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Overview of Complementary, Alternative & Integrative Medicine

Anne Nedrow, M.D. Medical Director, Womens Primary Care/Integrative Medicine Center for Womens Health Oregon Health & Sciences University 12/2/04

Components of Healthcare
Surgical and Emergency Medicine

Ingestive Therapies
Noningestive Therapies

Medicine (CAM) Statistics


30,000 herbs on the market currently Estimates of $30-40 billion dollars spent annually Eisenberg D. et al, JAMA, Nov 11, 1998(18) 1569-1575 Estimates of 42% of population use CAM currently Eisenberg D. et al, JAMA, Nov 11, 1998(18) 1569-1575 Sales of Metabolite 356 approached $1billion in 1999 Alternative Medicine Alert, January 2000

Why?

What is complementary and alternative medicine?


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. The list of what is considered to be CAM changes continually, as those therapies that are proven to be safe and effective become adopted into conventional health care and as new approaches to health care emerge.

National Initiatives in Complementary and Alternative Medicine Education in Allopathic Health Professional Learners
The National Center for Complementary and Alternative Medicine (NCCAM) R25 Education Grants http://nccam.nih.gov/ The Consortium of Academic Health Centers for Integrative Medicine (CAHCIM) www.imconsortium.org

History of NCCAM
October 1991 - $2 million dollars to establish Office of Alternative Medicine (OAM) within the NIH to study unconventional medicine practices October 1995 -A Research Centers Program is established to provide a nationwide focus for interdisciplinary CAM research in academic institutions October 1998 OAM is elevated to NIH Center status and NCCAM is established. May 1999 NCCAM independently awards its first research project grant. 2002 budget exceeded $100 million with nearly $80 million in grant awards

NCCAM Classification of CAM therapies


http://nccam.nih.gov/health/whatiscam/

Alternative Medical Systems Mind-body interventions Biologically based Therapies

Manipulative and Body-Based Methods


Energy Therapies

Alternative Medical Systems


Alternative 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. Examples of alternative medical systems that have developed in Western cultures include homeopathic medicine and naturopathic medicine. Examples of systems that have developed in non-Western cultures include traditional Chinese medicine and Ayurveda.

Mind-Body Interventions
Mind-body medicine uses a variety of techniques designed to enhance the minds capacity to affect bodily function and symptoms. Some techniques that were considered CAM in the past have become mainstream (for example, patient support groups and cognitive-behavioral therapy). Other mind-body techniques are still considered CAM, including meditation, prayer, mental healing, and therapies that use creative outlets such as art, music, or dance.

Biologically Based Therapies


Biologically based therapies in CAM use substances found in nature, such as herbs, foods, and vitamins. Some examples include dietary supplements, herbal products, and the use of other so-called natural but as yet scientifically unproven therapies (for example, using shark cartilage to treat cancer).

Manipulative and Bodybased Methods


Manipulative and body-based methods in CAM are based on manipulation and/or movement of one or more parts of the body. Some examples include chiropractic or osteopathic manipulation, and massage.

Energy Therapies
Energy therapies involve the use of energy fields. They are of two types:
Biofield therapies are intended to affect energy fields that purportedly surround and penetrate the human body. The existence of such fields has not yet been scientifically proven. Some forms of energy therapy manipulate biofields by applying pressure and/or manipulating the body by placing the hands in, or through, these fields. Examples include qi gong, Reiki, and Therapeutic Touch. Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields, such as pulsed fields, magnetic fields, or alternating current or direct current fields.

National Center for Complementary and Alternative Medicine Education Grants


R-25 mechanism 15 funded nationally Up to 5 years in duration $1.5 million maximum Purpose to develop curriculum in complementary and alternative medicine for allopathic health professions students

R25 grantees
Georgetown University University of Michigan Maine Medical Center University of North Carolina Rush University College of Nursing Harvard - Childrens Hospital Boston Oregon Health & Sciences University University of Washington School of Nursing University of Washington School of Medicine University of Minnesota American Medical Student Association University of California, San Francisco Tufts University School of Medicine University Texas Medical Branch Kentucky Clinic

CAHCIM Members
Albert Einstein/Beth Israel Columbia University Duke University George Washington Georgetown Harvard OHSU University of CA/Irvine Thomas Jefferson University of Arizona University of Calgary University of Hawaii University of Washington University of California/LA University of California/SF University of Connecticut University of Maryland University of Massachusetts University of New Jersey University of New Mexico University of Michigan University of Minnesota University of Pennsylvania University of Pittsburgh University of Texas-Galveston

A graduating physician shall be able to: (knowledge)


Describe the distinction between integrative medicine (IM) and CAM. Describe the basic concepts of the most commonly used CAM modalities such as chiropractic, herbal and nutritional medicine, and mindbody therapies, and of one or more of the widely used traditional systems of medicine such as Chinese medicine and Ayurvedic medicine, including: Basic definitions/theory/philosophy/history Common clinical applications Potential for adverse effects Current research evidence for efficacy Reputable resources for in-depth information Training/credentialing standards for practitioners

Identify potential legal and ethical implications related to the inclusion or the exclusion of CAM modalities in a patient's treatment plan. Identify reputable information resources for CAM and IM in order to support life-long learning. Explain the current status of government regulation of herbal medicines and dietary supplements. Describe the evidence for mindbodyspirit relationships in illness and health. Describe the prevalence and patterns of CAM use in the patient's community.

A graduating physician shall be able to: (skills)


Demonstrate skills to communicate effectively: a. with patients about their use of CAM in a respectful and culturally appropriate manner; and Design a personal self-care program that includes: a. Learning to assess one's level of stress b. Implementing a self-care strategy (may include nutrition awareness, self-regulatory techniques, exercise, journaling, creative arts, spirituality, mindbody skills, etc.)

Demonstrate an ability to utilize the principles of evidence-based medicine in analyzing integrative medicine approaches, including: a. developing focused question regarding the application of IM principles or practices for an individual patient; b. utilizing databases, peer-reviewed publications, authoritative textbooks, Web-based resources, experiential knowledge of CAM practitioners, and participatory observation to gather relevant information; c. evaluating the information for scientific quality and clinical relevance; d. formulating a plan to implement findings in care of an individual patient; and e. evaluating the outcome of applying IM principles or practices in patient care.

The Continuum
CAM Skills

CAM Referral Base

CAM Literacy
CAM Consciousness

Licensure
CAM MODALITY
Chiropractors

LICENSURE
All states

Massage ther.
Naturopaths

27 states
13 states

Homeopaths
Acupuncturists

3 states
32 states

What is integrative medicine?


Integrative medicine, as defined by NCCAM, combines mainstream medical therapies and CAM therapies for which there is some high-quality scientific evidence of safety and effectiveness.

Recently Updated
Definition of Integrative Medicine (2003)
A healing-oriented medicine that takes account of the whole person (body, mind, and spirit), including all aspects of lifestyles. It emphasizes the therapeutic relationship and makes use of all appropriate therapies, both conventional and alternative.
Program in Integrative Medicine, University of Arizona Consensus of Fellows (Current and Graduated), 2003.

What Is Integrative Medicine?


Wellness

Patient Evidence Centered Care Based Cultural MedicinePower Sensitivity Of the Mind

Basic Science

CAM literacy

Changing Paradigms
Drugs and Surgery Mind Body Techniques Self Care

Risk-Benefit Analysis of CAM


Severity and acuteness of illness Curability with conventional treatment Degree of invasiveness, associated toxicities, and side effects of conventional treatment Quality of evidence of safety and efficacy of the desired CAM treatment Knowledge and voluntary acceptance of those risks by the patient Persistence of the patients intention to use CAM treatment
Ann Intern Med. 2002; 137:660-664

Pick Your Battles

Ethical Issues
Network marketing schemes Separation of church and medicine Legal implications of implicit knowledge Fraud and quackery Drug-herb interactions Quality control of OTC preparations Delay of Evidence-Based Medical treatments

Quick References
www.naturaldatabase.com ($92/yr) www.consumerlab.com ($15) www.intelihealth.com (free)

Mrs. E.R.
Multinutrient 6/day Taurine 500mg tid Tincture which includes coleus extract, Hawthorne, Hoxsey, licorice bid Magnesium glycinate 120mg tid Co-Q10 q d Fish oil concentrate tid Melatonin q d 5HTT (3 q hs) Betaine tid Vit E qod Black cohosh tid Thiamilate qd -two if having heart palpitations Homeopathic nerve tonic 6 tablets bid Calcium carbonate 2 qhs Tamoxifen 10mg bid Pre-op:
Phosphorus 9C qAM Staphysagria 30C qPM Arnika 9C (day of)

Mrs. P.G.
Chromium 100mg tid Garcinia cambogia 500mg tid Hydroxycitric 250mg tid Garlic powder 350mg tid Alph lipoic acid 100mg tid Evening primrose oil 500mg tid Quercetin 100mg tid Ginger root extract 50mg tid Dandelion root 130mg tid Alpha lipoic acid 70mg tid Gymnema Sylvestre 133 tid Banana leaf extract 5mg tid Colon Care fiber tid Multiple pancreatic enzymes Siberian Ginseng 67mg tid Holy Basil extract 67mg tid Vanadyl sulfate 33mg tid Cinnamon bark 100mg tid L-carnitine 200 mg bid Olive leaf extract 250mg bid Lemon balm 85mg bid B-complex q d Aspirin 81mg q d CoQ10 30mg q d Vit E 20 units tid 5-HTTP 50mg q d MSM 750mg bid-tid Glucosamine sulfate 657mg bid

The U.S. health care system is in need of fundamental changeHealth care today harms too frequently, and fails to deliver its potential benefits routinely. As medical science and technology have advanced at a rapid pace, the health care delivery system has foundered. Between the care we have and the care we could have lies not just a gap, but a wide chasm1
1 Institutes

of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C. National Academy of Sciences Press, 2001.

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