Objectives. Integrative East West Medicine for Chronic Conditions. What is CAM? OBJECTIVE 1

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1 Objectives Integrative East West Medicine for Chronic Conditions Dawn M. Upchurch, PhD, LAc Professor Department of Community Health Sciences 1. Discuss prevalence of complementary & alternative medicine (CAM) for chronic symptoms/conditions 2. Describe Traditional Chinese Medicine (TCM) & how it can be used to supplement standard care 3. Learn indications, benefits, side effects, & practical applications of TCM 4. Counsel patients & families about benefits of patient empowerment & holistic approach 1 2 What is CAM? Prevalence of CAM & Prevalence of Use for Chronic Symptoms & Conditions OBJECTIVE 1 National Center of Complementary & Integrated Health (NCCIH) of the NIH Formally NCCAM Defining CAM is difficult because field is broad & changing & conventional medicine (CM) is increasingly incorporating CAM modalities Boundaries between CAM & CM not absolute 3 4

2 What is CAM? Complementary Medicine Used together with CM Use of acupuncture to help with nauseas associated with chemotherapy Alternative Medicine Used in place of CM Acupuncture to treat osteoarthritis of knee instead of NSAIDS Integrated Medicine Combines CM treatments & CAM for which there is high quality evidence for safety & effectiveness Tai chi practice among breast cancer patients 5 6 Types of CAM NCCIH now recommends complementary health approaches 1. Natural Products Herbs (botanicals) Vitamins, minerals, probiotics Other OTC supplements 2. Mind & Body Practices Acupuncture Massage therapy Meditation & relaxation techniques Movement therapies Spinal manipulation & chiropractic Tai chi, qi gong, yoga TCM is really whole systems medicine 7 CAM use increasing National Health Interview Survey (NHIS) 2007 Nationally representative sample of adults & children 2012 NHIS just released 8

3 Mostly NOT Chinese herbs (except for ginseng)

4 Describe Traditional Chinese Medicine (TCM) & How It Can Be Used to Supplement Standard Care OBJECTIVE Traditional Chinese Medicine Whole System Medicine Theoretical paradigms for Understanding the human body Differential diagnoses Treatment based on diagnosis Lifestyle recommendations Holistic approach to health & illness Prevention Empowerment 14 Many Modalities used in TCM Acupuncture Auricular acupuncture Herbs Note: herbs include plants, minerals, & animals Electrical stimulation acupuncture Cupping Gua sha (skin scrapping) Tuina (Chinese medicinal massage) Modalities in TCM con t. Qi gong & tai chi Lifestyle counseling Diet Stress management Primary health care provider in many states 15 16

5 Practitioner Training Varies by state 43 states accredited by National Certification Commission for Acupuncture & Oriental Medicine (NCCAOM) Includes Oregon 6 states no Acupuncture & Oriental Medicine (AOM) act California own licensure & testing Combined acupuncturist & herbalist 4 + years, 970 clinic hours Practitioner Training: 3 or 4 year Programs TCM & Standard Care Chinese Medical Theory (1 yr) Chinese Internal Medicine (1+ yrs) Meridian Theory (1 yr) Acupuncture Techniques (1 + yr) Single herbs (1 yr) Pharmacognosy Herbal formulas (1 + yr) Other Case review History Qi development Basic Sciences Biology, chemistry, physics Anatomy & Physiology (1 yr) Pathophysiology (1 yr) Clinical Medicine (3 qtrs) Laboratory Methods & Tests (2 qtrs) Pharmacology (2 qtrs) Observation & Clinical Internships hours National Testing & Licensure (except CA) How might TCM modalities be used to supplement standard care? Several TCM modalities can be used to assist treatment for a number of conditions (next objective) Acupuncture Tuina & other massage Herbs Prevention & lifestyle focus* Patient centered emphasis* 19 20

6 Case study: Venice Family Clinic Provides no/low cost integrated care Integrated Chronic Pain Management Stress Management Program Health and Wellness Promotion Utilizes CAM modalities beyond TCM But the focus is on prevention, wellness, & empowerment Indications, Benefits, Side Effects, & Practical Applications of TCM OBJECTIVE Who Uses TCM for What & Why? Upchurch & Rainisch, 2014 Acupuncture prevalence US (NHIS 2007) 6.8% lifetime; 1.5% past 12 mo. Continues to increase Higher in states like OR & CA (~15%) Chinese Herbal Formulas Not used as much as acupuncture Difficult to determine Tai chi, meditation, some lifestyle components (diet) more common Who Uses TCM for What & Why? Upchurch & Rainisch, 2014 Acupuncture users more likely to be: Female Asian or white Middle aged or older Higher education & income Live in the West Doesn t appear to depend on health insurance status or lack of access to conventional care Have poorer health but also healthier lifestyles (??) 23 24

7 Acupuncture Usage Patterns Upchurch & Rainisch, 2014 Acupuncture Usage Patterns Upchurch & Rainisch, 2014 Primarily pain & musculoskeletal conditions Mostly used in conjunction with conventional care Acupuncture Usage Patterns Upchurch & Rainisch, 2014 Acupuncture: What is the Evidence? Few users stopped because of side effects Cost doesn t appear to be a barrier for most Lack of public awareness of possible benefits Medical skepticism minor 27 28

8 Acupuncture Evidence Several decades of RCTs: literally 1000s First generation Testing safety, efficacy, dosage Few adverse effects; safety issues; must be used properly Limitations: many pilot trials; heterogeneous protocols; sham arm Later: larger, multi site trials Second generation Building evidence Meta analyses, systematic reviews Effectiveness/pragmatic trials Evidence base for Acupuncture Summary: Meta analyses & high quality trials Acupuncture effective for/help ease chronic pain such as: Low back pain Neck pain Osteoarthritis/knee pain May reduce frequency of tension & migraine headaches May help with certain symptoms associated with cancer treatments Some Evidence for Acupuncture RCTs on a number of conditions: Treatment for menopausal hot flashes IBS; other digestive disorders Dysmenorrhea Depression/anxiety As a complement with infertility work up PTSD: military using Many others being conducted see:

9 Low Back Pain Systematic review (Yuan et al., 2008) Strong evidence for combining acupuncture with usual care helps more than usual care alone American Pain Society & American College of Physicians 2007 Recommended acupuncture as one non drug approach physicians should consider when patients do not respond to self care practices Knee Pain & Osteoarthritis Knee pain & osteoarthritis See Vickers et al. meta analysis Verum acupuncture more helpful than sham or no acupuncture Tension & migraine headaches Systematic reviews: Linde et al., 2008; 2009 Verum vs. sham or pain relieving drugs helped tension headaches Adding acupuncture to basic care for migraines helps to reduce frequency (but evidence not strong) References & other studies provided in the appendix 35 36

10 Herb Cautions Chinese Herb Research 100s of herbs Herbs used in combinations as formulas Rarely prescribe single herbs Non US herbs caution Herbalists should be licensed (many are not) Not all acupuncturists in OR are also licensed herbalists (unlike CA) Many being investigated by NIH researchers Do exhibit medicinal properties in additional to side effects & drug interactions Examples: RCT: Chinese herb thunder god vine (lei gong teng) not inferior to methotrexate for treatment of RA Qing hao (artemisia anna) for malaria treatment CAUTION ALWAYS for pregnant & breastfeeding women; For more information: NCCIH bsataglance.htm WHO Monographs on Medicinal Plants cs/en/d/js2200e/ FDA ysupplements/ Drug interactions: Medline Plus eplus/druginfo/herb_all.html Huang Qi (Milk Vetch) Some Common Chinese Herbs with Known Drug Interactions Astralagus membranaceus; mongholicus TCM uses: Support & enhance immune function; colds; fatigue; edema; ulcer/sores China: chronic hepatitis & adjunctive for cancer treatment Evidence limited: some support for immune support & cancer adjunctive CAUTION: May interact with medications suppress immune system (e.g., cyclophosphamide) 39 40

11 Dong Gui, Dong Quai (Angelica) Gan Cao (Licorice Root) Angelica sinensis; polymorpha TCM uses: Menstrual conditions; blood deficiencies; pain; constipation; anticoagulant Evidence limited CAUTION: potentiates effects of anticoagulants (e.g., clopidogrel, dicloenac, dalteparin, enoxaparin, heparin, wafarin, others) Glycyrrhiza glabra; uralensis TCM uses: 3 sweets : in majority of Chinese formulas; respiratory conditions; spasms; pain Evidence: OK for eczema & dyspepsia; otherwise limited CAUTION: many drugs Warfarin; antihypertensives; corticosteriods; diuretics; digoxin; estrogens; furosemide; drugs affecting cytochrome P40 2C9 Increases BP; NaCl & H20 retention, lower K Steroidal properties DGL (deglycyrrhizinated licorice) safer RenShen(Chinese Ginseng) Panax ginseng TCM uses: Very potent; boost health; immune function; fatigue; shortness of breath; diabetes; stress Evidence: COPD; mental functioning/alz; mixed for rest. Many RCTs underway CAUTION: estrogens; furosemide; insulin; antidiabetics; drugs affecting cytochrome P450 2D6 Counsel Patients & Families about Benefits of Patient Empowerment & Holistic Approach OBJECTIVE

12 Recommendations for Integrating TCM with Conventional Care Recognize role of acupuncture earlier in treatment of potentially disabling & chronic conditions Clinically, acupuncture often last resort Physicians can be more proactive in helping patients decisions about treatment if aware of options that have good evidence Refer or integrated team of providers Integrative Medicine and the Health of the Public, IOM Principles of Integrative Medicine Place the individual at the center Individual care Welcome family & loved ones Maximize healing influences within care Maximize healing influences outside care Rely on sophisticated, disciplined evidence Use all relevant capacities waste nothing Connect helping influences with each other Perspectives on Integrative Medicine Vision of optimal health Conceptually inclusive: physical, psychological, social, preventive therapeutic Person centered Prevention oriented Team based Integrates care, caring, & science Thank you! Dr. Dawn M. Upchurch UCLA Fielding School of Public Health upchurch@ucla.edu 47 48

13 Appendix Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine. 2007;147(7): Ezzo J, Richardson MA, Vickers A, et al. Acupuncture point stimulation for chemotherapy induced nausea or vomiting. Cochrane Database of Systematic Reviews. 2006;(2):CD [edited 2011]. Linde K, Allais G, Brinkhaus B, et al. Acupuncture for migraine prophylaxis. Cochrane Database of Systematic Reviews. 2009;(1):CD Appendix Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture for chronic pain: individual patient data meta analysis. Archives of Internal Medicine. 2012;172(19): Yuan J, Purepong N, Kerr DP, et al. Effectiveness of acupuncture for low back pain: a systematic review. Spine. 2008;33(23):E887 E900. Other references: NCCIH: Linde K, Allais G, Brinkhaus B, et al. Acupuncture for tension type headache. Cochrane Database of Systematic Reviews. 2009;(1):CD Manheimer E, Cheng K, Linde K, et al. Acupuncture for peripheral joint osteoarthritis. Cochrane Database of Systematic Reviews. 2010;(1):CD