Palliative Care Education Use of Complementary & Alternative Medicine in HIV/AIDS Palliative Care Learning objectives • Define some of the different types of complementary and alternative care • Understand why people use CAM and how culture plays a role in its use • Understand some of the benefits and risks of CAM treatments in HIV/AIDS & palliative care • Learn how to communicate with your patients about CAM Consider a case • 34yoM, HIV+ x 7 years, reluctantly on ARVs for past 2 yrs • Has used wide range of CAM therapies in the past, often not divulging to clinician • Just started acupuncture for n/v related to ARVs • Wants to start a garlic supp to boost immune system What is Complementary & Alternative Medicine (CAM)? • A group of diverse medical and health care systems, practices, and products not presently considered to be part of conventional medicine. (NCCAM) • Two types: –Healing practices used by general public –Practices used by specific ethnic or religious groups Kaptchuk; 2001, Ann Intern Med 135(3): 196-204 Five Domains of CAM • Alternative Medical Systems • Mind-Body Interventions • Biologically-based treatments • Manipulative therapies • Energy Therapies A full glossary of terms is available at http://nccam.nih.gov/health/whatiscam/ Who are CAM practitioners? Category Chiropractor Massage practitioner Acupuncturist Naturopath Training after B.A. degree 4-5 years 100 – 1000 hours 3 years 4-5 years Total number licensed 70,000 250,000 14,000 1,400 Eisenberg DM et al, Ann Int Med (2002) 137:965-973. Why learn about CAM? • Use of CAM in US has increased by 47% in the past decade • Many insurers and managed care providers now cover some CAM therapies • Patients pay billions of dollars for CAM therapies • CAM therapies may interfere or interact with conventional treatment Wetzl, Ann Intern Med 2003; 138: 191-6 Why do people use CAM? • • • • Poor health status A last resort Relief of symptoms Less adverse effects than conventional treatments • Consistent with patients cultural or health beliefs –Only 4.4% of CAM users do not also use conventional medical care. Dissatisfaction with conventional care did not predict use. Astin; JAMA, 1998; 279:1548-1553 Pan; J Pain & Symptom Mgmt 2000; 20: 374-897 CAM use in cancer and HIV patients 70 60 50 40 30 20 10 0 Cancer patients N=356 HIV patients on HAART N=118 Any CAM use Massage therapy Acupuncture Chiropractic Mind/body therapy Herbal Patterson (2002) J Alt and Comp Med 8(4):477-485 Risa (2002) Int J STD AIDS 13:706-713 Specific CAM therapies used in HIV/AIDS & palliative care • • • • • • Herbs & supplements Acupuncture Massage therapy Naturopathic medicine Chiropractic Mind-Body therapy Herbs and supplements • Most common form of CAM used in US • Benefits: Vitamins and nutritional supplements may improve well being • Risks: Certain herbal treatments have been shown to interact with medications and in some cases are toxic • Most herbs and supplements have not been carefully tested Common uses of herbs & supplements in HIV/AIDS care • Omega 3 oil as an anti-inflammatory--used to treat neuropathy • High dose vitamin, mineral and antioxidant therapy to build immune system and slow disease progression • Vitamin therapy--treats wasting, lack of appetite, malabsorption of nutrients • Chinese herbs to treat diarrhea • St. John’s Wort as antidepressant, antiviral, anti-inflammatory agent. Effect of a vitamin and mineral supplement on infection incidence 100 90 80 70 60 50 40 30 20 10 0 No diabetes Type 2 diabetes mellitus n=130 patients Percent with infection Placebo Treatment Barringer et al (2003) Ann Int Med 138:365 Herbs and supplements: Recent problems and concerns • Echinacea: Some believe it may stimulate the immune system and cause progression of HIV. • Milk Thistle: May increase the levels of other drugs by slowing down liver enzymes that process these substances • St. John’s Wort: May reduce the levels of HAART and interfere with chemotherapy • Kava: May cause liver dysfunction • Garlic supplements: May lower levels of certain protease inhibitors Acupuncture • A component of Chinese medicine insertion of fine needles into well-defined specific sites to balance energy and promote health • Sites of insertion correspond to different energy pathways that relate to symptoms and conditions Common uses of acupuncture in HIV/AIDS & palliative care • • • • • Help with pain-related syndromes Reduction of nausea and vomiting Relief of dyspnea Treatment of addiction Risks: –Rare cases of pneumothorax –Bruising and bleeding may occur but are also rare Capsicum plaster on acupuncture points for post-operative nausea and vomiting 70 60 50 40 30 20 10 0 Nausea Vomiting Anti-emetics Kim KS et al, Anesth Analg 2002;95:1103-1107 Control Korean Chinese Massage therapy • Manipulation of muscle and connective tissue to enhance function of those tissues and promote relaxation and well-being • Many different schools of massage therapy and body work Common uses of massage therapy in HIV/AIDS & palliative care • • • • Enhance immune function Reduce musculoskeletal pain Increase lymph flow Decrease anxiety, increase self-esteem and positive body image. • Provide human touch • Risks: –Few risks with licensed and trained practitioners –An inexperienced or poorly trained practitioner may cause bruising or pain by the use of rough techniques Naturopathic medicine • Naturopathic physicians have extensive training. • They rely on natural treatments, such as herbs and supplements, dietary and lifestyle modification, and mind-body medicine Common uses of naturopathy in HIV/AIDS & palliative care • Uses: –Treatment of nausea with ginger –Immune enhancement agents –Hyperthermia to increase immune functioning • Risks: –Most treatments have low toxicity; however, herbal remedies used may have not been adequately studied or may interact with medications Chiropractic • Focuses on the relationship between bodily structure (primarily that of the spine) and function, and how that relationship affects the preservation and restoration of health • Chiropractors use spinal manipulative therapy as an integral treatment tool • Frequently requested by patients with musculoskeletal pain Chiropractic • Benefits: –Users claim relief from musculo-skeletal complaints • Risks: –Cervical manipulation has been associated with vascular injury and stroke –Chiropractic spinal manipulation is NOT recommended for the treatment of pain secondary to cancer Mind-body therapy • A variety of techniques used to enhance the mind’s capacity to affect the body • Includes meditation, visualization, mental healing, prayer, and creative outlets such as music and art • Benefits: Emotional support, peace of mind and reduced stress have been reported in studies Common uses of mind-body therapy in HIV/AIDS & palliative care • Meditation to alleviate emotional distress • Relaxation techniques used to treat pain and dyspnea • Risks: Virtually none unless the patient is coerced into treatments they do not want or if patient has unrealistic expectations of the benefit (i.e. cure) Recommendations for CAM • May be useful for non-pharmacologic treatment of a number of concerns, including musculoskeletal pain, nausea and vomiting • Use a licensed provider • Re-evaluate the costs and the benefits after several weeks • Consultation between the conventional care team and CAM provider is recommended to avoid contraindicated therapies Other healing practices • Ethno-medicine –Native American traditional healers –Mexican American curanderismo –Haitian vodun • Folk medicine • Religious healing Why talk about CAM with patients? • Information available to patient can be confusing or misinformed • Patient may have misconceptions about conventional treatment available • Potential for adverse effects and drug interactions if provider does not know about CAM use by patient Talking to a patient about CAM • Ask the question: –“Patients with HIV/AIDS often use other kinds of therapy for symptom relief or to help their immune system. For example, some patients use massage, acupuncture, herbs, etc. Have you used these or thought about using them for your illness?” Eisenberg; Ann Intern Med (1997); 127:61-9 Talking to patients about CAM • Use pt. response to identify the issue of concern • Ask for patient’s expectations or experience of the proposed treatment • Review issues of safety and efficacy • Recommend that patient use a licensed provider • Consult with the CAM provider • Raise allopathic alternatives if relevant Eisenberg (modified); Ann Intern Med (1997); 127:61-9 Reconsider a case • 34yoM, HIV+ x 7 years, B3, reluctantly on ARVs for past 2 yrs. • Has used wide range of CAM therapies in the past, often not divulging to clinician • Just started acupuncture for n/v related to ARVs • Wants to start a garlic supp to boost immune system Summary • Encourage: –Responsible use of complementary and alternative therapies –Good communication with pt. and between all providers • Discourage: –Treatment by unlicensed practitioners –Injections of substances not approved by FDA –Treatments that have known adverse effects or drug interactions Resources • The Body is a Web site for HIV related issues; There is a forum called “Ask The Experts” http://www.thebody.com/index.html • Bastyr Center for Natural Health is a comprehensive clinical service in Seattle staffed with a variety of trained CAM providers. Their telephone number is 206.834.4100 Contributors The primary author of this module is William Lafferty, MD, Assistant Professor, University of Washington, Department of Health Services Anthony Back, MD J. Randall Curtis, MD, MPH Frances Petracca, PhD Liz Stevens, MSW Director Co-Director Evaluator Project Manager Visit our Website at uwpallcare.org Copyright 2003, Center for Palliative Care Education, University of Washington This project is funded by the Health Resources and Services Administration (HRSA) and the Robert Wood Johnson Foundation (RWJF).
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