Complementary and Alternative Medicine (CAM) Resources for the Practitioner: Where to look and Who to Trust

1. Complementary and Alternative Medicine (CAM) Resources for the Practitioner: Where to look and Who to Trust John D. Mark MD Clinical Assoc Professor of Pediatrics Pediatric Pulmonary Medicine Lucile Packard Children’s Hospital at Stanford

2. CAM- Where is it? • A 14 yr old athlete with moderate, persistent asthma comes to clinic. He has an asthma action plan and has been adherent with his controller medication. Now he wants to try a breathing technique (Buteyko) so he can “get off” his meds. • A 3 yr old comes to the clinic for a well-child check-up. On exam you find a right otitis media. She is asymptomatic and you recommend watchful waiting. The parents would like to try a homeopathic remedy because they had heard that homeopathy worked better than placebo for children with an ear infection. Answer: Everywhere

3. CAM- every where you look

4. CAM in the News • Dying Woman Loses Marijuana Appeal March 14, 2007 • Evidence Mounts That Coping Skills Can Boost HIV Survival March 14, 2007 • Omega-3 in Fish Oils Might Ease Depression March 7, 2007 • Insomnia: Alternative Medicine Popular • 1.6 Million Adults Use Complementary Or Alternative Medicine For Insomnia September 2006

5. Ernst MJA 2006; 185 (11/12): 680-681

6. Complementary and Alternative Medicine (CAM) • Complementary and alternative medicine • A group of diverse medical and health care systems, practices, and products • Not considered part of conventional medicine • Some scientific evidence exists regarding CAM therapies • For most, questions of safety and efficacy persist • Complementary medicine is used together with conventional medicine. Alternative medicine is used in place of conventional medicine. http://nccam.nih.gov/health/whatiscam/

7. Integrative or Holistic Medicine • Integrative 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.” http://nccam.nih.gov/health/whatiscam/ http://www.integrativemedicine.arizona.edu/about2.html

8. Major Classes of CAM Enhance the mind’s capacity to affect bodily function and symptoms • Chiropractice • Osteopathy • Massage Alternative medical systems Mind-body interventions Biologically -based therapies Manipulative & body-based methods Energy therapies • Homeopathic • Naturopathic • Traditional Chinese and Ayurvedic treatments • Dietary supp • Herbs • Foods • Vitamins • Natural • substances • Biofield therapy • Bioelectro- • magnetic • therapy http://nccam.nih.gov/

10. CAM Utilization Reasons for using CAM: • Consistent with patient’s and families values: natural, and empowering • CAM providers are “patient-centered”, dedicated to promoting health. • Conventional therapies are perceived to be emotionally or spiritually without benefit • Conventional therapies are not effective or are associated with side effects. • CAM use is a circular: usage determines number of CAM practitioners Archives of Disease in Childhood 2006;91:96-97

11. CAM Therapies http://nccam.nih.gov/news/camsurvey_fs1.htm#domain

12. CAM Therapies

13. Pediatric Use of CAM • Asthma80%Reznik, 2003 (Bronx, NY) • Adolescents54-69%Wilson, 2002 (NY)Braun, 2005 (MN) • Special Needs64%Sanders, 2003 (Tucson, AZ) • Rheumatology64%Hagen, 2003 (Toronto) • ADHD54%Chan et al, 2003 (Boston Children’s) • Emergency13-45%Losier, 2005 (Ottawa)Lanski, 2003(Atlanta)

14. Pediatric Use of CAM • Oncology 47-84%McCurdy, 2003 (WFU) Neuhouser, 2001 (Seattle) Kelly, 2000 (NYC) • Cerebral Palsy 56% Hurvitz, 2003 Ann Arbor, MI • IBD 41%Heuschkel, 2002 London, Boston, Detroit • Autism Spectrum 30%Levy, 2003 CHOP, PA • Preoperative 29.5%Lin, 2004 Boston Children’s • Primary Care 12-21%Sawni, 2002 (Detroit) Ottolini, 2001 (Wash D.C.)

15. Evidence Based CAM Therapies in Pediatrics • Effectiveness well documented: • Acupuncture for nausea and vomiting • Biofeedback for constipation • Biofeedback for headache • Hypnotherapy for headache • Hypnotherapy for irritable bowel syndrome • Lemon balm for herpes simplex • Massage for constipation Archives of Disease in Childhood 2006;91:96-97

16. Effectiveness uncertain Acupuncture for asthma Acupuncture for hay fever Acupuncture for rheumatoid arthritis Chromium for diabetes Echinacea for common cold prevention or treatment Evening primrose for eczema Effectiveness unlikely Acupuncture for body weight reduction Acupuncture for smoking cessation Flower remedies for anxiety Homeopathy for anxiety Spinal manipulation for asthma Spinal manipulation for infantile colic CAM Treatments Commonly Thought Effective in Pediatrics Archives of Disease in Childhood 2006;91:96-97

17. Use of Herbs- Evidence? • Alternative Health supplement of the 2002 National Health Interview Survey: data on 10 common herbs • Of 30,616 adults, 19% used herbs in past 12 mo, 57% for a specific condition • Approximately 2/3 used herbs (except Echinacea) not in accordance with evidence based indications Mayo Clin Proc, May 2007;82(5): 561-566

18. Conventional Medicine, Evidence? • Most conventional physicians believe in unconventional medicine because it is not scientific • What is evidence-based medicine? Treatment that will improve patient outcomes by well-designed, appropriately powered, randomized, controlled clinical trials. • There is not good evidence (Grade A) that many of the commonly used therapies in conventional medicine are effective (ex: heparin, aspirin, and warfarin). • The principal distinguishing characteristic of unconventional and conventional medicine therapies is the source of introduction. • Conventional therapies are introduced by mainstream Western physicians and scientists, whereas most unconventional modalities are introduced by "outsiders." • One of the reasons that most unconventional modalities are not evidence based is that the majority of them were introduced prior to the 20th Century Arch Intern Med. 1998;158:2179-2181

19. CAM & Pediatric Care • Evidence is lacking even for the most popular, if there is evidence, most is in adults • However, the Institute of Medicine states: “the same principles and standards of evidence of treatment effectiveness apply to all treatments whether currently labeled as conventional medicine or CAM”. • Only 1/3-1/3 of patients or their parents reported CAM use to their doctors. Indicates a need to promote dialogue about CAM use between patients and their health care providers.

20. 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 the Mayo (<46 years or female more likely) • Less 25% discussed benefits or risks with CAM • 57% thought incorporation of CAM would be have a positive impact on pt satisfaction

21. 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

22. Physician’s Attitudes • 41% of the physicians neither agreed or disagreed that physician knowledge had an impact on patient’s health • 52% felt physician’s 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 physician’s 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

23. Federation of State Medical Board Guidelines (excerpts) • Patient evaluation: Includes the use of non-conventional methods of diagnosis and treatment • Consultation and/or referral to licensed or otherwise state-regulated health care practitioner- the Physician is responsible for monitoring the results • Medical records should also document: What conventional medical options have been discussed, offered, tried, or refused • Education- All physicians must be "able to demonstrate a basic understanding of the medical scientific knowledge" connected with any CAM therapy www.fsmb.org

24. What to do………. • Be aware of the growing scientific evidence concerning the safety and effectiveness of relevant complementary, as well as mainstream, therapies. • Balance the risks and benefits of any therapy before recommending a course of action, and continue to monitor patients appropriately. • Discuss and document with patients and their families any information regarding treatment decisions, conventional or CAM. • Know professional guidelines including ethics

25. CAM Education in Pediatrics • CAM education in medical schools • American Academy of Pediatrics (AAP) • Pediatric Integrative Medicine Leadership Initiative and Pediatric Integrative Medicine Conference (PIMC) • International Pediatric Integrative Medicine Network (IPIM-N) • Canadian network linking pediatric CAM researchers & educators (PedCAM)

26. CAM Education in Medical Schools • 1998 survey found 75 medical schools (out of 125) offered CAM electives or including these topics in required courses • 81% of the schools that included CAM in the curriculum did so by adding stand alone courses or electives, 41% used required courses, and 23% had both stand-alone and in required courses JAMA. 1998;280:784-7 • Barriers included: lack of money, lack of time to plan and prepare, and outright animosity on the part of faculty. • …unscientific, lack of mechanistic explanation or demonstrated clinical efficacy….if taught could be viewed as advocacy • Change is occurring: • Harvard: Division for Research and Education in Complementary and Integrative Medical Therapies • Albert Einstein, Columbia, Duke, Mount Sinai, Stanford, Arizona, Maryland, Pennsylvania, and several branches of the University of California have included CAM in the curriculum

27. How to Include CAM in Education • Teach One Medicine • Create Opportunities for Cross-Fertilization • Develop Support and Commitment from the Institution • Offer a Well-Designed Electives • Include an Experiential Component (acupuncture, massage, homeopathy, craniosacral etc) • Plan across the Curriculum from Undergraduate to Graduate and Continuing Medical Education (often a void during residency and fellowships) Wetzel MS, et al. Ann Intern Med 2003; 138: 191–6

28. Current Status - AAP • Provisional Section on Complementary, Holistic & Integrative Medicine (CHIM) • Kathi Kemper, Chair for Holistic and Integrative Medicine and Professor of Pediatrics, Wake Forest University • Section will promote policies to enhance patient-centered care, integrating evidence-based, safe and effective complementary therapies • Meetings: • Super CME Courses • AAP National Conference October 2007 • Four sessions by CHIM members

29. Current status - PIMC • Pediatric Integrative Medicine Conference • Collaboration of academic faculty at multiple pediatric integrative medical centers in US/Canada • 1st-2000, University of Arizona, Tucson • 2nd-2001, University of Minnesota, Minneapolis • 3rd- 2005, New York Academy of Medicine, NYC • 4th- 2006 October, 27-29th, Chicago • 5th- 2007, October 26-27th, San Francisco http://www.pangeaconference.com/index.asp

30. Current Status - IPIM-N • International Pediatric Integrative Medicine Network • List serve connecting PIM practitioners and organizations • Facilitates communication and collaboration • Promotes clinical, educational and research initiatives • Provides resources and links • Secure electronic network • ldrdoc@alum.mit.edu

31. Resource Evaluation • Introduction • Who runs this site? • Who pays for the site? • What is the purpose of the site? • Where does the information come from? • What is the basis of the information? • How is the information selected? • How current is the information? • How does the site choose links to other sites? • What information about you does the site collect, and why? • How does the site manage interactions with visitors?

32. A Guide for Providers Using CAM Government sites • National Center for CAM: http://nccam.nih.gov/ • Office of Dietary Supplements: http://ods.od.nih.gov/Research/CARDS_Database.aspx • MedWatch: http://www.fda.gov/medwatch • CAM on PubMed: http://www.nih.gov/news/pr/feb2001/nccam-05a.html

33. AcupunctureArthritisBlack CohoshCancerChelationChiropracticChondroitinDepressionDietary Supplements EchinaceaEphedraGinkgoGinsengGlucosamineHerbs at a GlanceHomeopathyMenopauseSt. John's Wort Introduction to Naturopathy New Herbs at a Glance: Grape Seed Extract AARP/NCCAM Report on Older Americans Past Highlights News from NCCAM:  Subscribe to quarterly newsletter Monthly e-bulletin NCCAM Website

34. A Guide for Providers Using CAM Academic sites • Boston-Longwood Herbal Task Force: • http://www.longwoodherbal.org/ University of Pittsburgh: http://www.pitt.edu/~cbw/database.html • Beth Israel Medical Center NYC: http://www.healthandhealingny.org/ • Columbia University: http://www.rosenthal.hs.columbia.edu/Botanicals.html • University of California, Berkeley Newsletter: http://www.wellnessletter.com/html/ds/dsSupplements.php

35. Longwood Website • ABC's of Herbal Medicine | Herbs | Dietary Supplements | Vitamins & MineralsIn-depth Monographs (71) | Clinician Information SummariesPatient Fact Sheets | Articles by LHTF MembersInteractions and Toxicity Information| Resources & LinksAbout the LHTF | How to Support the LHTF

36. Courses and Websites • Herbs and Dietary Supplements-Wake Forest University http://northwestahec.wfubmc.edu/learn/herbs/index.asp#CurrDesc • Botanicals and Health series-University of Arizona http://integrativemedicine.arizona.edu/online_courses/#botanicals • Botanical Medicine in Modern Clinical Practice (NYC) http://cait.cpmc.columbia.edu:88/dept/rosenthal/Botanicals_CME.html • Consumer Labs http://www.consumerlab.com • Natural Medicines Comprehensive Database http://www.therapeuticresearch.net/(ctt54155qny2vs55ryiv2d32)/home.aspx?li=0&st=0&cs=&s=ND • Quackwatchhttp://www.quackwatch.com.

37. Consumer Labs • ConsumerLab.com, is a provider of independent test results and information to evaluate health, wellness, and nutrition products. • 2.5 millions visits/year and as a certification company, CL enables companies of all sizes to have their products voluntarily tested for inclusion in its list of Approved Quality products and bear the CL Seal. • In the past 7 years, tested more than 1,800 products, representing over 350 different brand and supplements. One-year (12 months) subscription is $27.00 • Natural Products Encyclopedia and free newsletter

38. Natural Medicine Database • Search - enter natural product name, disease or condition, or drug name: objective product information, Effectiveness Ratings, or potential interactions with drugs • Natural Product Effectiveness Checker - tells you the level of effectiveness for natural products used for various medical conditions. • Natural Product / Drug Interaction Checker - tells you potential interactions between any natural product and any drug. • Disease / Medical Conditions Search - shows you medical conditions, and allows you to see which natural products might be effective. • Search Colleagues Interact - shows you questions, answers, and comments posted by other health professionals.

39. Fellowships and Residencies • University of Arizona Associate Fellowship http://www.integrativemedicine.arizona.edu/af/index.html (residential and associate) • Family Practice and CAM residencies • Albert Einstein College of Medicine • Maine Medical Center • Middlesex Hospital Family Practice Residency Program • Oregon Health & Science University • University of Arizona College of Medicine • University of Wisconsin – Madison

40. CAM –Local Resources • Stanford Center for Integrative Medicine (SCIM) • http://www.stanfordhospital.com/clinicsmedServices/clinics/complementaryMedicine/default • Osher Center for Integrative Medicine • http://www.osher.ucsf.edu// • Five Branches Institute • http://www.fivebranches.edu/ • College of Botanical Healing • http://www.cobha.org/ • Ryan Ranch, Integrative Medicine • http://www.ryanranchmedicalgroup.com/integrative_medicine.htm