1. Bridging the Worlds of Allopathic and Alternative Therapies: Why Should We Try? Jane L. Murray, MD Sastun Center of Integrative Health Care

2. Terminology b “Alternative” b “Complementary” b “Complementary and Alternative” (CAM) b “Traditional” (vs “conventional”) b “Holistic” b “Integrative”

3. Becoming Mainstream b Eisenberg study: 42% of Americans use CAM techniques and practitioners b OAM (Office of Alternative Medicine) at NIH established in 1992, became NCCAM in 1999 b 9 Alternative Medicine Centers funded by NIH b WHO sponsors international research in traditional medicine

4. Health Information - Renner b Folklore b Quackery b Untested b Investigational b Proven

5. NIH NCCAM Categories b Mind/Body b Bioelectric b Other cultures’ medicine b Manual healing b Pharmacology and biologics b Herbal b Diet and Nutrition

6. Mind-Body Medicine b Relaxation Response b Meditation b Biofeedback b Psychoneuroimmunology

7. Energy Therapies b Body work - massage, reiki, etc b Movement - T’ai Chi, Yoga b TCM - acupuncture & herbs b Homeopathy b Therapeutic Touch b Magnets

8. Cultural Medicine b Traditional Chinese Medicine b Herbs b Curandismo b Spiritual practices b Ayurvedic medicine

9. Structural & Manipulative b Osteopathic medicine b Chiropractic b Deep tissue massage (rolfing, hellerwork, etc.) b Movement Therapy, Feldenkrais, Alexander, Trager, etc.

10. Why patients use CAM b Not necessarily dissatisfied with conventional medicine b Alternatives are more congruent with personal values, beliefs about health & life b Poorer health status b More educated

11. Evidence-Based Medicine b “The conscious, explicit, and judicious use of current best evidence in making decisions about the care of patients.” »David Sackett, MD

12. Evidence-Based Medicine b Provides a level playing field for evaluation of both conventional and CAM therapies b Disease- Oriented Evidence (DOEs) vs Patient -Oriented Evidence that Matters (POEMs) b Cochrane Library - Controlled Trials Registry and Database of Systematic Reviews - http://archie.cochrane.co.uk

13. Making EBM more relevant b Two kinds of outcomes: –Patient-oriented outcomes (e.g. morbidity, mortality, symptoms, duration,hospitalization, cost) –Disease-oriented/intermediate/surrogate outcomes (e.g. BP, Hgb A1c, peak flow rates, MIC in respiratory epithelium)

14. EBM, POEM’s and Alternative Medicine b “We’ve always done it that way” does not mean it works: –patching corneal abrasions –10 days of antibiotics instead of 5 for OM –Just because a pharmaceutical company develops a drug doesn’t mean it works: –antibiotics for most bronchitis

15. b Just because an intervention is considered non-traditional doesn’t mean it doesn’t work: –St. John’s Wort –glucosamine –acupuncture –saw palmetto –mangnets for painful diabetic neuropathy

16. The “Golden Question” of EBM b What is the evidence that this herb/drug/surgery/device will help my patient live better and/or longer? –Not LDL or HDL - do patients live longer? –Not the MIC in respiratory epithelium - do patients feel better quicker? –Not sales of magnets - do they improve function and reduce pain?

17. Some Examples

18. Herbs & Nutritionals Probably Effective & Safe b Ginko biloba - cerebrovascular/memory b St. John’s wort - mild/moderate depression b Garlic - lower BP, decrease platelet aggregation, lower cholesterol b Ginger - anti-inflammatory b Valerian - sleep, anxiety b Saw Palmetto - BPH

19. b Cranberry - UTI b Echinacea - prophylaxis & treatment of viral symptoms b Feverfew - migraine headaches b Milk Thistle - hepatoprotective agent b Ginsing - antistress, general tonic b Glucosamine - joint disease

20. Herbs & Nutritionals Possibly effective, safe if careful b Dong quai - menopause b Black cohosh - menopause b Melatonin - sleep b Passion flower - sleep b L-tryptophan - sleep b DHEA - energy level (androgenic SE’s)

21. Herbs & Nutritionals Potentially dangerous b Ma huang (ephedra) - weight loss b Chaparral - hepatitis b Comfrey - topical use only b Germander - serious hepatotoxicity b Licorice - hypertension in high doses

22. Other Modalities Probably safe & effective b Acupuncture for nausea, anesthesia, pain, fibromyalgia b Chiropractic for non-surgical acute LBP, minor ligamentous/facet alignment problems b T’ai Chi - osteoporosis, balance in elderly

23. b Biofeedback for hypertension, headache, TMJ, anxiety b Osteopathy - wide variety of ailments, especially musculoskeletal problems b Meditation and other Mind-body practices for stress-related conditions, chronic pain b Diet, nutrition, lifestyle

24. Other Modalities Possibly effective, not harmful b Body work techniques for a variety of musculoskeletal problems b Energy therapies for pain syndromes, fibromyalgia, respiratory conditions, emotional stress (PTSD, depression, anxiety, etc.) b Homeopathy in general

25. Other Modalities Dangerous b Chiropractic with structural instability b Delay in appropriate diagnosis & treatment

26. Why should we try? b Costs of health care continue to climb b Providers and patients are dissatisfied b Chronic disease is not being impacted effectively b Personal responsibility for health and health care decisions seems lacking b Many alternative therapies work

27. Limits of Conventional Medicine b No “scientific” basis for 80% of treatments b Relatively poor results with chronic illness b Serious iatrogenic problems: e.g. adverse drug reactions responsible for 100,000 deaths in U.S. hospitals/year b High cost b Disease focus

28. What Can “Bridging” Offer? b More personal responsibility for health (e.g. learning self-care techniques for stress, minor ailments, chronic conditions) b Utilizing less expensive prevention and treatment techniques (nutrition, mind-body modalities, movement therapies, etc.) b Admitting the limits of conventional therapies - takes some burden off!

29. b Target use of expensive therapies to those conditions that will actually benefit b Promote use of “alternative” approaches at the appropriate time (i.e. not “last resort”) b Overall provide better outcomes for patients

30. Where from here? b Learn more - conferences, journals, try some new methods. b Consult with other practitioners as we would other specialists - phone calls, letters, etc. Share space as appropriate; form a group practice. b Create truly patient-centered environments - hospital, office, etc.

31. b Conduct research on empirically interesting interventions. b Change the medical school curriculum. b Standardize practices of various fields, so outcomes can be compared. b Change the health care payment system.

32. b Create a social culture that values and reinforces individual choice and responsibility about health. b Create health care environments that are healthy and supportive for those working in them.

33. Challenges of Integration b Wide array of alternative therapies - some with an evidence base, some without b Lack of physician familiarity b Paradigm clashes b Western “scientific” concepts b Paying for it

34. Personal Observations b Wide variety in practitioners of a given art b Lack of open-mindedness of some CAM therapists, as well as some physicians b Patients want their doctor to at least be open minded b Patients want to be heard and taken seriously b Patients want their practitioner to have hope

35. CAM May Be Superior b Chronic fatigue syndrome b Fibromyalgia b Irritable bowel syndrome b Arthritis b Low back pain b Skin diseases

36. RESOURCES b NIH Office of Alternative Medicine: http://altmed.od.nih.gov b Clearinghouse: (888) 644-6226 b FDA: http://www.fda.gov b American Botanical Council: http://www.herbalgram.org b Ask Dr. Weil: http://www.drweil.com

37. b Journal of Family Practice POEM’s feature http://jfp.msu.edu b Databases NAPRALERT (312) 996-2246 Herb research Foundation (303) 449-2265 b Cochrane Library: Controlled Trials Register & Database of Systemic Reviews http://archie.cochrane.co.uk

38. b Core Library for Evidence-Based Practice www.shef.ac.uk/~scharr/ir/core b National Health Service and Development Centre for Evidence-based Medicine www.cebm.jr2.ox.ac.uk b Patient-oriented Evidence that Matters www.infopoems.com