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An Introduction to CAM
Introduction
OAM, NCCAM, and the White House Commission on Alternative Medicine
Common Threads Through CAM Therapies
The Problem of Evidence and Experimental Design
CAM: A Confusion of Tongues
Working With Patients
The Future
Resources
References

Introduction

The term complementary/alternative medicine (CAM) embraces myriad healing systems, many with centuries of accumulated practitioner knowledge and experience. Several of the world's great healing traditions include a variety of therapeutic modalities: Ayurveda (the traditional healing system of India), Traditional Chinese Medicine (TCM), and Native American medicine systems each employ medicinal herbs, but in each system the choice of herbs, their formulation, and explanations of mechanisms of action are different. In the United States, such traditions and modalities have been labeled "alternative" for several reasons—scientific, cultural, and political. Varied in cultural underpinnings, worldviews, theoretical models, and therapies, all alternative medical practices by definition operate outside the Western biomedical model and have thus been seen to be unscientific by modern Western standards. Since medical systems are defined as much by cultural or social influences as by theoretical constructs, systems arising out of non-Western milieus will be fundamentally different from their Western counterparts. Finally, non-Western healing practices are considered alternative because decisions have been made not to teach them in United States medical schools, make them available to patients in hospitals, or cover them as benefits of health insurance.

The barriers to an integrative medicine are beginning to fall, or at least become less insurmountablebecome less formidable. Nonconventional healing practices are increasingly being investigated and validated—or in some cases invalidated—in well-designed research studies; the intermixing and growing interdependence of diverse cultures in the West are bringing once distant cultural perspectives into close proximity, and the institutions of Western medicine are beginning to respond. As of 1998, 75 out of 117 United States medical schools offer at least one course in CAM. In a survey published in 1994, 60 percent of physicians reported recommending CAM to their patients; 47 percent of the responding physicians acknowledged using CAM themselves. More and more health insurance plans are covering CAM, especially those modalities, such as acupuncture and chiropractic, whose safety and efficacy in the treatment of certain conditions has been well researched. A number of health plans now cover the Ornish cardiovascular rehabilitation program, which has a foundation in yoga and clinical nutrition, and the state of Washington now requires healthcare coverage of unconventional therapies even where there is no research supporting safety or efficacy. All indications point to the careful movement—often with a healthy dose of skepticism—toward an integrative medicine system that incorporates the most useful therapies from the world's many healing traditions.


OAM, NCCAM, and the White House Commission on Alternative Medicine

The movement toward integrative medicine in the United States has been catalyzed by a growing consumer demand for CAM services. Eisenberg et al, in a now famous study published in 1993, reported on the widespread use of CAM by American healthcare consumers. The study found, in part, that more than one-third of Americans had sought CAM therapies, that in 1990 they had made more visits to CAM providers than to their primary care physicians, and that the unreimbursed expense of these visits exceeded 13 billion dollars. In 1991, under a Congressional mandate, the National Institutes of Health (NIH) established the Office of Alternative Medicine (OAM) with an annual budget of 2 million dollars to coordinate NIH research on nontraditional health practices. Specifically, OAM was to evaluate CAM practices, support CAM research and training, and establish a CAM information clearinghouse for the general public.

In 1998 Congress established the National Center for Complementary and Alternative Medicine (NCCAM) to supersede the OAM. With a FY2000 budget of more than 68 million dollars, NCCAM's mission is to support basic and applied CAM research, including training in research methodology for CAM, and provide information to healthcare providers and the public. Among other efforts, NCCAM focuses on research that evaluates the safety and efficacy of herbal medicines and nutritional supplements and their potential for interaction with standard pharmaceuticals. It also evaluates such CAM modalities as acupuncture and chiropractic. NCCAM funds several research centers outside of the NIH (to learn more about the centers and their research agendas, visit NCCAM's web site at http://nccam.nih.gov/nccam/fi/research/centers.html).

In July of 2000, the White House announced the establishment of a White House Commission on Alternative Medicine, designating the Chair and the first 10 members. The charge to the commission is to develop a set of legislative and administrative recommendations to maximize the benefits of CAM for the American public. Going beyond the research goals of NCCAM, the commission will set the agenda for the education and training of CAM practitioners as well as provide policy recommendations for the insurance industry coverage of alternative therapies.


Common Threads Through CAM Therapies

While the histories, theoretical underpinnings, and practices of nonconventional healing traditions vary widely, several themes can be traced through them all:

a)The whole person—physical, emotional, social, and spiritual—is the healer's focus. Indeed, illness is often considered a manifestation of the loss of balance or right relationship among these personal aspects, and therapy is directed at restoring balance and integration.

b)Prevention of illness is a primary concern. But in contrast to the Western approach of pharmacotherapeutic or surgical intervention, CAM practitioners tend to call upon the participation of the individual, supporting that person's use of inner resources to maintain health. In this model, according to CAM anthropologist Marc Micozzi, MD, PhD, wellness results from the "balance of internal resources with the external natural and social environment."

c)Treatment regimes are highly individualized, devised in response to the unique totality of the individual rather than to a disease entity.

d)Treatment is directed at the causes of illness rather than at symptoms.

e)Treatment is designed to support what are seen as the natural healing processes inherent in all human beings.


The Problem of Evidence and Experimental Design

Another common theme running through healing systems not grounded in the biomedical model is an absence of scientific research supporting (or disproving) safety and efficacy. While the knowledge base for practitioners of CAM is provided by hundreds—in some cases thousands—of years of weeding out the unsuccessful from the successful therapies, those practicing in the Western conventional tradition look to scientific evidence for validation of therapeutic efficacy. This has been a major contributor to the slow pace of acceptance of CAM by the conventional medical community. (Ironically, while the numbers vary according to the source, the Office of Technology Assessment has estimated that "only 10 to 20 percent of all [standard] procedures currently used in medical practice have been shown to be efficacious by controlled trial.") Even though there exists a substantial body of well-designed research studies on CAM and the number of new studies being launched is growing, there are many CAM modalities that do not lend themselves to investigation with standard clinical research techniques (i.e., the randomized, placebo-controlled, blinded trial). Sham acupuncture or massage as placebo, for instance, has proven very difficult to devise or use successfully. Perhaps the most fundamental barrier to research investigations, however, has been CAM's typical practice of treating the person rather than the condition, thus eliminating the availability of standardized treatment protocols that can be applied to all subjects with the same diagnosis. While CAM researchers are becoming more clever and sophisticated in their study designs, it is unlikely that some popular and effective CAM therapies will ever find validation through the sort of clinical research that is currently being demanded by many in the medical community. Indeed, the challenge may be to sharpen the collection and use of data from case studies and other empirical sources.


CAM: A Confusion of Tongues

CAM relies on culturally based and therefore unique sciences and scientific vocabularies, making communication with Western practitioners difficult if not sometimes impossible. For example, a TCM practitioner will examine a patient to identify overall disharmony rather than simply an agent of disease; a resulting diagnosis of "dampness of the spleen" or "liver wind" is not likely to edify a Western clinician. However, with more cross training for physicians in alternative therapies, greater participation on the part of both conventional and alternative providers in integrative conferences and consultations, more CAM textbooks written for a Western audience, and more CAM courses being offered in United States medical schools, the barriers are lowering. Certainly, in learning to be comfortable with any new culture, immersion, not avoidance, is the answer.

Conventional medicine and CAM can no longer be an either/or proposition. The integration of the most useful therapies from all healing traditions has begun, driven largely by consumer demand. Increasingly, working with patients will mean taking a nonparadigmatic perspective on therapeutics, seeking out trusted colleagues with CAM experience for advice and support, and becoming informed about the most authoritative sources of clinical information on CAM modalities.


Working With Patients

As indicated above, Americans are turning to CAM in large and growing numbers. In many cases they do so without telling their physician for fear of being scolded. At the same time, they are increasingly bringing questions about CAM to their providers. To be able to respond to patients and to oversee a patient's total care, physicians need, at minimum, to learn about CAM and to keep the lines of communication open with their patients regarding their use of alternative therapies. The following guidelines may be helpful in responding to patients' interest in and use of CAM therapies.

a)Solicit from patients the details of their CAM use—therapies they may be using or are interested in, CAM practitioners they are seeing, their experiences with CAM therapy, and their perception of outcomes. Perhaps the number one concern for most physicians regarding their patients' use of CAM is that a patient will postpone needed treatment while he or she seeks alternative approaches, and in such cases a physician should try to dissuade such behavior. If unsuccessful, the physician should document the disagreement in the patient's record.

b)Inform patients about how to find the most qualified alternative providers. They can be coached to ask about a provider's certification and licensure and ask to see the appropriate certificates. Patients should then question the provider about any proposed treatment, its cost, duration, the changes they can expect in their condition and when, signs that the treatment is or isn't working, possible risks/side effects, and whether the practitioner is prepared to communicate with the patient's primary care physician regularly about his or her care.

c)If referring a patient to a CAM provider, make certain the provider is certified or licensed and carries malpractice insurance.

d)Having worked with the patient to establish expectations for improvement, monitor a patient's CAM treatment. If there is no improvement or there is deterioration in the patient's condition after an agreed upon course of treatment (say, six visits to an acupuncturist), the physician, together with the patient, can then reassess the treatment.

e)Many CAM therapies are essentially harmless, such as most homeopathic treatments, but others carry serious risks. This is especially true with the use of herbal medicines, available over-the-counter in pharmacies, health food stores, and increasingly over the Internet. Many people who use such products do not understand that these substances are drugs, in many cases quite powerful ones, and that severe health risks can attend their use. It is therefore especially important to ascertain which herbs (or nutritional supplements) a patient is using and in what dosage. Since the per dose percentage of active ingredients in a particular herbal product can vary considerably among product lines, it may be necessary to ask the patient to bring in the herbal medicine in order to determine whether it is being used safely. The potential for drug-herb interactions with any conventional pharmaceuticals the patient may be taking should also be considered. Herbal medicines—also called phytomedicinals—are more widely used in Europe; in Germany, where up to 80 percent of physicians routinely prescribe herbal medicines and board examinations of medical students include a section on phytomedicine, the manufacture and sale of herbal medicines are regulated by the government. Indeed, the German government's Commission E has investigated the safety and efficacy of more than 400 medicinal herbs. The complete Commission E monographs on these herbs are available in English. 

Perhaps the single most important point in dealing with a patient's use of CAM is to maintain open communication about the subject. If patients are made to feel that their interest in CAM is not condoned out-of-hand, they are likely to hide their CAM use from their physicians and deprive themselves of the counsel that could help them avoid untoward consequences.


The Future

There are many encouraging signs that CAM is finding an increasingly receptive audience in the conventional medicine community, perhaps none better than the recent attention CAM research is receiving in prestigious Western peer-reviewed journals. Still, there are real obstacles to the achievement of truly integrated medicine. In addition to cultural conflicts and the problems of evidence, there are difficult administrative issues, such as billing and coding procedures (in some venues, CPT and ICD-9 codes are presently being massaged adjusted to cover CAM), scope of practice regulations, the integration of medical records, and the like. However, given the consensus goals of efficacy, safety, accessibility, and cost-effectiveness of medical treatment, certainly these are not insurmountable obstacles to the integration of the best of CAM into conventional Western medicine.


Resources

The following web sites are all available free of charge, without subscription.

Government sites:

FDA Center for Food Safety and Applied Nutrition: Dietary Supplements

http://vm.cfsan.fda.gov/~dms/supplmnt.html

National Cancer Institute: Office of Cancer Complementary and Alternative Medicine (OCCAM)

http://occam.nci.nih.gov/

National Center for Complementary and Alternative Medicine (NCCAM)

http://nccam.nih.gov/

NIH Office of Dietary Supplements (ODS)

http://odp.od.nih.gov/ods/

Directories:

University of Wisconsin HealthWeb—Alternative / Complementary Medicine

www.medsch.wisc.edu/chslib/hw/altmed/

NOAH (New York Online Access to Health): Alternative Medicine Resources

www.noah.cuny.edu/alternative/alternative.html

Rosenthal Center: Information Resources

http://cpmcnet.columbia.edu/dept/rosenthal/CAM.html

University of Pittsburgh: Alternative Medicine Homepage

www.pitt.edu/%7Ecbw/altm.html


References

Blumenthal M. Introduction. In: Blumenthal M, Busse WR, Goldberg A, eds. The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Boston, Mass: Integrative Medicine Communications; 1998:5-70.

Davant C III. What you should tell patients about alternative medicine. In: Micozzi MS, Bacchus AN, eds. The Physician's Guide to Alternative Medicine. Atlanta, Ga: American Health Consultants; 1999:363-366.

Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the United States. N Engl J Med. 1993;328(4):246-252.

Jonas WB. One kind of medicine or many? The view from the NIH. In: Micozzi MS, Bacchus AN, eds. The Physician's Guide to Alternative Medicine. Atlanta, Ga: American Health Consultants; 1999:367-369.

Micozzi MS. Characteristics of Complementary and Alternative Medicine. In: Micozzi MS, ed. Fundamentals of Complementary and Alternative Medicine. New York, NY: Churchill Livingstone; 1996:3-8.

National Center for Complementary and Alternative Medicine. About NCCAM: General Information. Accessed on August 8, 2000 at http://nccam.nih.gov/nccam/an/general/index.html.

Novey DW. Basic principles of complementary/alternative therapies; The dilemma of evidence; Leaving the medical model; and Integration. In: Clinician's Complete Reference to Complementary/Alternative Medicine. St. Louis, Mo: Mosby; 2000:5-7, 7-9, 10-12, 13-16.

The White House: Office of the Press Secretary—Statement by the President [press release]. M2 Presswire; July 14, 2000.


Copyright © 2000 Integrative Medicine Communications

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