Complementary, Alternative, Holistic, Integrative Medicine:

							Complementary, Alternative,
Holistic, Integrative Medicine:
            Meeting Patient Needs

       Sara Warber, MD
       Co-Director, Michigan Integrative Medicine
            and CAM Research Center
       Assist Professor, Dept of Family Medicine
       University of Michigan
CAM - What‟s in a Name?
   Alternative, unconventional

   Complementary

   Holistic

   Integrative
Objectives
 Why CAM is important
 What patients are using
 Introduction to broad categories of CAM
 How to evaluate the evidence
Importance
   Prevalence of use

   Potential application when effective

   Potential risks

   Doctor-Patient Relationship
Early Indicators

   1990 national telephone survey
   1/3 of patients use alternative methods
   72% of users did NOT inform their
    physician


    Eisenberg, et al. NEJM 1993; 328:246-52.
Follow-up Study
   1997 study of 2055 households
   42% used at least 1 of 16 therapies
   Disclosure rates did not improve



Eisenberg DM, et al. JAMA 1998; 280(18):1569-75.
CAM Spending
   $36 - $47 billion in 1997
   $12 - $20 billion for the services of
    professional CAM health care providers
   $5 billion on herbal products
   > out-of-pocket for all hospitalizations


    Eisenberg DM, et al. JAMA 1998; 280(18):1569-75
CAM Use 2002 (n=31,044)
Why do patients use CAM?
   National survey: 1035/1500 responses
   40% had used CAM in past year
   4.4% primarily relied on CAM
   Perceived benefits
     Relief   of symptoms
     Treatment   works better than standard therapy
Austin JA. JAMA 1997;279(19):1548-53.
Predictors of CAM Use
   “Cultural creative”         Specific health
   Transformational             problems
    experience                    Anxiety
                                  Back problems
   Holistic philosophy
                                  Urinary tract problems
   Poorer health
                                  Chronic pain
   More educated


        Austin JA. JAMA 1997;279(19):1548-53.
What are patients‟ goals?
 30% Prevention
 44% Wellness
 79% Specific Problems
     Back Pain
     Headache
     Anxiety
     Etc




                  Elder NC, et al Arch Fam Med 1997
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Rafferty et al, AJPH 2002;92(10):1598-9
Alternative Medical Systems
        Traditional Chinese
        Ayurvedic
        Native American
        Homeopathy
        Naturopathy
        Anthroposophic
Alternative Medical Systems
 Different views of body, illness
 Different basis for “knowing”
 Different diagnoses
 Different treatments
Meta-analysis of Homeopathy
 Like cures like
 89/186 trials met quality criteria
 Homeopathic remedy vs. placebo
 Odds ratio 2.45 (2.05-2.93) for homeopathy
 Homeopathic effects not completely due to
  placebo

Linde K, et al. Lancet 1997;350:834-843
Manipulative & Body-based
Methods
     Chiropractic
     Massage
     Acupuncture
     Acupressure
Manipulative & Body-based
Methods
   Different understanding of the body
     Meridian   system




   Physical methods of treatment
Acupuncture
   1996 FDA approves            Nausea
    single-use needles             chemotherapy

   1997 NIH Consensus                     anesthesia
                                   surgical

    Conference                     pregnancy

   Safety                       Pain
     adverse effects              postsurgical
      substantially lower          musculoskeletal
      than many drugs


Http://altmed.od.nih.gov/oam/cam/1998/jan/#acupuncture
Mind-body Interventions
   Hypnosis
   Meditation
   Biofeedback
   Imagery
   Yoga
   Tai Chi
   Prayer/mental healing
   Art, Music, Dance
Mind-body Interventions
 Engages mind and body in healing process
 Emphasis on healing rather than curing
 Emphasis on meaning of illness
 Relaxation response
 Psycho-neuro-immunology
Meditation for Stress Reduction
   Animal studies: chronic stress   basal
    cortisol,  response to stress  disease

   Prospective, randomized study TM vs.
    stress education
        basal cortisol,  response to stress
   TM technique reverses effects of chronic
    stress significant for health
MacLean CR, et al. Psychoneuroendo. 1997;22(4):277-95.
Biologically Based Therapies
 Herbal Medicine
 Nutritional Approaches
 Pharmacological Therapies
Herbal Medicine
 Indigenous medicine
 European phytomedicine
 German Commission E
     Historical use as evidence
     Scientific evidence
Nutritional Approaches
 Diet-based therapies
 Megavitamins
 Food intolerance
Vitamin E & Coronary Artery Ds
    20% of population              Prospective secondary
     taking Vit E.                   prevention
    Anti-oxidant highly              CHAOS:   800 IU Vit E
     associated with LDL                MI by 77%

    Epidemiologic                  HOPE trial - no effect
     evidence                       Safety: do not use
      Nurses‟ Health Study          with warfarin
      Health Professionals         Dose: 100 - 1000 IU
       Follow-up Study               daily
    Sorrentino M. Alt Med Alert 1998;1(2):20-22.
Pharmacological Therapies
   Alternative drugs or vaccines
     Chelation
     Cartilageproducts
     Apitherapy
Long term effects of
Glucosamine on Osteoarthritis
 RCT: 1500 mg glucosamine vs. placebo
  daily
 212 subjects x 3 years duration
 Joint space narrowing -0.06 mm (-0.22 to
  0.09) vs. -0.31 mm (-0.48 to -0.13)
 WOMAC symptom scale: glucosamine
  improved symptoms, placebo worsened

    Reginster, et al. Lancet 2001; 357: 251-6
    Energy Therapies

   Pulsed EM fields / DC
    fields
   Magnetic fields

   Therapeutic Touch
   Polarity therapy
   Reiki
Evidence Based Medicine
 Nov, 1992: A new paradigm emerges
 Randomized controlled trials, meta-analysis
 Clinical experience misleading
 Mechanisms insufficient
 Apply rules of evidence
 Produce better outcomes

EBM Working Group. JAMA 1992;268(17):2420-2425
Evaluating the Evidence
   Ask a question
     Exposure patient  outcome
     Glucosamine  my pt  better??

 Search the literature
 Evaluate the evidence
Levels of Evidence


            Clinical Practice
               Guidelines

             Meta-analysis

         Prospective clinical trial

           Retrospective report
        Case report & Case series
When Evidence is Incomplete
 Evaluating harm
 Risk/benefit ratio
 “n of 1” trial
Evaluating Harm
 Randomized controlled trial
 Be wary of case reports
Risk/Benefit Ratio
   Risk                     Benefit
     Side effects             Physical
     Toxic effects            Mental
     Withholding other        Emotional
      treatment                Spiritual
     Cost                     Social
        $$$$
                               Environmental
        Time

        Environmental
“n of 1” Trial
 You & your patient become the scientists
 Decide what symptoms to address
 Decide what outcomes are important
 Document & test
 Apply intervention
 Re-document & test
 Discuss together
What to look for in your career
 More patient demand
  for Integrated care
 Access to discounted
  CAM services
 „Bilingual‟ colleagues
 More educational
  opportunities