A Practical Approach to Complementary and Alternative Medicine (CAM) Reid Blackwelder, M.D., FAAFP (blackwel@etsu.edu) Professor and Chair, Family Medicine Quillen College of Medicine, ETSU Goals People utilize many therapies not prescribed Recognize some of the more common modalities being used Give you some new tools to use Mess with your minds! Definitions and terms Eisenberg s definition (Harvard 1992) Not taught in US medical schools Not available in US hospitals Not reimbursed by third party payers Medical curricula changing Over 2/3 of schools have some courses Hospital and practice milieu changing Planetree PCMH Definitions and terms Complementary Used with conventional medicine Alternative Used in place of conventional medicine Uncommon they don t see you! Integrative Bringing conventional and complementary approaches together in a coordinated way NIH: Complementary Health Approaches Definitions and terms Western based often called Traditional 80% world uses traditional healing systems Western medicine unavailable, unaffordable Many cultures healing approaches are available now Often only aspects though! Who uses CAM? Who has seen a patient who is doing something you have not prescribed? Who knows someone close to you that does so? People who see doctors, too 36% with some use per several studies So, complementary use 1
Who uses CAM? Spans people of all backgrounds. Greater by: Women than men People with higher educational levels People who have been hospitalized in the past year Former smokers, compared with current smokers or those who have never smoked 10 most commonly used CAM modalities (NIH 2012) Natural Products 17.7% Deep breathing 10.9% Yoga, Tai Chi, Qi Gong 10.1% Chiropractic or OMM 8.4% Meditation 8.0% Massage 6.9% Special Diets 3.0% Homeopathy 2.2% Progressive relaxation 2.1% Guided Imagery 1.7% Most Common Conditions for which People use CAM Backpain Headcold Neck pain Joint pain Arthritis Anxiety/Depression Stomach upset Headache Recurrent pain Insomnia Why should you learn about CAM? Potential effects Especially interactions of supplements and herbs with prescription drugs Patients health care philosophy Techniques and products become mainstream OMM Acupuncture Hypnosis Herbs and supplements Placebo Effect Redefining views Treatment ally All treatments can have a specific effect All treatments have some healing effect All encounters have potential effect Key part of a good bedside manner Randomized Double-Blind Controlled Studies Current "standard Only 20% current medical practices supported by RDBC trials (1996) Changing as more evidence-based reviews done Recognize not knowing about the Evidence for something Does not equal the absence of evidence! 2
Patient-Centered Reframe I don t have a treatment for cancer NIH: National Center for Complementary and Integrative Health but I have lots of things I can do for you Categories Two Main Complementary Health Approaches Natural Products Herbs Vitamins Minerals Probiotics Mind and Body Practices Yoga Chiropractic, OMM Acupuncture Whole Medical Systems Complete systems of theory and practice TCM, Ayurveda, Homeopathy, tribal Patients get long sessions and intense interaction with practitioner Often access only parts of these systems (acupuncture, herbs) Insurance covers acupuncture in more and more cases Whole Medical Systems Implications for Medicine in the US: Mainly cultural & regional Some systems w/botanicals Acupuncture Stress reduction Respiratory difficulties Pain syndromes N/V from chemotherapy Well-supported for stroke rehab Chelation for CAD Disodium EDTA infusion Anecdotal and non-randomized studies report dramatic symptom relief NIH Trial TACT Trial to Assess Chelation Therapy) Modestly reduced CV events in older adults who had suffered a prior MI Impact actually in patients with DM 41% reduction for any CV event Adding high dose vitamins increased effect 3
Chelation for CAD Not enough evidence to make this a routine approach TACT2 in process May end up with FDA approval! Stents for CAD Compare with EB for stents Changing landscape No change in mortality from stents vs other approaches J Am Coll Cardiol 2016;68:29-36 CABG, as compared with PCI with DES, significantly reduced the long-term risk of mortality in nondiabetic patients with multivessel CAD Rate of MI lower after CABG Biologically Based Practices A major factor in all healing systems 25% US pharmacopoeia comprised of plants; 50% plant-based Digoxin, foxglove and pharm Different types/systems: Teas and capsules and tinctures, oh my Easily accessible Top Supplements Fish oils/omega supplements Echinacea Ginseng Ginkgo Garlic Glucosamine St. John s Wort Peppermint Ginger Soy supplements Evening Primrose Oil Herbs and Drugs Herbs as Drugs Herbs Are drugs! They have effects because of active chemical compounds We do not always know which ones do what! They tend to have lower concentrations of the active components So take longer to act Generally are safer But that is a relative term Natural does not mean safe! Anything that can have an effect can have a bad effect! 4
Botanical/Phytopharmaceuticals Side effects and Interactions Dr. Tiorona Low Dog In terms of plants, I really think people should sit in a garden with them rather than take them as an herb. It is just substituting one drug for another. Can be caused by contaminants Especially Chinese herbs Interactions are likely fairly common Most people taking herbs also take prescription drugs Most people take concentrated extracts and not whole plant which changes constituents Herb Interactions Often from effects on cytochrome P450 Very often are theoretical Not necessarily proven Considered possible Controversial Especially during cancer treatments Top Herbs and Effects Black Cohosh For menopausal symptoms Data not yet clear on safety in women with hormone sensitive breast cancer Garlic Used for lowering cholesterol May have small effect May help lower BP but weak evidence Ginkgo biloba Does not help memory, or cognitive decline Interactions and the Top Herbs Grapefruit Juice Works on an enzyme in the stomach Can affect drug absorption Delays some and increases others Drink it separately from any prescribed drug Interactions and the Top Herbs St. John s Wort Extensive research Mixed support for use in mild to moderate depression Many real and potential drug interactions Main take-home!! 5
Interactions Potential concerns Commonly raised Some cases get major press Standardization issues are critical For perspective, however 200-400,000 deaths/yr from ADR to correct prescription drugs used properly Fourth leading cause of death in US "All illness is psychosomatic" Weil Enhance mind's ability to affect bodily function and symptoms Types: Yoga Chiropractic, OMM Biofeedback, imagery, relaxation, meditation, hypnosis, movement therapies Manipulation or movement of one or more body parts Osteopathy, Chiropractic, Therapeutic Touch Value of touch and hands-on approach Conflicting views on mechanism and efficacy Chiropractic reimbursed; available without referral Implications for Medicine in the US: Almost any condition can be approached and helped manually Hard to find DOs who do OMM Techniques available for nonosteopaths Implications for Medicine in the US: Yoga/PT Relaxation breath for panic attacks Hypertension treatment options Hypnosis for anesthesia Operating Room Emergency Room Bedside manner 6
Medicine and Healing Our Health Care System" Doesn t support health It is an Anti-Disease system at all levels No belief in body s natural tendency toward health and balance Tends toward frustration, anger In users And providers Attitude and Healing Our jobs/lives create daily opportunities Patients come to us at their most vulnerable Even though we may be frustrated by our system We need to help be the calm guide for our patients We know the value of compassion Studies support positive attitudes and healing Energy Medicine Based on premise of bioelectric fields Anything to this? What about EEG, EKG, MRI? Energy Medicine Implications for Medicine in the US: Most common use magnets for pain Testimonials Anything to these claims? Overall studies not of good quality or inconclusive Early studies encouraging for diabetic nerve pain (Am Jour Pain Management 1999) What do you do? Energy Medicine Woo-Woo Remarkable research at U of AZ by G. Schwartz (The Living Energy Universe) Do you believe in Physics? Tuning forks and energy transmission Where does the energy measured by the EKG go once it leaves the skin? Keep an open mind Diet and Nutrition By definition included in CAM Lack of training in medical education Health oriented Ornish integrative system Reversal of CAD Only slight change, but real 7
Diet and Nutrition - Implications Many fad diets on the market Some with risky recommendations Need to explore diet history Many supplements available Limited info/data High cost Emerging research Omega 3s - heart healthy and good! Mediterranean Diet - ditto! Ceremony - priceless! Bottom Lines Make this practical Practice Mind-Body Medicine Communication skills & tolerance Behavior/Lifestyle Issues Key Be patient-centered Engaged and present Maintain compassion Keep your mind open Empower yourself! Explore your interests Experiential as well as intellectual Thanks for your time Enjoy the experience! 8