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Integrative Medicine

Integrative Medicine. Caroline Oczachowski, PGY 2 Emory Family Medicine. Adapted from Dr. J. Michelfelder at Loyola University in Chicago.

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Integrative Medicine

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  1. Integrative Medicine Caroline Oczachowski, PGY 2 Emory Family Medicine Adapted from Dr. J. Michelfelder at Loyola University in Chicago

  2. 54 year-old female presents with peripheral neuropathy, shoulder tendonitis, and carpal tunnel syndrome about 15 months after completing chemotherapy for breast cancer. She is believed to be in complete remission currently. She states that she is exercising, doing physical therapy, taking a multi-vitamin and following all of the recommendations of her physicians, but feels like she could be doing more for her issues. What more do you want to know? What options would come to mind for you? How would you find information about those options?

  3. Approximately 38 percent of adults in the United States aged 18 years and over and nearly 12 percent of U.S. children aged 17 years and under use some form of complementary and alternative medicine (CAM), according to a 2007 nationwide government survey

  4. Definitions “Complementary and Alternative Medicine is a Group of Diverse Medical and Health Care Systems, Practices, and Products That are Not Presently Considered Part of Conventional Medicine” NCCAM

  5. Definitions • “Complementary Medicine is Used TogetherWith Conventional Medicine.” • “Alternative Medicine is Used in Place of Conventional Medicine.” NCCAM

  6. Definitions “Integrative Medicine Combines Mainstream Medical Therapies and CAM Therapies for Which There is Some High-Quality Scientific Evidence of Safety and Effectiveness.” “Healing-oriented medicine that takes account of the whole person (body, mind, and spirit), including all aspects of lifestyle. It emphasizes the therapeutic relationship and makes use of all appropriate therapies, both conventional and alternative.” NCCAM http://www.integrativemedicine.arizona.edu/about2.html

  7. The National Center for Complementary and Alternative Medicine (NCCAM) is the Federal Government's lead agency for scientific research on CAM. • They are 1 of the 27 institutes and centers that make up the National Institutes of Health (NIH) within the U.S. Department of Health and Human Services.

  8. The mission of NCCAM is to: • Explore complementary and alternative healing practices in the context of rigorous science. • Train complementary and alternative medicine researchers. • Disseminate authoritative information to the public and professionals.

  9. What are the conditions for which adult pts most frequently seek CAM? ???

  10. What are the conditions for which pediatric pts most frequently seek CAM? ???

  11. 5 Domains of CAM As defined by NCCAM

  12. Other CAM therapies • Aromatherapy • Colonic Irrigation • Therapeutic Touch • EDTA Chelation • Cupping • Primordial Sound Meditation

  13. Definitions • Ayurveda - India's traditional, natural system of medicine that has been practiced for more than 5,000 years. Ayurveda provides an integrated approach to preventing and treating illness through lifestyle interventions and natural therapies. Ayurvedic theory states that all disease begins with an imbalance or stress in the individual's consciousness. Lifestyle interventions are a major ayurvedic preventive and therapeutic approach. Ayurvedic practices is to cleanse the body of substances that can cause disease, and this is believed to help reestablish harmony and balance.

  14. Definitions • Homeopathy - a system of medical practices based on the theory that any substance that can produce symptoms of disease or illness in a healthy person can cure those symptoms in a sick person. For example, someone suffering from insomnia may be given a homeopathic dose of coffee. Administered in diluted form, homeopathic remedies are derived from many natural sources—including plants, metals, and minerals.

  15. Definitions • Naturopathy – an alternative medical system. Naturopathic medicine proposes that there is a healing power in the body that establishes, maintains, and restores health. Practitioners work with the patient with a goal of supporting this power through treatments such as nutrition and lifestyle counseling, dietary supplements, medicinal plants, exercise, homeopathy, and treatments from traditional Chinese medicine.

  16. Definitions • Qi gong - A component of traditional Chinese medicine that combines movement, meditation, and regulation of breathing to enhance the flow of qi (an ancient term given to what is believed to be vital energy) in the body, improve blood circulation, and enhance immune function.

  17. Definitions • Reiki - A Japanese word representing Universal Life Energy. Reiki is based on the belief that when spiritual energy is channeled through a reiki practitioner, the patient's spirit is healed, which in turn heals the physical body.

  18. Why Should We Care? • 30,000 herbs on the market currently • Estimates of $30-40 billion dollars spent annually Eisenberg D. et al, JAMA, Nov 11, 1998(18) 1569-1575 • Sales of Metabolite 356 approached $1billion in 1999 Alternative Medicine Alert, January 2000 • Avlimil – est. $100 million in sales in 2003  Herbal entrepreneur proving that sex sells: Local business reaps millions from supplementsThe Cincinnati Enquirer • Relacor $23 Million; 900,000 bottles by July 06 • Enzyte has 21,400 repeat customers at $99.95 a month for a whopping $2,138,930.00 a month in sales ($25,667,160.00 annually)USA today

  19. Why Should We Care? • 600 Million Visits a year to CAM Providers – More Than to Primary Care Providers • An estimated 15 million adults took prescription medications concurrently with herbal remedies and/or high-dose vitamins Eisenberg D. et al, JAMA, Nov 11, 1998(18) 1569-1575

  20. Why? What is Mainstream Medicine Not Offering to Our Patients?

  21. Have We Missed the Boat? • Dissatisfaction with health care providers and medical outcomes • Side effects of drugs and treatments • High health costs • Technology • Lack of control in their own health care practices • Time spent with practitioner Stephen Strauss, M.D., NCCAM Director

  22. Have We Missed the Boat? • Looking for “cures” • Want to use “natural” products • Patient feels empowered • Focus on spirituality and emotional well-being • Health Care Provider provides the 3 T’s: touch, talk, time Stephen Strauss, M.D., NCCAM Director

  23. What about communication? Between 40 and 70% of CAM users do not disclose their use to their physician. Eisenberg 2001

  24. Why do patients not tell their physician about their CAM use? • 60% - “My doctor never asked.” • 60% - “It wasn’t important for my doctor to know.” • 20% - “My doctor wouldn’t understand.” • 14% - “My doctor would disapprove.” Eisenberg DM. Ann Int Med 2001;135(5):344-51

  25. What are our patients reading???

  26. PRESS RELEASE: • Medication errors are among the most common medical errors, harming at least 1.5 million people every year, says a new report from the Institute of Medicine of the National Academies.  The extra medical costs of treating drug-related injuries occurring in hospitals alone conservatively amount to $3.5 billion a year, and this estimate does not take into account lost wages and  productivity or additional health care costs, the report says. - IOM July 2006

  27. Evidence Based Medicine • Difficulties With CAM Research • Sham Acupuncture • Non Standardized Herbal Formulations • Difficult to Blind Patients and Practitioners • Treatments Very Individualized – Difficult to Formulate Protocols • Drug companies have to do studies to go on the market—supplement companies do not, so clinical trials sponsored by supplement companies are rare

  28. Comparison • Mainstream Medicine • Large Double Blind Placebo Controlled Trials • Many Exclusions Such As Multiple Medicines, Other Illnesses, Female, Pregnant, Children, Race • “Placebo Effect” Discounted • Apply These Narrow Results to The Individual • Integrative Medicine • Very Individualized • “Placebo Effect” Not Discounted

  29. Patients are choosing integrative and alternative medicine, but what about physicians?

  30. Physician’s Attitudes • Survey sent to 660 physicians at the Mayo Clinic (233 responded) • Three areas: utilization, familiarity and attitudes • Utilization: • 75% had never referred to CAM practitioner • 44% said they would consider if available at Mayo (<46 years or female more likely) • Less than 25% discussed benefits or risks with CAM • 57% thought incorporation of CAM would have a positive impact on pt satisfaction

  31. Physician’s Attitudes • Familiarity: • Biofeedback, massage, chiropractic and relaxation therapies were the most familiar • 59% were unfamiliar with energy healing, 53% with naturopathic medicine • Of the 13 herbs listed, only 3 were commonly listed as familiar • 66% were not familiar with feverfew and 52% were not familiar with Kava • 49% of the physicians felt it was difficult or very difficult to find reliable information about herbs

  32. Physician’s Attitudes • 41% of the physicians neither agreed or disagreed that physician knowledge had an impact on patient’s health • 52% felt physicians’ spiritual beliefs were important and 87% felt patients’ spiritual beliefs and practices were important • 67% agreed some CAM therapies hold promise but 70% felt current practices of CAM was a “threat” to the public health • Most important factors in changing physicianss attitudes were RCT’s and evidence demonstrating mechanism • 70% of the physicians felt Mayo clinic should provide proven CAM therapies eCAM 2006;3(4) 495-501

  33. Where Are We Today? • Clinical Fellowships: • University of Arizona (Founding Program) • University of Michigan • University of Maryland • University of Wisconsin • Maine Medical Center • Cooper Health System (NJ) • Lawrence MA • Beth Israel Medical Center • UCLA • Academic Fellowships (Research) • Harvard University • Tufts • Boston University • Stanford • Duke • Residencies in Integrative Medicine • Oregon Health Sciences University • Montefiore Medical Center (NY)

  34. Where Are We Today?

  35. CAHCIM Members • Albert Einstein/Beth Israel • Columbia University • Duke University • George Washington • Georgetown • Harvard • Laval University • Mayo Clinic • OHSU • Stanford University • Yale University • Wake Forest University • University of Alberta • University of CA/Irvine • Thomas Jefferson • UMDNJ • University of Arizona • University of Calgary • University of Hawaii • University of Washington • University of California/LA • University of California/SF • University of Colorado • University of Connecticut • University of Kansas • University of Maryland • University of Massachusetts • University of New Jersey • University of New Mexico • University of North Carolina-Chapel Hill • University of Michigan • University of Minnesota • University of Pennsylvania • University of Pittsburgh • University of Texas-Galveston • University of Vermont • University of Wisconsin

  36. The Future of Integrative Medicine • Definition of Integrative Medicine From the CAHCIM “Integrative medicine is 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 therapeutic approaches to achieve optimal health and healing.”

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