FP rotation CAM orientation revised 2003-10-29

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					An Integrative Approach to Complementary and Alternative Medicine in Primary Care Settings
Maureen A. Flannery MD, MPH Department of Family Practice and Community Medicine University of Kentucky College of Medicine


Learning Objectives
• To define complementary and alternative medicine (CAM) in relationship to conventional medicine. • To discuss characteristics of CAM users and practitioners and their implications for primary care clinicians.


Learning Objectives
• To review research in progress on CAM modalities for common problems.

• To discuss issues CAM use raises for primary care clinicians related to communication and liability.


Complementary and Alternative Medicine (CAM)
• a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine (1)
• healing therapies that typically fall outside the Western biomedical model of disease, diagnosis, and treatment (2)
(1) Eisenberg 1993; (2) Drivdahl 1998


Complementary and Alternative Medicine (CAM)
The list of what is considered to be CAM changes continually as those therapies that are proven to be safe and effective become adopted into conventional health care and as new approaches to health care emerge.

NCCAM 2003


Major Domains of CAM
• • • • Alternative medical systems Mind-body interventions Biologically-based treatments Manipulative and body-based methods • Energy therapies
NCAAM 2003


Who uses CAM?
• Surveys show marked increase in past 50 years in US and other industrialized countries (1). • Between 1990 to 1997, increase from 34% to 42% of US households reporting CAM use (2). • In 1997 in US, more visits to CAM practitioners than to all primary care providers (2).
(1) Kessler 2001; (2) Eisenberg 1998


Who uses CAM?
• Surveys of primary care clinic populations show 28-47% utilization of CAM. • 21% of patients in primary care practices reported using CAM for the same health problem for which they sought conventional care on that visit.
Palinkas 2000


Who uses CAM?
• Herbal therapy is used by 12-14% of the US population, up from 2.5% in 1990. • 16-18% of patients taking prescription medications also take herbal remedies.

Kaufman 2002


Why do people use CAM?
• Desire for health and wellness (1) • Prevention • Pain – Musculoskeletal pain accounted for 1/3 of all CAM use among primary care patients

– Between 60 and 94% of rheumatic disease patients use CAM (3).
(1) Wolsko 2002; (2) Palinkas 2000; (3) Ramos-Remus 1999

Why do people use CAM?
• Very few individuals rely exclusively upon alternative modalities (1). • Most individuals who use CAM do so because of preference, related to the perception that the combination of CAM and conventional treatments are superior to either alone (2).
(1) Astin 1998; (2) Eisenberg 2001


Who practices CAM?
• Wide variation in background and approach • Diversity in training programs

Barrett 2000


Who practices CAM?
• No standardization of approach to accreditation and licensure • Controversies about regulation

Chez 1999


Who practices CAM?
Some common beliefs and values The body has self-healing potential. Body mind and spirit are all important. Therapy must be individualized. People are responsible for their own healing.
Curtis 2003

• • • •


Who practices CAM?
• More nonphysicians than physicians practice CAM • Increasing numbers of dual-trained MDs
– American Board of Medical Acupuncture – American Board of Holistic Medicine


Who practices CAM?

How did I get to be a ―dual-trained MD‖?


What about communication?
• Between 40 and 70% of CAM users do not disclose their use to their physician. WHY? • Patients usually say that they do not report because they are not asked.
Eisenberg 2001

Why does this matter?
• The substantial overlap between use of prescription medications and herbal supplements raises concerns about unintended interactions. • Patient use of CAM is often a clue to values and preferences that need to be acknowledged.
Kaufman 2002

How can we communicate?
1. Always ask! ―What else are you doing for your health?‖ 2. Be open and nonjudgmental. 3. Consider patient preferences and values. 4. Encourage self-monitoring of results.
Eisenberg 1997


How can we communicate?
5. Coordinate care as appropriate. 6. Be honest about your lack of knowledge and open to education. 7. Monitor safety and efficacy, arrange follow-up. 8. Document all discussions and advice.
Eisenberg 1997


EBM and CAM
While some scientific evidence exists regarding some CAM therapies, for most there are key questions that are yet to be answered through well-designed scientific studies— questions such as whether they are safe and whether they work for the diseases or medical conditions for which they are used.
NCCAM 2003

Where are we now?
There is an urgent need for more and better trials of CAM therapies! There may be hope: • OAM funding FY 1992: $2 M • NCCAM funding FY 2003: $113.2 M

Research in Progress
NCCAM funded Research Centers Program • 12 Centers for CAM Research, each with focus on a particular condition • 4 Centers for Dietary Supplements Research • Many clinical trials in progress, for example – 18 on acupuncture – 16 on cancer


Research in Progress
Biologically-based therapies • Safety of ―natural‖ products • Efficacy of glucosamine and/or chondroitin for pain of osteoarthritis – NIH-GAIT

Research in Progress
Mind-body approaches


Some now mainstream
– Clinical hypnosis – Cognitive therapy – Biofeedback


Meditation for fibromyalgia
– Transcendental meditation – Mindfulness meditation – Relaxation response Hadhazy 2000


Research in Progress
Manipulative therapies: chiropractic • Most accepted professional therapy • Good review of safety • Current trials of effectiveness for
– Chronic neck pain – Low back pain
Stevinson 2002


Research in Progress
Manipulative therapies: massage Low back pain
• • Comparison with acupuncture & self-care (1) Combined with education and exercise (2)

(1) Cherkin 2001; (2) Furlan 2002


Research in Progress
Alternative medical systems: Traditional Chinese Medicine (TCM)

Current trials of acupuncture for
• • • • Fibromyalgia Knee osteoarthritis Repetitive stress disorder TMJ pain


Research in Progress
“Frontier Medicine Program”
NCCAM initiative to encourage research on widely used CAM practices for which there is ―no plausible biomedical explanation‖ – Energy therapies – Homeopathy – Prayer – Spiritual healing

Where does this leave us?
Many conventional treatments • have been adopted without good quality research • are costly • are invasive • are likely to have adverse effects • AND often provide inadequate relief.

Where does this leave us?
CAM interventions generally • are low cost • are low-risk • are free of serious side effects • AND are widely used.


Advising patients about CAM
Use evidence for  efficacy  safety to place therapy on continuum recommend accept discourage
Weiger 2002

Towards Integration
Liability Risks Based on Evidence • Support for safety and efficacy • Support for safety, inconclusive for efficacy • Support for efficacy, inconclusive for safety • Indication of serious risk or inefficacy
Cohen 2002

Framework for approaching CAM in clinical situations
• • • Protect against dangerous practices. Permit practices that are harmless and that may help. Promote and use practices that are safe and effective. Partner with patients and encourage communication about CAM.
Jonas 2000


Framework for approaching CAM in clinical situations
Question: Is “permit” the right word here? Do physicians have the power to “permit” practices that their patients choose?

Integrative Medicine
a combination of mainstream medical therapies and CAM therapies for which there is high-quality scientific evidence of safety and effectiveness
NCCAM 2003

Integrative Medicine
requires a paradigm shift from • the disease-centered approach of conventional biomedicine to • an approach in which patient values and participation of patients are central.
Maizes 1999


Towards Integration
The satisfaction that patients report from relationship-centered and individualized CAM therapies serves to remind us: We can never know with certainty what therapy- alternative or otherwise- will work for an particular patient, no matter what randomized controlled clinical trials indicate.

Towards Integration
Our patients’ use of CAM invites us • to ask and listen to our patients, • to contribute what evidence based medicine offers, • to advocate for better evidence-based research, and at the same time • to acknowledge the existence of other types of information that may be more relevant to a given individual or for a particular situation.

Framework for approaching CAM in clinical situations
• Protect against dangerous practices. • Permit practices that are harmless and that may help. • Promote and use practices that are safe and effective. • Partner with patients and encourage communication about CAM.
Jonas 2000

Partner with patients and
communicate about CAM
• ASK!
• “Build” a history that includes CAM use. (Don’t “take” one.) • When patients tell, LISTEN!
Haidet 2003

Integrative Medicine
• an opportunity to bring together

strengths and balance weaknesses of
different systems of health care • ―a coming together of heart, head, and hand‖
Owen 2001


Integrative Medicine

“Could this be a healing process in itself”?

Owen 2001


An Integrative Approach to Complementary and Alternative Medicine in Primary Care Settings
Maureen A. Flannery MD, MPH Department of Family Practice University of Kentucky College of Medicine

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