with adverse effects? One might start by exploring patterns relative to pain medications and opioids. These are health services research questions. The USA population is known to be over-treated and over-drugged.

If the community of general integrative practitioners wants to make the case for its value, pushing such a health services research agenda makes a good deal of sense. If the general research community cares to examine where the emerging integrative practice models may offer immediate value, it may be smart to stop scratching biomedicine’s “but which of the integrative modalities what caused it” reductive itch. Instead, allow the ambiguity. Ask instead – or at least at the same time: “Where else might there be evidence that integrative practitioners can diminish chronic over-prescribing?”