Alternative (CAM) Approaches to Health and Healing

1. Alternative (CAM) Approaches to Health and Healing Ronald Schneeweiss MBChB Professor, Family Medicine

2. HERE'S WHAT YOU NEED TO KNOW: A Short History of Medicine I have an earache: 2000 B.C. -Here, eat this root. 1000 A.D. -That root is heathen. Here, say this prayer. 1850 A.D. -That prayer is superstition. Here, drink this potion. 1920 A.D. -That potion is snake oil. Here, swallow this pill. 1965 A.D. -That pill is ineffective. Here, take this antibiotic. 2000 A.D. -That antibiotic is artificial. Here, eat this root. (Nutrition News Focus, October 29, 1999.)

3. What is CAM?(Complementary/Alternative Medicine) • Complementary and alternative medicine is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. • NCCAM definition: www.nccam.nih.gov

4. CAM Therapies/Domains (NCCAM) 1. Mind-Body interventions -52% (meditation, yoga,hypnosis) 2. Biological therapies -21% (herbs, supplements) 3. Manipulative methods -11% (chiropractic, massage) 4. Alternative medical systems -2.7% (TCM, naturopathy) 5. Energy Therapies -0.5% (reiki, magnets, qi gong)

5. Our Use of Alternative Approaches ◊ I personally use daily vitamins and/or other dietary supplements.

6. Our Use of Alternative Approaches ◊ I personally use daily vitamins and/or other dietary supplements. ◊ I have personally consulted a CAM practitioner.

7. Our Use of Alternative Approaches ◊ I personally use daily vitamins and/or other dietary supplements. ◊ I have personally consulted a CAM practitioner. ◊ I know patients who have improved with CAM therapies.

8. Our Use of Alternative Approaches ◊ I personally use daily vitamins and/or other dietary supplements. ◊ I have personally consulted a CAM practitioner. ◊ I know patients who have improved with CAM therapies. ◊ I would refer patients to CAM providers.

9. Our own Use of Alternative Approaches ◊ I personally use daily vitamins and/or other dietary supplements. ◊ I have personally consulted a CAM practitioner. ◊ I know patients who have improved with CAM therapies. ◊ I would refer patients to CAM providers. ◊ I would work together with CAM providers in my practice.

10. What do physicians need to know about CAM?

11. Why is this important?

12. Are you using any Herbals or Supplements?

13. CAM Use in the USA • 42% of US population used CAM in 1997 (vs 30% in 1990). Much higher with chronic illness. • In ‘97 there were 629 million visits to CAM providers vs 386 million visits to 10 MDs • Expenditures on CAM in 2002 exceeded $26 billion (58% were out-of-pocket expenses). • Use of dietary supplements has skyrocketed over the past 10-15 years (~$5 billion in 2002).

14. Why do Patients Use CAM?

15. Characteristics of Adult CAM Users • In USA: • Highly educated • Holistic orientation to health • Female:Male=3:1 • Higher socio-economic status • WHO data indicates that 65-80% of the world’s population (developing countries) depend chiefly on plant medicine for their primary health care

16. 60% of patients do not tell their physician about their CAM use? Why Not?

17. Avoid treatments that might inhibit the healing power of nature (Vis medicatrix naturae -Hippocrates). Reliance on Nature - heal by supporting and stimulating nature. Active intervention - doing something active vs waiting. Heroic therapy - purgatives like calomel (mercurous chloride, emetics, bleeding, blistering). Historic Background Alternative Medicine vs Conventional Medicine 600 BC 400 BC 1340 A.D. Removing excess humors by vomiting. Barber-surgeon bleeding a patient (removing excess red bile) Greek Music Therapy Whorton JC. Nature Cures: the History of Alternative Medicine in America.2002, Oxford University Press.

18. Alternative medicine follows an alternative ‘science’ based on intuition, common sense, patience and observation. Restores people spiritually as well as physically. Approach is confident and definite. Patients given time and personal attention. Treatments change over time based on scientific studies: RCTs, empirical clinical research Patient’s subjective experience subordinate to objective evidence of pathology. Scientific approach often with uncertainty about outcome.* Increasing time constraints. Historic Background Alternative medicine vs Conventional medicine *Thomas KB. General practice consultations: Is there a point in being positive? BMJ 1987;294:1200-2

19. The Placebo Effect • In various studies the ‘placebo effect’ ranges from 5-70% • On average the placebo effect is about 35%

20. The Art of Medicine “..evidence-based medicine deals with populations; clinicians deal with individuals” Michael O’Donnell. Lancet 2000;355:489-91 “Any sick individual patient presents new problems. One can never say one disease is just like the other…The physician should not treat the disease but the patient who is suffering from it”. Maimonides: 1135-1204

21. All of CAM is quackery and nonsense. There is no evidence that proves efficacy.

22. 1a. Acupuncture

23. Modern Scientific Research fMRI study: Occipital cortex activation by: (a) visual light (b) stimulation of foot acupoint used to treat eye disease (c) sham acupoint (control) [Proc Natl Acad Sci 1998;95:2670-73]

24. Levels of Evidence 1-Good quality patient–oriented evidence (high quality RCTs, systematic reviews and meta-analyses of RCTs with consistent results) ------------ 2-Lower quality patient-oriented evidence (retrospective cohort studies, case control studies, case series) ------------- 3-Other evidence (consensus guidelines, clinical experience, expert opinion) Strength of Recommendation (SOR) A ----------------------- B --------------------------- C Assessing Evidence

25. % of Conventional Medicine that isEvidence-based

27. Dietary Supplements include: • Herbalse.g. Gingko, Saw palmetto • Supplements e.g. Glucosamine, Co-Q10, • Trace mineralse.g.Selenium, chromium, zinc • Vitaminse.g. Vits B6, A, C, E, folic acid • Hormonese.g. Melatonin, DHEA • Amino-acidse.g. L-tryptophan,

28. Echinacea -------------- Treat URI(Studies inconsistent) Garlic powder*-------------- Lowers cholesterol-modest (bad odor) Ginger root*---------------- Nausea Glucosamine + chondroitin-- Osteoarthritis Horse chestnut -------------- Venous insufficiency Peppermint oil -------------- Irritable bowel syndrome Red yeast rice -------------- T. cholest., LDL,  Trigl, HDL St. John’s wort ** ---------- Mild-moderatedepression Note: Serious drug interactions * coumadin ** SSRIs, CCB, Anti-retrovirals, BCP Safe and Effective Herbals and Supplements(based on good quality evidence)+ +http://www.uwcam.org

29. CoenzymeQ10 (CoQ10)-------- Ischemic heart disease (CHF) Feverfew ------------ Migraine Gingko --------------- Dementia, peripheral vascular disease (PVD) Milk thistle ---------------- Cirrhosis, alcoholic hepatitis Omega-3 fatty acids ---------- Prevent coronary artery disease (CAD) Saw palmetto ---------------- Benign prostatic hypertrphy (BPH) Valerian ------------- Insomnia, (anxiety) Safe and Likely Effective Herbals(based on moderately good quality evidence)+ + http://www.uwcam.org

30. Dietary Supplement and Health Education Act (DSHEA) - 1994 • If they occur naturally, products can go to market without testing of safety or efficacy. • Companies do not have to prove that their products are safe only ‘reasonable assurance’ • Supplements do not have to be manufactured according to any standards Slide #1

31. Dietary Supplement and Health Education Act (DSHEA) - 1994 • Labeling claims: almost any claim can be made as long as no disease is named. • FDA to have a very limited role in regulating the quality of individual products (can prohibit if safety concerns identified). Slide #2

32. Quality of OTC Dietary Supplements Quality Contamination Adulteration www.consumerlab.com

34. INFORMATION RESOURCES ConsumerLab.com

35. Reliable Information Sources UW Healthlinks: Provider Toolkit Natural Medicines Comprehensive Database UW CAM website www.uwcam.org National Center for Complementary and Alternative Medicine www.nccam.nih.gov Consumerlab www.consumerlab.com Memorial Sloan-Kettering Cancer Center http://www.mskcc.org/mskcc/html/11570.cfm

36. www.uwcam.org

37. Some Clinical Cautions (1)  Black licorice(imported) Chronic intake of >20g/d can cause pseudo-hyper aldosteronism leading to hypokalemia, hypernatremia, hypertension, edema and even CHF.  Garlic, Ginger, Ginseng, Gingko, Feverfew, CoQ10 Increase effect of coumadin and prolong INR. STOP 2 weeks before surgery.  Chromium Can decrease blood sugar. Use with care in diabetics on anti-diabetic agents.

38. Some Clinical Cautions (2)  Avoid combinations with additive effects….. So do not use: Hawthorn with cardiac drugs Valerian with benzodiazepines St. John’s wort with SSRIs (serotonin syndrome) Red yeast rice (Monascus purpureus) with statins  St. John’s wort induces cytochrome P450 with many herb-drug interactions: HIV antivirals, immunosuppressants, CCBs, statins, BCPs, some anesthetic agents (hypotension)

39. “Something from the supplement cart?”

40. Integrative Medicine 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, healthcare professionals and disciplines to achieve optimal health and healing. Developed and Adopted by CAHCIM, May 2004 Edited May 2005

41. Time permitting I will present a brief overview of the major CAM disciplines and therapies. If you wish to read more please go to: • www.uwcam.org (select modalities)

42. 1. Alternative Medical Systems • a. Traditional Chinese Medicine (TCM) • b. Homeopathy • c. Naturopathy

43. 1a.Traditional Chinese Medicine (TCM)(AOM - Acupuncture and Oriental Medicine) • Emphasizes the proper balance or disturbance of qi (chee) or vital energy, in health and disease. • Consists of a group of techniques and methods including acupuncture, Chinese herbal medicine, oriental massage, and qi gong (combines movement, meditation, and regulation of breathing to enhance immune function).

44. Diagnosis • Detailed history • Tongue examination • Taking the pulse • Therapy • Acupuncture • Acupressure • Herbals • Meditation • Manual therapy Manual Therapies Diagnostic statuette

45. 1b. HOMEOPATHY • Founded in1770 by Dr. Samuel Hahnemann: • Like cures like (Law of Similars) • the more a remedy is diluted the greater it’s potency (Law of Infinitesimal Dose) • An illness is specific to an individual • Similar cures exist for similar diseases; dilution and succussion (shaking) potentiates medicines

46. 1c.NATUROPATHY • Views disease as manifestation of alterations in the processes by which the body heals itself. • Emphasizes health restoration, prevention, and self-responsibility. • Examples of naturopathic treatments include: diet, homeopathy, hydrotherapy, herbs, massage, detoxification, counseling, soft tissue and spinal manipulation. St. John’s wort

47. 2. Manipulative and Body-based Methods • Chiropractic and • Osteopathic manipulation • Massage therapy (e.g. conventional therapeutic massage, Feldenkrais, Alexander, Heller, Rolfing)

48. 2a. CHIROPRACTIC • Founded in 1895 by D.D. [Daniel David] Palmer- (restored sense of hearing to a deaf janitor in Davenport, Iowa by adjusting a single cervical vertebra). • Relates disease to malalignments (subluxations) of vertebrae which create nerve interference and block the ‘innate intelligence’ of the body to heal itself. This is a controversial theory even among Chiropractors.

49. 3. Mind-body Interventions Employs a variety of techniques designed to facilitate the mind’s capacity to affect bodily functions and symptoms: • hypnosis, biofeedback, meditation, yoga, dance, music and art therapy, prayer, mental healing Greek Music Therapy 600 B.C.

50. 4. Biologically-based Therapies • Examples are herbals, special diets (Atkins, Ornish, Pritikin), • Orthomolecular therapies employ vitamins, minerals and amino acids to create optimum nutritional content and balance in the body. • Other biologic therapies include: • Shark cartilage to treat arthritis and cancer. • Bee pollen to treat auto-immune and inflammatory disease. • Chelation therapy with EDTA (IV) - purported to reverse atherosclerosis by removing calcium from atheromatous plaques.