Complementary & Alternative Medicine
What is Complimentary & Alternative Medicine
• “Complementary and alternative medicine, as defined by NCCAM, is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. 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)
CAM Classification of Alternative Medicine Practices
Methods of CAM
•Megavitamin and Orthomolecular Therapy •Diet Therapy •Biologics •Clinical Ecology and Environmental Medicine •Hypnotherapy •Relaxation •Meditation and Mindfulness •Transcendental Meditation •Imagery •Radionics •Music Therapy •Sound Healing •Art Therapy •Light Therapy •Prolotherapy •EDTA Chelation Therapy •Behavioral Kinesiology •Electrodermal Diagnostics •Magnetic Therapy •Natural Hygiene •Cayce-Based Therapy •Psychic Surgery •Medical Acupuncture •Phytomedicine •Shamanistic Practices •Spiritual Healing •Bioelectricmagnetic Effects on Health and Disease •Massage •Other Bodywork Approaches •(Rolfing, Alexander, Feldenkrais, Orthobionomy, Trager, Reflexology) •Therapeutic Touch •Qigong •Yoga •Other Energy Approaches •(Reiki, Shen, Polarity, Wirkus, Brennan) •Cranial/Sacral Therapies •Bioenergetics and Orgonomic Medicine •Biofeedback •Neurobiofeedback •Behavioral Medicine
Unconventional Medicine
• Popular • 1/3 of Americans use • more visits than to primary care (425M) • "minor" - self care, weight loss, pediatrics • 50% of cancer patients • Sophisticated AIDS users • More than $15 billion a year spent in the US • Concealed - 72% don't talk about it to doctor • Combined - 83% used conventional treatment
Physician Use of CAM
90 80 70 60 50 40 30 20 10 0 Relax 22 2 3 5 1 5 Diet 86 85
N=572
66 63 56 54 48 47 Refer Use
Percent
17 1 Yoga
Biof. Masg. Hypn. Acup. Med.
Blumberg DL, ATHM, 1(3):31 (1995)
Physician Use of CAM
40 35 30 25 20 15 10 5 0 Imag Spirit Homeo Energy 7 5 1 15 14 10 6 3 0 Rolf 0 Herb MegaVit 6 3 24 Refer Use 37
N=572
Percent
Blumberg DL, ATHM, 1(3):31 (1995)
Is CAM "Non-scientific" Practice?
• Conventional scientific base
• 20 - 50% backed by quality research
•
Herbal medicine
• Ginkgo biloba • Hypericum • garlic, ginseng, echineacca, ginger, cranberry
Mind/Body and Behavioral medicine; Diet and Nutritional Supplements • Homeopathic
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• 150+ controlled clinical trials • 15-20% of studies "good"
Expanding Horizons of Healthcare: Five-Year Strategic Plan, 2001-2005 to increase research; train investigators; expand outreach; and facilitate integration • Clinical trials (research studies in people) are also under way. Some of these trials are investigating: • Acupuncture and whether it reduces anxiety and improves quality of life in patients with advanced colorectal cancer • Shark cartilage for its safety and effectiveness as a treatment in patients with advanced colorectal or breast cancer
• An alternative diet (the macrobiotic diet) and flax seed, to see if they help decrease the risk of developing breast cancer or uterine cancer
• Noni, a CAM therapy originating from Asian and Pacific Islands, and its possible usefulness in treatment and symptom management for cancer patients • The vitamin L-carnitine and whether it reduces fatigue in cancer patients • Massage therapy, to find out whether it eases swelling of the arms and legs related to treatment for breast cancer.
Why Patients Use Complementary Medicine
• The following variables emerged as predictors of alternative health care use: more education; poorer health status; a holistic orientation to health; having had a transformational experience that changed the person's worldview; any of the following health problems: anxiety; back problems; chronic pain; urinary tract problems; and classification in a cultural group identifiable by their commitment to environmentalism, commitment to feminism, and interest in spirituality and personal growth psychology. Dissatisfaction with conventional medicine did not predict use of alternative medicine.
JAMA. 1998 May 20;279(19):1548-53.
Myths About Complementary Medicine Users
• Disillusioned with medicine in general • Anti-science • Largely motivated by lower cost
Vincent, C. 1996 “Why do patients turn to complementary medicine? An empirical study. British Journal of Clinical Psychology 35:37-48
Concerns with Conventional Medicine
• • • • • Cost (14% of GNP) Safety (11% of hospitalizations iatrogenic) The Burden of Chronic Illness Depersonalization Role of Science in Medicine
Is CAM Safe?
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• •
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“Natural” Medicine Direct toxicity occurs Indirect effects Little is still known; lots of unknowns
Independent Laboratory Analysis of Leading Garlic Products
Product A B C D allicin/tablet 7,500 mcg 4,920 mcg 4,625 mcg 3,300 mcg allicin/tablet 19,800 mcg 10,853 mcg 12,837 mcg 7,370 mcg S-allylcysteine/tablet 6,500 mcg 234 mcg 3,055 mcg 508 mcg
E
F G H I
3,150 mcg
1,45 8 mcg 740 mcg 0 mcg 0 mcg
8,480 mcg
3,240 mcg 1,560 mcg 0 mcg 0 mcg
1,750 mcg
378 mcg 185 mcg 1,500 mcg 0 mcg
Murray, M.T. The American Journal of Natural Medicine. 1995 2(5)5-7.
Is CAM Personal?
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Understandable & Esthetic Time - 7 vs. 30 minutes Psychological - 60%+ High - touch? - care and healing Partnership? - complementary
Evaluation Guidelines
• Get a three part education
• Understand the concepts thoroughly • Evaluate the data critically • Experience the practice openly
• Take a deeper look
• Scientific - strength/likelihood of attribution • Pragmatic - benefit/magnitude of effect • Use good methods of evaluation
• Define the detail, not just label the system • Distinguish “under evaluated” from “ineffective”
Look at the Research
• Evaluate the study
• Efficacy? • Randomized trial? • all outcomes reported? • clinical significance? • statistical significance? • complete follow-up achieved? • study patients broad or similar to yours? • treatment feasible?
National Center for Complementary & Alternative Medicine (NCCAM)
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General - facilitate research in CAM
• Evaluation • Investigation • Validation
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Specific
• Information Clearinghouse • Research Training Program • Good resource for researching and evaluating AM
Physician Responsibilities
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Protect
• toxic therapies - meditation vs. megavitamins • ineffective therapies - if substituted for effective
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Permit
• safe, inexpensive - homeopathy vs. herbalism vs. clinical ecology • chronic disease management (non-specific effects)
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Promote
• safe and effective? - P6 for nausea; relaxation for pain • mechanism ? - endogenous opioids in acupuncture
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Partner
• communicate with patient • co-manage illness provide the input on evidence
Hypericum (St. John’s Wart)
Some use for depression and have good results Side effects are few and mild but new information has led to serious interaction with P450 Enzyme o Lower cost than prescription antidepressants o Available without a prescription • Regularly taken in Germany • Do not take with MAOIs. • Caution—advise against taking with other antidepressant; warfarin, or retrovirals
Supplements of vitamins A, C, or E; multivitamins with folic acid; or antioxidant combinations for the prevention of cancer
or cardiovascular disease.
• The USPSTF found poor evidence to determine whether supplementation with these vitamins reduces the risk for cardiovascular disease or cancer. The available evidence from randomized trials is either inadequate or conflicting, and the influence of confounding variables on observed outcomes in observational studies cannot be determined. As a result, the USPSTF could not determine the balance of benefits and harms of routine use of supplements of vitamins A, C or E; multivitamins with folic acid; or antioxidant combinations for the prevention of cancer or cardiovascular disease.
US Preventive Services Task Force (USPSTF) 2003
• Kava Kava • Safety is a concern for users of kava. People, especially those with liver disease or liver problems, or persons who are taking drugs that can affect the liver, should talk with their health care practitioner before using kava. (July 23, 2002) • Ginkgo Biloba • Star Anise Teas • The Food and Drug Administration (FDA) today is advising consumers not to consume "teas" brewed from star anise. It has come to FDA’s attention that brewed "teas" containing star anise have been associated with illnesses affecting about 40 individuals, including approximately 15 infants. The illnesses, which occurred over the last two years, ranged from serious neurological effects, such as seizures, to vomiting, jitteriness and rapid eye movement. (9/10/2003) • What are your experiences with alternative medicine? • Supplements? • Massage? • Yoga, Tai Chi, Relaxation, Hypnosis?