Complementary

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Complementary Alternative Medicine
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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)

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CAM Classification of Alternative Medicine
Practices

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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 Phytomedici
ne 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 Neurobiofeedb
ack Behavioral Medicine
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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

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Physician Use of CAM
N572
Blumberg DL, ATHM, 1(3)31 (1995)
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Physician Use of CAM
N572
Blumberg DL, ATHM, 1(3)31 (1995)
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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
• 150 controlled clinical trials
• 15-20 of studies "good"

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Expanding Horizons of HealthcareFive-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.

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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 20279(19)1548-53.
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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 3537-48
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Concerns with Conventional Medicine

• Cost (14 of GNP)
• Safety (11 of hospitalizations iatrogenic)
• The Burden of Chronic Illness
• Depersonalization
• Role of Science in Medicine

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Is CAM Safe?

• Natural Medicine
• Direct toxicity occurs
• Indirect effects
• Little is still known lots of unknowns

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Independent Laboratory Analysis of Leading Garlic
Products
Product
allicin/tablet
allicin/tablet
S-allylcysteine/tablet
19,800 mcg
7,500 mcg
6,500 mcg
A
4,920 mcg
10,853 mcg
234 mcg
B
C
4,625 mcg
12,837 mcg
3,055 mcg
7,370 mcg
508 mcg
D
3,300 mcg
E
3,150 mcg
8,480 mcg
1,750 mcg
F
1,45 8 mcg
3,240 mcg
378 mcg
G
740 mcg
1,560 mcg
185 mcg
H
0 mcg
0 mcg
1,500 mcg
I
0 mcg
0 mcg
0 mcg
Murray, M.T. The American Journal of Natural
Medicine. 1995 2(5)5-7.
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Is CAM Personal?

• Understandable Esthetic
• Time - 7 vs. 30 minutes
• Psychological - 60
• High - touch? - care and healing
• Partnership? - complementary

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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

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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?

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National Center for Complementary Alternative
Medicine (NCCAM)

• General - facilitate research in CAM
• Evaluation
• Investigation
• Validation
• Specific
• Information Clearinghouse
• Research Training Program
• Good resource for researching and evaluating AM

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Physician Responsibilities

• Protect
• toxic therapies - meditation vs. megavitamins
• ineffective therapies - if substituted for
  effective
• Permit
• safe, inexpensive - homeopathy vs. herbalism vs.
  clinical ecology
• chronic disease management (non-specific effects)
• Promote
• safe and effective? - P6 for nausea relaxation
  for pain
• mechanism ? - endogenous opioids in acupuncture
• Partner
• communicate with patient
• co-manage illness provide the input on evidence

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Hypericum (St. Johns 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
• Lower cost than prescription antidepressants
• Available without a prescription
• Regularly taken in Germany
• Do not take with MAOIs.
• Cautionadvise against taking with other
  antidepressant warfarin, or retrovirals

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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
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• 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 FDAs 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?