Integrative Medicine: What the Health

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Integrative Medicine What the Health?

• Lisa W. Corbin, MD
• Medical Director, Integrative Medicine
• University of Colorado Denver Anschutz Medical
  Campus
• Associate Professor, Internal Medicine

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Objectives

• After this talk, you should be able to
• Define CAM, Integrative Medicine
• Discuss the basic background, risks, and
  benefits of some common CAM therapies
• Discuss CAM with patients (or self!)
• Identify qualified CAM practitioners
• List resources for finding more information

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What is Integrative Medicine?
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What is Integrative Medicine?
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Real Definitions

• CAM
• Complementary / Alternative Medicine
• Therapies not usually associated with hospitals
  or medical schools
• Acupuncture, Massage Therapy, Chiropractic
• Integrative Medicine
• CAM therapies coordinated with conventional
  medical treatments

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Who Uses CAM Therapies?
Adults, 2002 incidence of CAM use

• Over 80 also using conventional medicine

Barnes PM. www.cdc.gov/nchs/data/ad/ad343.pdf
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Why Discuss CAM in the SOP?

• Pharmacists viewed by public as among the most
  trusted, accessible HCP
• Pharmacists report being asked about CAM
  therapies by patients
• 68 of senior students at UMinn SOP hoped to be
  able to have CAM therapies available in their
  practices

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Why Discuss CAM in the SOP?

• U Minn SOP survey 83 of students wanted CAM
  education
• 73-86 of SOP offer some CAM in curriculum, but
  mostly electives, focus on natural product

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• CAM Potential Risks

• CAM Potential Benefits

• Directly harmful treatment
• Indirectly harmful treatment
• Reducing efficacy of conventional treatment
• Replacing curative conventional care
• Cost

• Symptom control
• Reduce use of medications with side effects
• Better tolerance of curative conventional care
• Empowering to patient
• Less cost
• Less risk

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Balancing Risks and Benefits

• Discuss CAM openly
• Normalize the behavior
• Why?
• Enhance HCP / patient relationship
• Improve health
• Dissuade from harmful practice
• Encourage beneficial treatments
• Integrate care with all providers
• Be informed about specific risks and benefits

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CAM Considerations

• Avoid harmful practices
• Use evidence-based, safe therapies
• Consider plausible, safe modalities

Hippocrates First, do no harm
Sugarman J, Burk L. Physicians ethical
obligations regarding alternative medicine. JAMA
1998280(18)1623-1625.
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Harmful CAM Therapies

• Colonic enemas
• Chelation therapy
• IV therapies
• Restrictive diets
• Megavitamins
• Some herbs / supplements
• Direct toxicity
• Indirect drug interactions
• Stimulate tumor growth, immune system
• Anything used IN PLACE OF proven, curative,
  conventional treatments

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Therapies to Highlight

• Mind / body techniques
• Sleep
• Exercise
• Acupuncture
• Massage
• Chiropractic
• Herbs and supplements
• Chinese Herbs

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Why Mind-body?

• Perception of pain requires processing by the
  mind mind-body therapies can alter perception
• Stress / anxiety perceived as a threat, processed
  by the mind as equivalent to pain
• Insomnia worsens pain
• Mind-body therapies are generally safe
• Caution with blame the victim

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Mind-body Therapies

• Cognitive Behavioral Tx
• Relaxation techniques
• Breathing techniques
• Stress management
• Biofeedback / heart math
• Art, music, pet therapy
• Mindfulness / Meditation
• Imagery / visualization
• Yoga / tai chi
• Hypnosis

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Mind-body Details

• Typically meet with therapist 5 10 visits
• Patient needs to practice at home
• Not all therapists comfortable with all methods
• Often covered by insurance
• Workbook
• Caudill, Margaret. Managing Pain Before It
  Manages You, Revised Edition (Paperback)

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Mind-body Highlighted Uses

• Stress reduction
• Anxiety, depression, insomnia
• Grieving / acceptance
• Behavior change
• Symptom management
• Pain (FM, muscle pain, HA)
• Dyspnea (COPD, VCD)
• Nausea

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Get Some Sleep!

• Restorative sleep improves pain, fatigue, and
  mood
• Sleep deprived normals develop chronic pain
• Links breast cancer, weight gain
• Behavioral approaches
• Dont eat, drink, exercise just before bed
• Avoid late day caffeine , too much alcohol
• Get consistent exercise earlier in the day
• Pay attention to room environment
• Establish consistent sleep times
• Get out of bed if not tired
• Dont nap

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Exercise Highlighted Uses

• Improves sleep, depression, anxiety -improving
  overall health
• Duh cholesterol, weight, BP, DM
• Wow!
• Decreased pain in arthritis
• Decreased hot flashes
• Improvement in BMD
• One of the cornerstone treatments for
  fibromyalgia and chronic fatigue
• Dramatic reduction of breast CA recurrence
• Improvement in immune function
• Too much decreased immunity

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Exercise Instruction FIT

• F requency
• Exercise every day
• I ntensity
• Break a sweat increase difficulty of exercise
• T ime
• Start with 5 minutes daily, increase by 1 minute
  daily each week goal 30 minutes / day

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Acupuncture

• Chinese Medicine Background
• Health balance of yin and yang
• Qi energy force created by interaction
• of yin and yang
• Meridians channels that carry qi throughout the
  body each corresponds with a specific organ
• Excess, deficiency, or stagnant flow of qi
  results in disease
• Examples of TCM diagnoses
• Yin deficiency and yang predominance with reduced
  kidney qi
• Stomach qi rebelling

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Acupuncture

• Western Medicine Background
• Osler, 19th century
• best treatment for lumbago
• James Reston, China, 1971
• Biological effects
• Local nerve activation
• Endorphins, ACTH, endogenous opiods (reversal of
  analgesia with naloxone)
• SPECT scanning increased activity and reversal
  of asymmetry in chronic pain patients in thalamic
  and prefrontal cortex during acupuncture over
  baseline

Han JS. Neurosci Lett 2004361(1-3)258-61.
Newberg AB et al. J Neuroimaging
200515(1)43-9 Mayer (1977) Brain Res
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General Advice Acupuncture

• Acupuncture is generally safe
• Adverse events minor or rare (pain, bleeding,
  fatigue)
• Disposable needles, alcohol wipes to avoid
  infection
• Practitioners
• Must have a license in CO (LAc) scope of
  practice for MD, DO, DC
• TCM National Certification Commission for
  Acupuncture and Oriental Medicine
  (www.nccaom.org)
• MD American Academy of Medical Acupuncture
  (www.medicalacupuncture.org)
• Costs
• Initial / follow up 80 (MD 175) / 55 (MD
  100)
• Covered by some insurances

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Acupuncture Highlighted Uses

• WHO - Chronic pain of any etiology
• Fibromyalgia / myofascial pain
• Low back, neck pain
• Headaches
• Carpal tunnel
• Osteoarthritis
• IBS
• Depression / anxiety
• Fertility / menstrual irregularity
• Nausea (chemo, pregnancy, post op)

Acupuncture. NIH consensus statement
199715(5)1-34.
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Massage Therapy

• Developed by almost all cultures
• Many different forms
• Emphasis on improving circulation, releasing
  muscle tension, calming and relaxing patient

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General Advice Massage

• Generally safe. Use caution with
• Congestive heart failure
• Infections
• Blood clots / bleeding disorders
• Osteoporosis or bone metastases
• Pregnancy
• A license is NOT required in Colorado
• Look for CMT or LMT
• Look for involvement in AMTA (www.massagetherapy.o
  rg)
• 60 / hour, occasionally covered

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Massage Therapy Highlighted Uses

• Relaxation, improved QOL
• Post-operative wound healing
• Lymphedema treatment
• Pain management
• Musculoskeletal complaints
• Tension headaches
• Fibromyalgia

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Chiropractic

• Manipulation referenced by Hippocrates Galen
• Daniel David Palmer, 1895
• Normalization of the nervous system is key to
  health
• CAM vs. subspecialty

• Manipulation often exercises, fitness, general
  health advice acupressure, supplements
• Practice styles, practice philosophies vary

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Chiropractic General Advice

• Safety
• Generally safe
• Local discomfort, headache, fatigue
• Excessive xrays from some DCs
• Stroke, dislocation, fracture rare but possible
• Risk of serious complication estimated at 6.39
  per 10 million cervical manipulations (3.2 per
  1000 for NSAIDS)
• Avoid high velocity neck manipulation
• Caution cerebrovascular disease, osteoporosis,
  rheumatoid arthritis, metastatic cancer, bleeding
  disorders

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Chiropractic General Advice

• Practitioners
• 4 year accredited school
• Philosophies and styles vary widely
• Licensing required in 50 states scope of
  practice variable
• Costs / reimbursement
• Initial / follow-up 35 - 150 / 25 - 50
• OMT usually covered chiropractic often covered

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Chiropractic Highlighted Uses

• Back pain
• Neck pain
• Headaches
• Other msk complaints

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Herbs and Supplements

• Three types of medicines
• Prescription (Rx)
• Over-the-counter (OTC)
• Dietary Supplements
• Unlike Rx and OTC, supplements
• Are not required to prove safety or efficacy
• Burden of proof on FDA to show unsafe
• Are not required to enforce quality control
• GMP to be required beginning in 2008
• Can vary in concentration of ingredients

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General Advice Supplements

• Natural ? safe
• Use extra caution when taking prescriptions
• Herb / drug interactions may be dangerous
• Use trustworthy resources for information
• If you choose recommend supplements
• Look for well-labeled brands
• Avoid combination products, MLM
• Ask all patients about use!

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Manufacturers More Likely to Produce Quality
Products

• Natures Way
• Natures Made
• Natures Bounty
• Costco
• Phytopharmica
• Puritans Pride

Susan Paulsen, PharmD, personal communication -
2007
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Supplements to Avoid

• Vitamin E
• (No) benefit, meta-analysis revealed toxicity at
  higher doses
• St. Johns wort
• Too many drug interactions, ? DNA damage
• Phytoestrogens in women with breast cancer risk
• No evidence they are any safer
• All supplements - pre-op
• Blanket statement stop all products 2 weeks
  prior to surgery / upon hospital admit
• Beware of metabolic / pharmacokinetic implications

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Supplements to Consider

• Multivitamin
• But latest data doubts benefit good diet likely
  better
• Calcium (women)
• 1000 - 1500 mg / day total
• Vitamin D
• Most Americans deficient
• Cancer prevention, muscle pain
• Fish oil (Omega 3 FA)
• Heart disease, TG, HTN, HA, weight loss,
  depression, cancer prevention

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Supplements to Consider

• Probiotics
• Infectious diarrhea, IBD, IBS, antibiotic
  associated diarrhea
• Coenyme Q10
• Deficiencies beta blockers, statins, CHF
• May help statin-associated muscle pain, reduces
  doxirubicin cardiac toxicity

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Chinese Herbals

• Traditional Chinese Medicine (TCM) uses
  acupuncture, cupping, diet, exercise and Chinese
  Herbal Medicines (CHM)
• In TCM theory, herbs are always given as
  mixtures, with emperor (main) herbs and
  helper herbs the mixtures are thought to be
  more effective and also with less side effects
• Because of the use of mixtures, CHM is more
  complicated and patients should avoid
  self-medicating with these products

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Chinese Herbals

• Common adverse reactions
• GI intolerance (diarrhea, gas, bloating)
• Headaches,
• Insomnia
• Pruritis
• More serious adverse reactions
• Anaphylactic shock
• Liver or kidney failure
• Miscarriage
• To help assure safety when using CHM
• Consult with professionals educated in CHM
• Intermittent use (1-2 week break every 3-6
  months)
• Periodic self assessment
• Seeking reputable manufacturers (GMP)
• Exercise caution with liver and kidney
  dysfunction, other meds

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Finding a Good Practitioner

• Training and licensure
• Experience with symptom
• Risks
• Costs / reimbursement
• Time frame / progress assessment
• Ability to work with conventional physicians

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What the Health!

• Integrative medicine coordinates CAM with
  conventional care
• Dont use harmful CAM therapies
• Use beneficial, safe therapies
• Consider plausible, safe therapies
• Talk to your patients
• Throw them a bone approach
• Find good practitioners
• Use reliable information sources

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The Center for Integrative Medicine

• University of Colorado Hospital
• Anschutz Medical Campus
• 720-848-1090
• www.uch.edu/integrativemed

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• General Assessment / Oversight
• Lisa Corbin, MD
• Traditional Chinese Medicine
• Daisy Dong, L.Ac
• Mel Drisko, L.Ac
• Massage therapy
• Molly Monahan, CMT
• Ann Mathews, CMT
• Nutritional Counseling
• Colleen Gill, RD
• Pamela Ham, RD
• Pharmaceutical / Herbal Consults
• Susan Paulsen, Pharm D
• Chiropractic
• Brian Enebo, DC
• Behavioral Medicine / Biofeedback
• Bennett Leslie, PsyD
• Denise McGuire, PhD

Clinical Care
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Access to Services

• Referrals
• Self referred
• UCH physician or provider referred
• Outside physician or provider referred
• Insurance / authorizations checked
• Visits scheduled
• With specific practitioner, and / or
• With Medical Director to explore all options and
  make a personalized plan

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Integration of Care

• Notes for each visit available in EMR
• Referral letter written to physicians, other
  providers, and patient
• Formal case reviews
• Integrates the care from within TCFIM
• Further integration with other care providers

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• www.imconsortium.org
• 39 member schools in US, Canada
• Collaboratively working to promote Integrative
  Medicine care, education, and research
• Resource to learn from each other

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Education UCD-AMC

• Resident elective (est. 1999)
• Medical student elective (2003)
• Medical student required lectures
• Herbal pharmacology / small groups
• Chiropractic theory and practice
• Advising patients on use of CAM
• Formal classroom teaching in PT and Pharmacy
  Schools (required courses)
• Lectures in CHA/PA training

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Education

• Other medical professionals / CME
• Public education support groups
• School of Nursing, Metro separate courses
• Half-day shadowing experiences

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Research

• CAMPUS group
• REST study
• Demographic descriptive articles
• Reviews

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Future directions

• Clinical Care
• Expand outpatient services
• Develop satellite programs
• Education
• CME conferences, lectures
• Hands-on time

• Research
• Participate in campus-wide projects
• Fund small grants
• Follow treatment-specific clinical outcomes data