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Bridging the Worlds of Allopathic and Alternative Therapies: Why Should We Try?

Bridging the Worlds of Allopathic and Alternative Therapies: Why Should We Try?. Jane L. Murray, MD Sastun Center of Integrative Health Care. Terminology. “Alternative” “Complementary” “Complementary and Alternative” (CAM) “Traditional” (vs “conventional”) “Holistic” “Integrative”.

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Bridging the Worlds of Allopathic and Alternative Therapies: Why Should We Try?

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  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 • “Alternative” • “Complementary” • “Complementary and Alternative” (CAM) • “Traditional” (vs “conventional”) • “Holistic” • “Integrative”

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

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

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

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

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

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

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

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

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

  13. Making EBM more relevant • 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 • “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. 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 • 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 & NutritionalsProbably Effective & Safe • Ginko biloba - cerebrovascular/memory • St. John’s wort - mild/moderate depression • Garlic - lower BP, decrease platelet aggregation, lower cholesterol • Ginger - anti-inflammatory • Valerian - sleep, anxiety • Saw Palmetto - BPH

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

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

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

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

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

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

  25. Other ModalitiesDangerous • Chiropractic with structural instability • Delay in appropriate diagnosis & treatment

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

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

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

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

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

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

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

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

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

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

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

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

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

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