Complementary

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Complementary Alternative Medicine

• Rosalie C. Diaz, Psy.D. UTMB-SAHS 2006

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What is it?

• 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 Practices

• Biologically based practices use substances found
  in nature, such as herbs, special diets, or
  vitamins (in doses outside those used in
  conventional medicine). 
• Energy medicine involves the use of energy
  fields, such as magnetic fields or biofields
  (energy fields that some believe surround and
  penetrate the human body). 
• Manipulative and body-based practices are based
  on manipulation or movement of one or more body
  parts. 
• Mind-body medicine uses a variety of techniques
  designed to enhance the mind's ability to affect
  bodily function and symptoms. 
• Whole medical systems are built upon complete
  systems of theory and practice. Often, these
  systems have evolved apart from and earlier than
  the conventional medical approach used in the
  United States.

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Methods of CAM

• Megavitamin and Orthomolecular Therapy
• Diet Therapy
• Acupressure
• Acupuncture
• Hypnotherapy
• Relaxation
• Meditation and Mindfulness
• Transcendental Meditation
• Imagery
• Music Therapy
• Sound Healing
• Art Therapy
• Light Therapy
• Aromatherapy
• Chelation Therapy
• Behavioral Kinesiology

• Psychic Surgery
• Medical Acupuncture
• Phytomedicine
• Shamanistic Practices
• Spiritual Healing
• Massage, Rolfing, Reflexology
• Therapeutic Touch
• Qigong
• Yoga
• Cranial/Sacral Therapies
• Bioenergetics and Orgonomic Medicine
• Biofeedback
• Behavioral Medicine
• Magnetic Therapy
• Iridology
• Electrodermal Diagnostics

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Factors that influence the spectrum

• Availability
• Research Support
• Medical Evaluation
• Licensing
• Reimbursement
• Feasibility
• Theoretical/Explanatory Model

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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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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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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.

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NCCAM, National Institutes of Health 2004
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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 Personal?

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

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Is CAM "Non-scientific" Practice?

• Conventional scientific base
• 20 - 50 backed by quality research
• Mind/Body and Behavioral Medicine
  Diet and Nutritional
  Supplements
• Homeopathic
• 150 controlled clinical trials
• 15-20 of studies "good"
• Herbal medicine
• Ginkgo biloba
• Hypericum
• Garlic, Ginseng, Echinacea, Ginger, Cranberry

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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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NCCAM, National Institutes of Health 2004
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Physician Use of CAM
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Physician Use of CAM
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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
• http//nccam.nih.gov
• www.nationalstandard.com
• www.mdanderson.org
• http//www.drweil.com
• http//cam.utmb.edu/resources.asp

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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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• Hoodia Gordonii
• New miracle pill from the Kalahari desert
• 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)
• 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)

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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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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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Advising patients about CAM

• Have you tried any other treatment approaches for
  this problem?
• Have you ever seen a CAM practitioner for this
  problem?
• Have you ever tried changing your diet because
  you thought it might help this problem?
• Have you used any herbal or natural remedies that
  you have bought from a pharmacy or health food
  shop?
• What was it that encouraged you to try CAM?
• What are your goals in using this treatment?
• Why did you choose this particular intervention
  or treatment?
• How did you select this particular provider?
• Did the intervention help?
• Did the intervention result in new problems?
• Would you like to ask your CAM therapist to let
  me know about your treatment and progress?