According to the World Health Organization, between 65% and 80% of the world’s health care services are classified as traditional medicine. These practices become relabeled as complementary, alternative, or unconventional medicine when they are used in Western countries. In April 1995, a panel of experts, convened at the National Institutes of Health (NIH), defined complementary and alternative medicine (CAM) as “a broad domain of healing resources that encompasses all health systems, modalities, practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period.” Subsequent surveys of CAM use by the public and health care providers have defined it as those practices used for the prevention and treatment of disease that are not an integral part of conventional care, and are neither taught widely in medical schools nor generally available in hospitals. Table 49-1 lists the major types/domains of complementary and alternative medicine, while recognizing there can be some overlap, adapted from the National Center for Complementary and Alternative Medicine (NCCAM) at NIH.

Use of Complementary and Alternative Medicine

Practices that lie outside the mainstream of “official” or current conventional medicine have always been an important part of the public’s management of their personal health care. Complementary, alternative, and unconventional medicine has become increasingly popular in the United States. Two identical surveys of unconventional medicine use in the United States, done in 1990 and 1996, showed a 45% increase in use of CAM by the public. Visits to CAM practitioners increased from 400 million to over 600 million per year. The amount spent on these practices rose from $14 billion to $27 billion—most of it not reimbursed. Recent data from the National Health Interview Survey (NHIS) has increased this estimate to $33.9 billion. Professional organizations are now beginning the “integration” of these practices into mainstream medicine. In 2002, the number of CAM use was similar between 1997 and 2002 (36.5% vs 35.0%, respectively P = 0.21). The greatest relative increase in CAM use between 1997 and 2002 was seen for herbal medicine (12.1% vs 18.6%, respectively) and yoga (3.7 vs 5.1%, respectively), while the largest relative decrease occurred for chiropractic (9.9%-7.4%, respectively).

The public uses these practices for both minor and major problems. Multiple surveys have now been conducted on populations with cancer, human immunodeficiency virus (HIV), children, minorities, and women on CAM use. Rates of use are significant in all these populations. For example, more than 50% of women surveyed have been found to explore and use CAM both for themselves and as health care decision makers for their family. A recent national survey showed that 12% of children use CAM regularly. More than 68% of patients with cancer and HIV will use unconventional practices at some point during the course of their illness. Immigrant populations often use traditional medicines they experienced in their country of origin and not commonly used in the West.

The public’s interest and activity in CAM has increasingly resonated with the concurrent recognition that allopathic medicine cannot treat and solve many of the symptoms associated with acute and chronic illness. As a result, increasing scientific, educational, and clinical attention and resources have been committed to this area. Biomedical research organizations are investing more into the investigation of these practices. For example, the budget of the Office of Alternative Medicine at the US National Institutes of Health rose from $5 million to the present $123.1 million in 10 years and changed from a coordination office to an NCCAM. The fiscal year 2009 appropriation for NCCAM is $125,471,000, which represents a +2.7% increase over the fiscal year 2008 appropriation of $122,224,000. During fiscal year 2008, 210 new and ongoing research project grants, 10 small business research grants, 6 centers, 52 career development awards, 16 other research grants, 27 individual training grants, 10 institutional training grants, and 2 research contracts were funded by the NCCAM. NCCAM-supported studies, now carried out at more than 260 institutions, encompass the wide range of CAM practices and have resulted in more than 1500 scientific papers published in peer-reviewed journals.

More than 95 of the nation’s 125 medical schools require their medical students to take either formal or informal elective CAM coursework. However, the extent to which CAM coursework has become part of both medically and surgically based residencies is not clear. An increasing percentage of hospital systems and individual hospitals have developed complementary and integrated medicine programs that are offered to inpatients on written orders from the attending physician and/or in their outpatient areas. Some health management organizations are offering “expanded” benefits packages that include specific alternative practitioners and services with a reimbursement option. A recent survey of CAM use in the US hospitals showed that 37% of hospitals offer CAM services. The majority of all services are offered on an outpatient basis, with massage therapy (54%), acupuncture (35%), and relaxation training (27%) among the most popular. On an inpatient basis, the top modalities offered are pet therapy (46%), massage therapy (40%), and music/art therapy (30%).

One result of these activities has been the translation of the terms CAM and allopathic medicine into the term integrative medicine. The Consortium of Academic Health Centers for Integrative Medicine has defined integrative medicine as the practice of medicine that reaffirms the importance of the relationship between practitioner and patient; focuses on the whole person; is informed by evidence; and makes use of all appropriate approaches, health care professionals, and disciplines to achieve optimal health and healing. The application of integrative medicine can be defined as the purposeful, coordinative application of appropriate preventive and treatment modalities that support and stimulate the patient’s inherent healing preferences and self-recovery capacities. As such, these are treatments that are derived from the variety of practices and health care systems from around the world. Thus, the term integrative medicine has adopted concepts from various movements such as CAM person-centered care, humanistic medicine, holistic health care, and the medical home.

CAM, and more specifically integrated medicine, is finding a growing place in American medical practice. Undoubtedly, various facets of it will continue to be debated informally among medical staff and individual physicians and formally in peer-reviewed essays and clinical research, as well as medical societies, academies, and organizations. And importantly, the individual Western-trained medical doctor will continue to be the primary arbitrator and counselor for the patient through the time-honored fundamentals of the therapeutic alliance; that is, compassion coupled with trust, integrity, and empathy; concern coupled with caring and active listening; competence coupled with skill, intellect, and common sense; and communication coupled with availability, continuity, and follow-through.

Conventional Physician Use of CAM

Conventional physicians are not only frequently faced with questions about CAM, but also refer patients for CAM treatment and, to a lesser extent, provide CAM services. A review of 25 surveys of conventional physician referral and use of CAM found that 43% of physicians had referred patients for acupuncture, 40% for chiropractic services, and 21% for massage. The majority believed in the efficacy of these three practices. Rates of use of CAM practices ranged from 9% (homeopathy) to 19% (chiropractic and massage). National surveys have confirmed that many physicians refer for and fewer incorporate CAM practices into their health care management.

Risks of CAM

The amount of research on CAM systems and practices is relatively small compared with that on conventional medicine. There are over 1000 times more citations on conventional cancer treatments in the National Library of Medicine’s bibliographic database, MEDLINE, than on alternative cancer treatments. With increasing public use of CAM, and too often inadequate communication between patients and physicians about it, and few studies on the safety and efficacy of most CAM treatments, a situation exists for misuse and harm from these treatments. Many practices, such as acupuncture, homeopathy, and meditation, are low risk but require practitioner competence to avoid inappropriate use. Botanical preparations can be toxic and produce herb-drug interactions. Contamination and poor quality control also exist with these products, especially those harvested, produced, and shipped from Asia and India.

Potential Benefits of CAM

CAM practices have value for the way we manage health and disease. In botanical medicine, for example, there is research showing the benefit of herbal products such as ginkgo biloba for improving conditions due to circulation problems (though not Alzheimer disease) benign prostatic hypertrophy with saw palmetto and other herbal preparations, and the prevention of heart disease with garlic. A number of placebo-controlled trials have been done showing that Hypericum (St. John’s wort) is effective in the treatment of depression, although recent studies in the United States have cast doubt on the general validity of those studies. Additional studies report that Hypericum is as effective as some conventional antidepressants but produces fewer side effects and costs less. However, the quality of too many of these trials does not reach the standards set for drug research in this country. Thus, physicians need to have and apply basic skills in the evaluation of clinical literature.

What is the role of the family physician in the management of CAM? The goal is to help patients make informed choices about CAM as they do in conventional medicine. Specifically, physicians must continue to apply the ethical principle of beneficence, and play the role of patient advocate—a provider who protects, permits, promotes, and partners with patients about CAM practices as appropriate.

Protecting Patients from Risks of CAM

Many practices, such as acupuncture, biofeedback, homeopathy, and meditation are low risk if used by competent practitioners. But importantly, when used in place of more effective treatments, they can result in harm. The practitioners who apply these modalities should be qualified to help patients avoid inappropriate use. Many herbal preparations contain powerful pharmacologic substances with direct toxicity and herb-drug interactions. Contamination and poor quality control occur more often than with conventional drugs, especially if preparations are obtained from overseas. The family physician can help distinguish between CAM practices with little or no risk of direct toxicity (eg, homeopathy, acupuncture) and those with greater risk of toxicity (eg, megavitamins and herbal supplements). Physicians should be especially cautious about those products that can produce toxicity, work with patients so they do not abandon proven care, and alert patients to signs of possible fraud or abuse. “Secret” formulas, cures for multiple conditions, slick advertising for mail order products, pyramid marketing schemes, and any recommendation to abandon conventional medicine are “red flags” and should be suspect.