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The use of complementary and alternative medicine (CAM) has been increasing every year in the United States. In 1993, Dr. David Eisenberg of Harvard Medical School released a landmark study in The New England Journal of Medicine that showed one third of Americans were using unconventional medicine such as aromatherapy, acupuncture, and therapeutic touch. In May 2004, the National Center for Complementary and Alternative Medicine (NCCAM) and the National Center for Health Statistics (NCHS; part of the Centers for Disease Control and Prevention) released the results of the 2002 National Health Interview Survey (NHIS). This comprehensive report on the use of CAM in the United States concluded that as many as 62% of adults 18 years of age and older use some form of CAM. The most commonly used CAM modality in 2002 was herbal therapy (18.6%, representing more than 38 million U.S. adults), which was followed in frequency by relaxation techniques (14.2%, representing 29 million U.S. adults) and chiropractic medicine (7.4%, representing 15 million U.S. adults). Among CAM users, 41% had used two or more CAM therapies during the prior year. Factors associated with highest rates of CAM use were patients aged 40 to 64 years, female gender, nonblack/non-Hispanic race, and annual income of $65,000 or higher (Tindle et al, 2005). This trend continues.
Based on these statistics, this chapter is included in Pharmacology for the Primary Care Provider, fourth edition. Although a high level of scientific study and knowledge of all these products or techniques does not exist, and the information in this chapter must of necessity be somewhat brief, it is clear that primary care providers must have some exposure to the range of CAM practices because patients are using them. In general, not enough research has been done regarding CAM and various products to scientifically support or discredit their use, although European scientists have focused more attention on researching these products than have U.S. scientists. At this time, definitive conclusions cannot be drawn regarding the use of CAM, particularly the biologicals. Much of what appears in the literature continues to be based on observational reports and small studies although the number of scientific studies is increasing.
Defining Complementary and Alternative Therapies
Complementary, alternative, nontraditional, unconventional, and “Eastern” medicine are terms that are used interchangeably to describe diverse medical and health care practices considered outside the realm of conventional or allopathic medical therapies that have yet to be validated by scientific methods (Straus, 2002). The term complementary describes therapy used to supplement more traditional medical care, and the term alternative suggests that therapy has taken the place of usual medical therapy. Complementary or alternative medicine is the term most frequently seen in the lay literature. Integrative medicine is a term that is used to describe the appropriate use of conventional and alternative methods to facilitate the body’s innate healing response. Integrative medicine shifts the orientation of medicine to one of healing rather than disease and uses an approach that engages the body, mind, spirit, and community. It has also been defined as “the evidence-based combination of conventional with CAM for assuring the maximum therapeutic benefit for patients and practitioners” (Pelletier, 2007a). The NIH National Center for Complementary and Alternative Medicine (http://nccam.nih.gov) has identified five broad categories of CAM and integrative medicine for which a growing and substantial body of evidence about these techniques is based on research and clinical practice. The current literature describes the following (Pelletier, 2007a):
Now that some CAM modalities, such as guided imagery and massage for pain treatment, have been formally tested and integrated into standard practice, the distinction between CAM and mainstream medicine has become less apparent in some clinics and hospitals. The terms holistic medicine or integrative medicine are being increasingly substituted for CAM.
In a report by the American Association of Pediatrics on CAM, the task force says the following:
Holistic medicine refers to patient-centered care that includes consideration of biological, psychological, spiritual, social, and environmental aspects of health. . . . Integrative medicine is relationship-based care that combines mainstream and complementary therapies for which there is some high-quality scientific evidence of safety and effectiveness to promote health for the whole person in the context of his or her family and community. Integrative medicine also reaffirms the importance of the relationship between the practitioner and the patient, emphasizes wellness and the inherent drive toward healing, and focuses on the whole person, using all appropriate therapies to achieve the patient’s goals for health and healing.
Primary Care Providers and Complementary and Alternative Therapies
Patient interest has far outpaced the resources of the traditional health care system; standard texts and reference books do not cover herbs, supplements, and homeopathic remedies. Many patients believe they know more than their health care providers, and their providers are not listening to them or respecting their choices. Responsible providers seek reliable information about the choices their patients are making so they can provide better advice and treatment.
A poster presentation at a Sigma Theta Tau International conference discussed research showing 74% of the APRNs reported asking their patients about over-the-counter use, but only 35% inquired about herbal product use. The most commonly discussed herbal products were ginseng (15%), glucosamine and chondroitin (14%), echinacea (13%), St. John’s wort (9%), and ginkgo biloba (9%). Seventy-five percent of the APRNs rated their knowledge of OTCs as good to excellent, while 86% believed they had only a fair to poor understanding of herbal products (Waszak, 2004).
It is crucial for primary care providers to have up-to-date, balanced, and scientifically founded reference materials to assist them in understanding nonconventional therapy as they learn about the strengths, weaknesses, clinical indications, proper dosages, toxicities, and interactions of different therapies. It is important for primary care providers to be familiar with the many products available to patients that do not require a prescription. Many of these products contain ingredients that are useful in the treatment of common ailments. If primary care providers are familiar with these products and their ingredients, they can help patients choose the safest product for their ailment in the context of their present state of health or illness. It should be noted, however, that some of the active ingredients in these products may interact with prescribed medications or may even complicate existing medical conditions.
A growing body of knowledge is available to inform practitioners. Integrative medicine is part of a rapidly evolving face of health care that ushers in an era of genomics, international medicine, and evidence-based approaches (www.nap.edu/catalog/11182.html). Lack of knowledge about these techniques has caused practitioners to acknowledge and address the need for an adequate “evidence-based” foundation in conventional, CAM, and integrative medicine. The goal is to provide evidence-based standards by which all medicine should be judged and that will help both providers and patients as they consider new approaches to the treatment of old problems.
A good first approach regarding patient-initiated and controlled therapy is to obtain a thorough medication history because many patient-initiated alternative treatment remedies are purchased over the counter and patients often neglect to tell their providers about them. More than 70% of patients who use complementary therapies do not tell their providers of the use. Although easy availability of herbal and over-the-counter products makes many Americans consider these products safe, the fact is that not all herbal therapies are safe for all patients. General knowledge about patient-initiated products enables providers to evaluate specific regimens that their patients report taking; this decreases the potential for negative outcomes when products that may be harmful are used. (Kennedy, 2005).
Even providers who take a drug history from patients may focus on prescription drug use and may fail to adequately document other product use. Questions regarding alternative treatments should be a routine part of the patient’s medication history. Specific questions that may be asked include the following:
It is also important to have patients bring in any products they are using to each office visit so an accurate record may be maintained. Original containers for these products provide additional information that assists the practitioner in evaluating their safety. These steps may be important in preventing dangerous drug interactions and complications.
When obtaining a history about complementary health measures, primary care providers should try to remain as nonjudgmental or neutral about alternate primary care remedies as possible. This approach is essential in earning patients’ trust so they will answer completely and honestly. Providers should understand that patients who use alternative therapies or complementary treatments do so for many reasons:
Complementary Therapies and Herbal Medicine
Complementary and alternative therapies in general have been somewhat mysterious, and the scientific basis for their therapeutic action is often uncertain. Over the past several years, as research and interest in this area have increased, more universities and medical schools are incorporating the use and teaching of complementary/alternative modalities, and many are conducting research in this area. In 2000, 64% of medical schools were offering courses that addressed complementary and alternative therapies. The number of CAM practitioners in the United States is projected to increase by 88% between 1994 and 2010, and the number of conventional physicians who incorporate CAM into their practices will increase by 16% (Breuner, 2006).
Because of the widespread use of complementary therapies, interest in the scientific study of various products is growing. In 1991, the Office of Alternative Medicine (OAM) was established within the NIH, and an Alternative Medicine Advisory Council was established in 1993. In November 1995, the NIH established the Office of Dietary Supplements to promote the scientific study of dietary supplements. In October 1998, Congress mandated the establishment of the OAM NIH center—the National Center for Complementary and Alternative Medicine. In February 1999, a charter creating NCCAM was signed, making it the twenty-fifth independent component of the NIH. In October 1999, NCCAM and the NIH Office of Dietary Supplements established the first Dietary Supplements Research Center, with an emphasis on botanical medicine. Since its inception, NCCAM has funded multiple studies, which are summarized on their website. Particular evaluation of herbal products is also available through NCCAM (http://nccam.nih.gov/health/herbsataglance.htm).
Common Complementary and Alternative Practices
NCCAM has classified complementary and alternative modalities into five domains: alternate medical systems, mind–body interventions, manipulative and body-based methods, energy therapies, and biologically based therapies.
Alternative Medical Systems
Alternative medical systems are complete systems of theory and practice. Non-Western systems, such as traditional Chinese medicine and Ayurveda, are ancient systems that have been used for thousands of years, whereas systems developed in Western cultures, such as naturopathic medicine and homeopathic and osteopathic systems, have evolved apart from conventional allopathic medical practices used in the United States.
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