Complementary, Alternative, Holistic, Integrative

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Complementary, Alternative, Holistic, Integrative
Medicine

• Meeting Patient Needs

Sara Warber, MD Co-Director, Michigan Integrative
Medicine and CAM Research Center Assist
Professor, Dept of Family Medicine University of
Michigan
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CAM - Whats in a Name?

• Alternative, unconventional
• Complementary
• Holistic
• Integrative

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Objectives

• Why CAM is important
• What patients are using
• Introduction to broad categories of CAM
• How to evaluate the evidence

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Importance

• Prevalence of use
• Potential application when effective
• Potential risks
• Doctor-Patient Relationship

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Early Indicators

• 1990 national telephone survey
• 1/3 of patients use alternative methods
• 72 of users did NOT inform their physician

Eisenberg, et al. NEJM 1993 328246-52.
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Follow-up Study

• 1997 study of 2055 households
• 42 used at least 1 of 16 therapies
• Disclosure rates did not improve

Eisenberg DM, et al. JAMA 1998 280(18)1569-75.
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CAM Spending

• 36 - 47 billion in 1997
• 12 - 20 billion for the services of
  professional CAM health care providers
• 5 billion on herbal products
• gt out-of-pocket for all hospitalizations

Eisenberg DM, et al. JAMA 1998 280(18)1569-75
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CAM Use 2002 (n31,044)
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Why do patients use CAM?

• National survey 1035/1500 responses
• 40 had used CAM in past year
• 4.4 primarily relied on CAM
• Perceived benefits
• Relief of symptoms
• Treatment works better than standard therapy

Austin JA. JAMA 1997279(19)1548-53.
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Predictors of CAM Use

• Cultural creative
• Transformational experience
• Holistic philosophy
• Poorer health
• More educated

• Specific health problems
• Anxiety
• Back problems
• Urinary tract problems
• Chronic pain

Austin JA. JAMA 1997279(19)1548-53.
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What are patients goals?

• 30 Prevention
• 44 Wellness
• 79 Specific Problems
• Back Pain
• Headache
• Anxiety
• Etc

Elder NC, et al Arch Fam Med 1997
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What do Michiganders use? (n3764)
Rafferty et al, AJPH 200292(10)1598-9
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Alternative Medical Systems

• Traditional Chinese
• Ayurvedic
• Native American
• Homeopathy
• Naturopathy
• Anthroposophic

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Alternative Medical Systems

• Different views of body, illness
• Different basis for knowing
• Different diagnoses
• Different treatments

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Meta-analysis of Homeopathy

• Like cures like
• 89/186 trials met quality criteria
• Homeopathic remedy vs. placebo
• Odds ratio 2.45 (2.05-2.93) for homeopathy
• Homeopathic effects not completely due to placebo

Linde K, et al. Lancet 1997350834-843
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Manipulative Body-based Methods

• Chiropractic
• Massage
• Acupuncture
• Acupressure

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Manipulative Body-based Methods

• Different understanding of the body
• Meridian system
• Physical methods of treatment

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Acupuncture

• 1996 FDA approves single-use needles
• 1997 NIH Consensus Conference
• Safety
• adverse effects substantially lower than many
  drugs

• Nausea
• chemotherapy
• surgical anesthesia
• pregnancy
• Pain
• post surgical
• musculoskeletal

Http//altmed.od.nih.gov/oam/cam/1998/jan/acupunc
ture
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Mind-body Interventions

• Hypnosis
• Meditation
• Biofeedback
• Imagery
• Yoga
• Tai Chi
• Prayer/mental healing
• Art, Music, Dance

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Mind-body Interventions

• Engages mind and body in healing process
• Emphasis on healing rather than curing
• Emphasis on meaning of illness
• Relaxation response
• Psycho-neuro-immunology

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Meditation for Stress Reduction

• Animal studies chronic stress Þ Ý basal
  cortisol, ß response to stress Þ disease
• Prospective, randomized study TM vs. stress
  education
• ß basal cortisol, Ý response to stress
• TM technique reverses effects of chronic stress
  significant for health

MacLean CR, et al. Psychoneuroendo.
199722(4)277-95.
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Biologically Based Therapies

• Herbal Medicine
• Nutritional Approaches
• Pharmacological Therapies

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Herbal Medicine

• Indigenous medicine
• European phytomedicine
• German Commission E
• Historical use as evidence
• Scientific evidence

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Nutritional Approaches

• Diet-based therapies
• Megavitamins
• Food intolerance

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Vitamin E Coronary Artery Ds

• 20 of population taking Vit E.
• Anti-oxidant highly associated with LDL
• Epidemiologic evidence
• Nurses Health Study
• Health Professionals Follow-up Study

• Prospective secondary prevention
• CHAOS 800 IU Vit E ß MI by 77
• HOPE trial - no effect
• Safety do not use with warfarin
• Dose 100 - 1000 IU daily

Sorrentino M. Alt Med Alert 19981(2)20-22.
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Pharmacological Therapies

• Alternative drugs or vaccines
• Chelation
• Cartilage products
• Apitherapy

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Long term effects of Glucosamine on
Osteoarthritis

• RCT 1500 mg glucosamine vs. placebo daily
• 212 subjects x 3 years duration
• Joint space narrowing -0.06 mm (-0.22 to 0.09)
  vs. -0.31 mm (-0.48 to -0.13)
• WOMAC symptom scale glucosamine improved
  symptoms, placebo worsened

Reginster, et al. Lancet 2001 357 251-6
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Energy Therapies

• Pulsed EM fields / DC fields
• Magnetic fields
• Therapeutic Touch
• Polarity therapy
• Reiki

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TT worse than Mimic TT TT better than
Mimic TT
1
2
3
4
5
8
9
All
-10
-20
0
10
20
Difference in Mean Improvement Therapeutic
Touch minus Mimic TT
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Evidence Based Medicine

• Nov, 1992 A new paradigm emerges
• Randomized controlled trials, meta-analysis
• Clinical experience misleading
• Mechanisms insufficient
• Apply rules of evidence
• Produce better outcomes

EBM Working Group. JAMA 1992268(17)2420-2425
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Evaluating the Evidence

• Ask a question
• Exposure ?? patient ?? outcome
• Glucosamine ? my pt ? better??
• Search the literature
• Evaluate the evidence

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Levels of Evidence
Clinical Practice Guidelines
Meta-analysis
Prospective clinical trial
Retrospective report
Case report Case series
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When Evidence is Incomplete

• Evaluating harm
• Risk/benefit ratio
• n of 1 trial

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Evaluating Harm

• Randomized controlled trial
• Be wary of case reports

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Risk/Benefit Ratio

• Risk
• Side effects
• Toxic effects
• Withholding other treatment
• Cost
• Time
• Environmental

• Benefit
• Physical
• Mental
• Emotional
• Spiritual
• Social
• Environmental

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n of 1 Trial

• You your patient become the scientists
• Decide what symptoms to address
• Decide what outcomes are important
• Document test
• Apply intervention
• Re-document test
• Discuss together

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What to look for in your career

• More patient demand for Integrated care
• Access to discounted CAM services
• Bilingual colleagues
• More educational opportunities