Complementary and Alternative Medicine (CAM) Resources fo

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Complementary and Alternative Medicine (CAM)
Resources for the Practitioner Where to look
and Who to Trust

• John D. Mark MD
• Clinical Assoc Professor of Pediatrics
• Pediatric Pulmonary Medicine
• Lucile Packard Childrens Hospital at Stanford

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CAM- Where is it?

• A 14 yr old athlete with moderate, persistent
  asthma comes to clinic. He has an asthma action
  plan and has been adherent with his controller
  medication. Now he wants to try a breathing
  technique (Buteyko) so he can get off his meds.
• A 3 yr old comes to the clinic for a well-child
  check-up. On exam you find a right otitis media.
  She is asymptomatic and you recommend watchful
  waiting. The parents would like to try a
  homeopathic remedy because they had heard that
  homeopathy worked better than placebo for
  children with an ear infection.
• Answer Everywhere

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CAM- every where you look
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CAM in the News

• Dying Woman Loses Marijuana Appeal March 14, 2007
• Evidence Mounts That Coping Skills Can Boost HIV
  Survival March 14, 2007
• Omega-3 in Fish Oils Might Ease Depression March
  7, 2007
• Insomnia Alternative Medicine Popular
• 1.6 Million Adults Use Complementary Or
  Alternative Medicine For Insomnia September 2006

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Ernst MJA 2006 185 (11/12) 680-681
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Complementary and Alternative Medicine (CAM)

• Complementary and alternative medicine
• A group of diverse medical and health care
  systems, practices, and products
• Not considered part of conventional medicine
• Some scientific evidence exists regarding CAM
  therapies
• For most, questions of safety and efficacy
  persist
• Complementary medicine is used together with
  conventional medicine. Alternative medicine is
  used in place of conventional medicine.

http//nccam.nih.gov/health/whatiscam/
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Integrative or Holistic Medicine

• Integrative combines mainstream medical therapies
  and CAM therapies for which there is some
  high-quality scientific evidence of safety and
  effectiveness.
• Healing-oriented medicine that takes account of
  the whole person (body, mind, and spirit),
  including all aspects of lifestyle. It emphasizes
  the therapeutic relationship and makes use of all
  appropriate therapies, both conventional and
  alternative.

http//nccam.nih.gov/health/whatiscam/
http//www.integrativemedicine.arizona.edu/about2.
html
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Major Classes of CAM
Enhance the minds capacity to affect
bodily function and symptoms

• Chiropractice
• Osteopathy
• Massage

Alternative medical systems
Mind-body interventions
Manipulative body-based methods
Energy therapies
Biologically -based therapies

• Homeopathic
• Naturopathic
• Traditional
• Chinese and
• Ayurvedic
• treatments

• Dietary supp
• Herbs
• Foods
• Vitamins
• Natural
• substances

• Biofield therapy
• Bioelectro-
• magnetic
• therapy

http//nccam.nih.gov/
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CAM Utilization

• Reasons for using CAM
• Consistent with patients and families values
  natural, and empowering
• CAM providers are patient-centered, dedicated
  to promoting health.
• Conventional therapies are perceived to be
  emotionally or spiritually without benefit
• Conventional therapies are not effective or are
  associated with side effects.
• CAM use is a circular usage determines number of
  CAM practitioners

Archives of Disease in Childhood 20069196-97
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CAM Therapies
http//nccam.nih.gov/news/camsurvey_fs1.htmdomain
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CAM Therapies
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Pediatric Use of CAM

• Asthma 80 Reznik, 2003 (Bronx,
  NY)
• Adolescents 54-69 Wilson, 2002 (NY)
  
  Braun, 2005 (MN)
• Special Needs 64 Sanders, 2003
  (Tucson, AZ)
• Rheumatology 64 Hagen, 2003
  (Toronto)
• ADHD 54 Chan et al, 2003
  (Boston Childrens)
• Emergency 13-45 Losier, 2005 (Ottawa)
  Lanski, 2003 (Atlanta)

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Pediatric Use of CAM

• Oncology 47-84 McCurdy, 2003
  (WFU)
• Neuhouser, 2001 (Seattle)
• Kelly, 2000 (NYC)
• Cerebral Palsy 56 Hurvitz,
  2003
• Ann Arbor, MI
• IBD 41 Heuschkel, 2002
• London, Boston, Detroit
• Autism Spectrum 30 Levy,
  2003 CHOP, PA
• Preoperative 29.5 Lin, 2004
• Boston Childrens
• Primary Care 12-21 Sawni, 2002
  (Detroit) Ottolini, 2001 (Wash D.C.)

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Evidence Based CAM Therapies in Pediatrics

• Effectiveness well documented
• Acupuncture for nausea and vomiting
• Biofeedback for constipation
• Biofeedback for headache
• Hypnotherapy for headache
• Hypnotherapy for irritable bowel syndrome
• Lemon balm for herpes simplex
• Massage for constipation

Archives of Disease in Childhood 20069196-97
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CAM Treatments Commonly Thought Effective in
Pediatrics

• Effectiveness uncertain
• Acupuncture for asthma
• Acupuncture for hay fever
• Acupuncture for rheumatoid arthritis
• Chromium for diabetes
• Echinacea for common cold prevention or treatment
  
• Evening primrose for eczema

• Effectiveness unlikely
• Acupuncture for body weight reduction
• Acupuncture for smoking cessation
• Flower remedies for anxiety
• Homeopathy for anxiety
• Spinal manipulation for asthma
• Spinal manipulation for infantile colic

Archives of Disease in Childhood 20069196-97
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Use of Herbs- Evidence?

• Alternative Health supplement of the 2002
  National Health Interview Survey data on 10
  common herbs
• Of 30,616 adults, 19 used herbs in past 12 mo,
  57 for a specific condition
• Approximately 2/3 used herbs (except Echinacea)
  not in accordance with evidence based indications
• Mayo Clin Proc, May 200782(5) 561-566

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Conventional Medicine, Evidence?

• Most conventional physicians believe in
  unconventional medicine because it is not
  scientific
• What is evidence-based medicine? Treatment that
  will improve patient outcomes by well-designed,
  appropriately powered, randomized, controlled
  clinical trials.
• There is not good evidence (Grade A) that many of
  the commonly used therapies in conventional
  medicine are effective (ex heparin, aspirin, and
  warfarin).
• The principal distinguishing characteristic of
  unconventional and conventional medicine
  therapies is the source of introduction.
• Conventional therapies are introduced by
  mainstream Western physicians and scientists,
  whereas most unconventional modalities are
  introduced by "outsiders."
• One of the reasons that most unconventional
  modalities are not evidence based is that the
  majority of them were introduced prior to the
  20th Century

Arch Intern Med. 19981582179-2181
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CAM Pediatric Care

• Evidence is lacking even for the most popular, if
  there is evidence, most is in adults
• However, the Institute of Medicine states the
  same principles and standards of evidence of
  treatment effectiveness apply to all treatments
  whether currently labeled as conventional
  medicine or CAM.
• Only 1/3-1/3 of patients or their parents
  reported CAM use to their doctors. Indicates a
  need to promote dialogue about CAM use between
  patients and their health care providers.

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Physicians Attitudes

• Survey sent to 660 physicians at the Mayo Clinic
  (233 responded)
• Three areas utilization, familiarity and
  attitudes
• Utilization
• 75 had never referred to CAM practitioner
• 44 said they would consider if available at the
  Mayo (lt46 years or female more likely)
• Less 25 discussed benefits or risks with CAM
• 57 thought incorporation of CAM would be have a
  positive impact on pt satisfaction

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Physicians Attitudes

• Familiarity
• Biofeedback, massage, chiropractic and relaxation
  therapies were the most familiar
• 59 were unfamiliar with energy healing, 53 with
  naturopathic medicine
• Of the 13 herbs listed, only 3 were commonly
  listed as familiar
• 66 were not familiar with feverfew and 52 were
  not familiar with Kava
• 49 of the physicians felt it was difficult or
  very difficult to find reliable information about
  herbs

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Physicians Attitudes

• 41 of the physicians neither agreed or disagreed
  that physician knowledge had an impact on
  patients health
• 52 felt physicians spiritual beliefs were
  important and 87 felt patients spiritual beliefs
  and practices were important
• 67 agreed some CAM therapies hold promise but
  70 felt current practices of CAM was a threat
  to the public health
• Most important factors in changing physicians
  attitudes were RCTs and evidence demonstrating
  mechanism
• 70 of the physicians felt Mayo clinic should
  provide proven CAM therapies

eCAM 20063(4) 495-501
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Federation of State Medical Board Guidelines
(excerpts)

• Patient evaluation Includes the use of
  non-conventional methods of diagnosis and
  treatment
• Consultation and/or referral to licensed or
  otherwise state-regulated health care
  practitioner- the Physician is responsible for
  monitoring the results
• Medical records should also document What
  conventional medical options have been discussed,
  offered, tried, or refused
• Education- All physicians must be "able to
  demonstrate a basic understanding of the medical
  scientific knowledge" connected with any CAM
  therapy

www.fsmb.org
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What to do.

• Be aware of the growing scientific evidence
  concerning the safety and effectiveness of
  relevant complementary, as well as mainstream,
  therapies.
• Balance the risks and benefits of any therapy
  before recommending a course of action, and
  continue to monitor patients appropriately.
• Discuss and document with patients and their
  families any information regarding treatment
  decisions, conventional or CAM.
• Know professional guidelines including ethics

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CAM Education in Pediatrics

• CAM education in medical schools
• American Academy of Pediatrics (AAP)
• Pediatric Integrative Medicine Leadership
  Initiative and Pediatric Integrative Medicine
  Conference (PIMC)
• International Pediatric Integrative Medicine
  Network (IPIM-N)
• Canadian network linking pediatric CAM
  researchers educators (PedCAM)

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CAM Education in Medical Schools

• 1998 survey found 75 medical schools (out of 125)
  offered CAM electives or including these topics
  in required courses
• 81 of the schools that included CAM in the
  curriculum did so by adding stand alone courses
  or electives, 41 used required courses, and 23
  had both stand-alone and in required courses
  JAMA. 1998280784-7
• Barriers included lack of money, lack of time to
  plan and prepare, and outright animosity on the
  part of faculty.
• unscientific, lack of mechanistic explanation or
  demonstrated clinical efficacy.if taught could
  be viewed as advocacy
• Change is occurring
• Harvard Division for Research and Education in
  Complementary and Integrative Medical Therapies
• Albert Einstein, Columbia, Duke, Mount Sinai,
  Stanford, Arizona, Maryland, Pennsylvania, and
  several branches of the University of California
  have included CAM in the curriculum

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How to Include CAM in Education

• Teach One Medicine
• Create Opportunities for Cross-Fertilization
• Develop Support and Commitment from the
  Institution
• Offer a Well-Designed Electives
• Include an Experiential Component (acupuncture,
  massage, homeopathy, craniosacral etc)
• Plan across the Curriculum from Undergraduate to
  Graduate and Continuing Medical Education (often
  a void during residency and fellowships)

Wetzel MS, et al. Ann Intern Med 2003 138 1916
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Current Status - AAP

• Provisional Section on Complementary, Holistic
  Integrative Medicine (CHIM)
• Kathi Kemper, Chair for Holistic and Integrative
  Medicine and Professor of Pediatrics, Wake Forest
  University
• Section will promote policies to enhance
  patient-centered care, integrating
  evidence-based, safe and effective complementary
  therapies
• Meetings
• Super CME Courses
• AAP National Conference October 2007
• Four sessions by CHIM members

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Current status - PIMC

• Pediatric Integrative Medicine Conference
• Collaboration of academic faculty at multiple
  pediatric integrative medical centers in
  US/Canada
• 1st-2000, University of Arizona, Tucson
• 2nd-2001, University of Minnesota, Minneapolis
• 3rd- 2005, New York Academy of Medicine, NYC
• 4th- 2006 October, 27-29th, Chicago
• 5th- 2007, October 26-27th, San Francisco
• http//www.pangeaconference.com/index.asp

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Current Status - IPIM-N

• International Pediatric Integrative Medicine
  Network
• List serve connecting PIM practitioners and
  organizations
• Facilitates communication and collaboration
• Promotes clinical, educational and research
  initiatives
• Provides resources and links
• Secure electronic network
• ldrdoc_at_alum.mit.edu

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Resource Evaluation

• Introduction
• Who runs this site?
• Who pays for the site?
• What is the purpose of the site?
• Where does the information come from?
• What is the basis of the information?
• How is the information selected?
• How current is the information?
• How does the site choose links to other sites?
• What information about you does the site collect,
  and why?
• How does the site manage interactions with
  visitors?

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A Guide for Providers Using CAM

• Government sites
• National Center for CAM
• http//nccam.nih.gov/
• Office of Dietary Supplements
• http//ods.od.nih.gov/Research/CARDS_Database.asp
  x
• MedWatch
• http//www.fda.gov/medwatch
• CAM on PubMed
• http//www.nih.gov/news/pr/feb2001/nccam-05a.html
  

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NCCAM Website

• AcupunctureArthritisBlack CohoshCancerChelatio
  nChiropracticChondroitinDepressionDietary Supp
  lements
• EchinaceaEphedraGinkgoGinsengGlucosamineHerbs
  at a GlanceHomeopathyMenopauseSt. John's Wort

• Introduction to Naturopathy
• New Herbs at a Glance Grape Seed Extract
• AARP/NCCAM Report on Older Americans
• Past Highlights
• News from NCCAM 
• Subscribe to quarterly newsletter
• Monthly e-bulletin

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A Guide for Providers Using CAM

• Academic sites
• Boston-Longwood Herbal Task Force
• http//www.longwoodherbal.org/
• University of Pittsburgh
• http//www.pitt.edu/cbw/database.html
• Beth Israel Medical Center NYC
• http//www.healthandhealingny.org/
• Columbia University
• http//www.rosenthal.hs.columbia.edu/Botanicals.h
  tml
• University of California, Berkeley Newsletter
• http//www.wellnessletter.com/html/ds/dsSupplemen
  ts.php

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Longwood Website

• ABC's of Herbal Medicine Herbs Dietary
  Supplements Vitamins MineralsIn-depth
  Monographs (71) Clinician Information
  SummariesPatient Fact Sheets Articles by LHTF
  MembersInteractions and Toxicity Information
  Resources LinksAbout the LHTF  How to Support
  the LHTF

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Courses and Websites

• Herbs and Dietary Supplements-Wake Forest
  University
• http//northwestahec.wfubmc.edu/learn/herbs/index.
  aspCurrDesc
• Botanicals and Health series-University of
  Arizona
• http//integrativemedicine.arizona.edu/online_cour
  ses/botanicals
• Botanical Medicine in Modern Clinical Practice
  (NYC)
• http//cait.cpmc.columbia.edu88/dept/rosenthal/Bo
  tanicals_CME.html
• Consumer Labs
• http//www.consumerlab.com
• Natural Medicines Comprehensive Database
• http//www.therapeuticresearch.net/(ctt54155qny2vs
  55ryiv2d32)/home.aspx?li0st0cssND
• Quackwatch http//www.quackwatch.com.

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Consumer Labs

• ConsumerLab.com, is a provider of independent
  test results and information to evaluate health,
  wellness, and nutrition products.
• 2.5 millions visits/year and as a certification
  company, CL enables companies of all sizes to
  have their products voluntarily tested for
  inclusion in its list of Approved Quality
  products and bear the CL Seal.
• In the past 7 years, tested more than 1,800
  products, representing over 350 different brand
  and supplements. One-year (12 months)
  subscription is 27.00
• Natural Products Encyclopedia and free newsletter

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Natural Medicine Database

• Search - enter natural product name, disease or
  condition, or drug name objective product
  information, Effectiveness Ratings, or potential
  interactions with drugs
• Natural Product Effectiveness Checker - tells you
  the level of effectiveness for natural products
  used for various medical conditions.
• Natural Product / Drug Interaction Checker -
  tells you potential interactions between any
  natural product and any drug.
• Disease / Medical Conditions Search - shows you
  medical conditions, and allows you to see which
  natural products might be effective.
• Search Colleagues Interact - shows you questions,
  answers, and comments posted by other health
  professionals.

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Fellowships and Residencies

• University of Arizona Associate Fellowship
• http//www.integrativemedicine.arizona.edu/af/inde
  x.html (residential and associate)
• Family Practice and CAM residencies
• Albert Einstein College of Medicine
• Maine Medical Center
• Middlesex Hospital Family Practice Residency
  Program
• Oregon Health Science University
• University of Arizona College of Medicine
• University of Wisconsin Madison

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CAM Local Resources

• Stanford Center for Integrative Medicine (SCIM)
• http//www.stanfordhospital.com/clinicsmedServices
  /clinics/complementaryMedicine/default
• Osher Center for Integrative Medicine
• http//www.osher.ucsf.edu//
• Five Branches Institute
• http//www.fivebranches.edu/
• College of Botanical Healing
• http//www.cobha.org/
• Ryan Ranch, Integrative Medicine
• http//www.ryanranchmedicalgroup.com/integrative_m
  edicine.htm

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