Transcript CAM offers lens on health care

Overview of Complementary,
Holistic and Integrative
Medicine
Kathi J. Kemper, MD, MPH
Caryl J Guth Chair for Holistic
and Integrative Medicine
Professor of Pediatrics, Public
Health Sciences, Family and
Community Medicine
Wake Forest University Health
Sciences
OBJECTIVES. By the end of this session:
1. Name the new provisional Section
within the AAP and be able to join.
2. Apply an ethical framework for
recommending, avoiding, tolerating or
monitoring a therapy
3. Describe a model integrating CAM and
mainstream care into 4 major
categories
4. List four resources for answering
clinical questions about CAM
NIH NCCAM Definition
Complementary and
alternative medicine
(CAM) is a group of
diverse medical and
health care systems,
practices, and products
that are not presently
considered to be part of
conventional medicine. …
Resource: http://nccam.nih.gov/
Resource 1: NIH NCCAM
NCCAM
Clearinghouse:
1-888-644-6226
• Patient information sheets in
English and Spanish
• Ongoing research
projects/clinical trials
• Education and Training
opportunities
http://nccam.nih.gov
Resource 2: NCI OCCAM
• Health information for
patients
http://www.cancer.gov/cam/
health_understanding.htm
l
• Clinical trial information
• Grant funding for
research projects
Complementary, Alternative and
Mainstream Therapies
Alternative
Mainstream
Complementary
CAM Use in Kids
• 1992-2005, 66 pediatric
utilization studies US,
Canada, UK, Australia,
Turkey, Norway…
• General and subspecialty
populations
• Use increasing
Complementary and Alternative Research and Education Program
Pediatric Epidemiology
• Spiegelblatt ’94 Pediatrics ; 11% used prof. CAM
• Ottolini, et al, W, DC, ‘98: 20% of kids in 4 practices
• Taylor, et al, Seattle, ‘98: 30% -50% use echinacea or
vitamin C for kids’ colds
• Indiana teens ‘98: 20-30% of athletes take supplements
• Crow, et al. Ped Res, ’03: 46% w/vitamins; 15%
wo/vitamins in Chicago PPRG
• Wilson, et al AmbPeds ’02: 53% of Rochester teens
• Lin, et al J Clin Anesth ’04: 30% pediatric pre-op pts use
herbs
• Breuner APAM ‘98: 70% homeless teens
Children with other
conditions
• Autism: 30%;
• Asthma: 72%-81% of minority (H and Af.A.) families;
• Cancer: 47% of kids at WFUSM in 2003; 73% of kids in
Washington state in 2001;
• CF: 65%, mostly prayer
• Cerebral palsy: 56% of 235 families in Ann Arbor
• ED: 53% used herbs, Atlanta
• IBD: 41% of kids in Boston, Detroit, London
• Rheumatology: 64% of 141 in Toronto, 2003
• Special needs: 24% for kids with correctable condition vs.
76% for kids with non-correctable condition
Which CAM therapies most
commonly used?
• Prayer – most common, least worrisome to MDs
• Herbal therapies, vitamins, minerals and other dietary
supplements – most worrisome to MDs
• Chiropractic – most common professionally provided to
adults; historical competitive threat
• Massage – most common professionally provided to kids;
often taught to parents or provided informally
• Homeopathy – not well enumerated; confusion with herbs
• Yoga, Tai Chi
• Acupuncture/acupressure
• Biofeedback, hypnosis
What are pediatricians
most often asked about CAM?
• Herbs, dietary supplements (67%)
• Chiropractic (59%)
• Nutrition and special diets, vegetarian,
macrobiotic diets (46%)
• Homeopathy (36%)
• Therapeutic exercise, yoga (34%)
• Hypnosis, biofeedback or meditation
(23%)
• Massage or other bodywork (17%) ….
• Prayer (13%)
Kemper, O’Connor. Amb Peds, 2004
Only 40% tell docs about CAM
• “Natural”, not medical; irrelevant , “not
important for the doctor to know” 61%
• Docs not interested; “the doctor never
asked” 60%
• “None of the doctor’s business” 31%
• “Doctor would not understand” 20%
• Cultural practice - embarrassing or private,
<20%
• Fear of physician reaction (disapproval,
abandonment, worse medical care) < 15%
Eisenberg DM, et al. Arch Intern Med, 2001; 135:
344-51
How do you know what your
patients are doing?
•
•
•
•
<50% tell
Doctors need to ask!
Give examples
Ask in context (more later
on this)
Holistic
Caring for whole person - body,
mind, emotions, spirit,
relationships -- in the context of
family, culture and community
= Contextual pediatrics;
= Patient – centered care
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.
Consortium of Academic Health Centers
for Integrative Medicine, 5/05
Resource 3
•
•
•
•
•
•
•
Founded in 2000
Now has over 30 academic health centers
International Conference
Collaborative research
Developing “best practices” models
Education (residency and undergrad)
http://www.imconsortium.org/cahcim/about/home.
html
Resource 4: AAP Provisional Section
for Complementary, Holistic, and
Integrative Medicine
• Formed 7/05
• Dr. Larry Rosen organized
– NYC PIM 10/05;
– Pangea in Chicago 10/06
• Dr. Sunita Vohra (CARE) leads PIR
reviews; developing questions for
ABP; international liaison
• http://www.aap.org/sections/chim/de
fault.htm
AAP ps CHIM continued
• Dr. Richard Walls’ committee approved
CPS Statement on Herbs and Supplements
• Dr. Susan Hyman – autism statement
• Dr. Joy Weydert – Liaisons
• Dr. Hilary McLafferty – newsletter
• OJ Sahler – liaison to PAS
• Junelle Speller – staffer, web site
• TO JOIN, email Junelle: [email protected]
AAP ps CHIM continued
• NCE 2007 (SF) and beyond
presentations
–
–
–
–
–
Acupuncture
Herbs and supplements
Nutrition
Massage
Clinical practice, billing, coding,
time management
• Collaboration with PAS, TFOMH
• TFOCAM report (Periodic
survey)
TFOCAM Report
• CAM use is common
• Pediatricians need to be aware
of this and ASK about use of all
kinds of therapies
• Pediatricians need to coordinate
care, continue to learn about
diverse therapies
• Ethical approach to treatments
Ethical framework
Effective
Yes
Safe Yes Use/Recommend
No
Monitor closely
No
Tolerate
Advise against
Cohen M. Pediatrics, 2005
Effective? Safe?
– What therapy?
– For whom?
– For what condition? (cancer,
colds)
– Under what circumstances?
– For what desired outcome?
– When? immediate versus longterm
Kemper. Arch Dis Child, 2001
Nausea: Does CAM work?
Acupuncture
Effective
Yes
Safe Yes Use/Recommend
No
Monitor closely
No
Tolerate
Advise against
Chemotherapy for Cancer
Effective
Yes
Safe Yes Use/Recommend
No
Monitor closely
No
Tolerate
Advise against
Cohen M. Pediatrics, 2005
Chicken soup for colds
Effective
Yes
Safe Yes Use/Recommend
No
Monitor closely
No/Unknown
Tolerate
Advise against
Cohen M. Pediatrics, 2005
Surgery for Common Cold
Effective
Yes
Safe Yes Use/Recommend
No
Monitor closely
No/Unknown
Tolerate
Advise against
Cohen M. Pediatrics, 2005
TRUE/FALSE
Patients’ only goals are to cure
disease, reduce symptoms
and prevent serious illness or
injury. If you can do that,
you’re done!
What’s the desired outcome?
• Patients may have more than
one goal
• Non-articulated goals are often
as important as spoken goals
• Patients/families may have
goals they aren’t consciously
aware of
Goals for Healing
YANG-type/ Specific
Cure
Manage symptoms
Prevent specific disease
Reduce or manage
specific toxin
YIN-type/Global, unstated
Connection/Support/
Trust
Meaning/Transcendence
Harmony
Peace
Well-being/ Resilience
Reduce dependence
Models for Treatment
Treatment
Disease in
Organ or
Tissue
Yang
B
Treatment
Yin
Symptoms
Primary
Person
Peace
Connection
Trust
Harmony
QOL
Well-being
Secondary
Symptoms
or
Disease
Primary
Secondary
How (not) to ask
“You’re not using any
alternative medicines, are
you?”
Using written checklists that
don’t include common
alternatives.
Failing to provide examples.
Colic Case
You are in clinic seeing a tiredappearing mother with her one
month old infant who will not
stop screaming. After performing
a careful history and physical,
you diagnose colic.
What do you ask?
A.
B.
C.
You haven’t tried any CAM therapies,
have you?
Have you given your baby any medicine?
Mothers of babies who cry a lot try many
different things to help, such as rides in
the car, bouncy seats, Mylicon, Tylenol,
homeopathy, chamomile, prayer, tummy
rubs, changing formulas, homeopathy and
other things. What have YOU tried so far?
And how has that worked?
The Mother asks
I was in the grocery store last
week and saw these
HOMEOPATHIC colic
tablets. What do you think
about homeopathy for
colic?
The highly educated physician
responds…..
I know that many homeopathic
products are marketed for children,
but actually none has undergone
any randomized, controlled clinical
trials except for some 3rd world
studies on diarrhea and one early
study on otitis media. You’d
probably just be wasting your
money or doing an uncontrolled
experiment, using your baby as a
guinea pig.
The confused mother replies…
Well, actually, since it was so cheap and
it was right there and everything, I
bought it and gave it. It settled the
baby right down, and I’ve tried it a
couple of times since then and it works
great. I just wanted to know if you
thought it was safe and if you had any
particular brands you recommend.
Lesson 1:
THE TWO MOST IMPORTANT
QUESTIONS IN CLINICAL
MEDICINE:
– What have you tried so far (give
examples)?
– How has that worked? (Do NOT
give your opinion until you hear
theirs)
Case 2
A 13 year old recently diagnosed with
osteogenic sarcoma says she’s having
trouble sleeping. She doesn’t want any more
meds.
The teenager asks
I just don’t want any more meds,
but I do want to get some
sleep. I’ve heard that valerian
and kava kava may be helpful.
What do you think? I might go
on-line to find out.
Have you already gone on line?
What have you learned so far?
Have you brought any printouts with
you?
Have you tried any products so far?
Do you have any with you?
I’d like to see them and check them out.
Please bring everything you take for
your health so I can see it and write it
down accurately for your records.
More resources:
• MD Anderson Cancer Center:
http://www.mdanderson.org/departments/CIMER/
Natural Standard Review: Kava
Memorial Sloan Kettering
http://www.mskcc.org/mskcc/html/11570.
cfm
The girls responds
Yes, I’ve brought some
valerian and kava kava,
but I haven’t started taking
them yet, because I wanted
to ask your opinion first.
Do they work?
The knowledgeable clinician
responds,
Several randomized controlled trials in adults have
shown that valerian, 400 mg before bed, can help
reduce sleep latency, that’s the time it takes to fall
asleep. And it doesn’t seem to cause a morning
hangover. It appears to be safe, but then again,
herbal products aren’t well regulated, so you may
just be wasting your money. Valerian smells like
sweaty gym socks, so if you do decide to try it,
make sure you’ve got a really smelly product to
ensure you’ve got one that has the active
compound.
And responds some more
Now kava kava is an herb that’s been used in Polynesia for a
long time, mostly for social occasions, kind of the way
wine is used in Europe and the US. If you take it three
times a day every day for three weeks, it can significantly
improve anxiety that may be affecting your sleep.
However, there are several recent reports of serious
hepatotoxicity with kava, so if you decide to take it, we
have to monitor your liver function very closely. Any
questions?
The impressed teen replies,
Well, actually my mom
thought it might be helpful
just to take a hot bath and
have a glass of milk or a
turkey sandwich before bed.
And my grandmother told
me I should pray and count
my blessings. What do you
think about that?
Lesson: Be systematic
Do not jump in with an answer
until you have assessed ALL the
therapies of interest
• Efficient
• Comprehensive; avoid missing the key
• Example: differential diagnosis; organ
system approach in ICU
Integrative Approach
•
•
•
•
Biochemical
Lifestyle
Biomechanical
Bioenergetic
Biochemical
• Medications
• Dietary Supplements,
such as herbs,
vitamins, minerals,
glucosamine, etc.
Be specific
Do YOU use herbs
regularly, ie. 4 or more
days a week?
Be persistent; give sound advice
• Don’t stop at the first positive
answer
• Don’t stop at the first denial;
give examples that fit the
clinical situation
• Discourage use of remedies
KNOWN to have high risks,
e.g. aristolochic acid, Patent
Medicines from China, herbs
imported from developing
countries
More Resources on Herbs and
Dietary Supplements
• Natural Medicines Comprehensive Database:
http://www.naturaldatabase.com/
• ConsumerLabs: http://www.consumerlab.com/
• Natural Standard
http://www.naturalstandard.com/
• NIH NCCAM and OCCAM
• http://www.nlm.nih.gov/medlineplus/druginforma
tion.html
• MedLinePlus:
http://www.nlm.nih.gov/medlineplus/druginforma
tion.html
NIH Office of Dietary Supplements
http://ods.od.nih.gov/factsheets/Diet
arySupplements.asp
Lifestyle
• Nutrition, Diet, Habits to
avoid (tobacco, xs EtOH,
drugs)
• Exercise and Rest
• Mind-Body Therapies
• Environment
Environment
• No smoking; Clean house;
lead, allergens, air filters
• Minimize exposure to sick
people
• Read; Avoid guns
• Heat, cold, mist, sound,
magnets, color,
phototherapy, etc.
Mind-Body Therapies
•
•
•
•
•
•
Hypnosis
Guided imagery
Meditation
Journaling
Social Support
Psychological
counseling
• Peer support
Biomechanical
• Surgery
• Massage and bodywork
• Cranial, spinal or joint
adjustment
Bioenergetic
• Acupuncture
• Healing
Touch/TT/Reiki/Qi
Gung
• Prayer/Spirituality
• Homeopathy
ACUPUNCTURE
• Licensed in 43 states
• NIH strong evidence – post-op
nausea and dental pain;
promising for many other kinds
of pain; JAMA– turn breech
babies?
• http://nccam.nih.gov/health/acu
puncture/
Non-contact healing
HOMEOPATHY
•
•
•
•
•
Like cures like
Law of dilutions
Licensed in only 2 states
Most is OTC
Few pediatric studies –
diarrhea; otitis media;
allergies
Integrative Medicine Model
Biochemical
Lifestyle
Patient
Bioenergetic
Biomechanical
Remember:
• Ask
• Give examples when you ask
• Ask systematically –
biochemical, lifestyle,
biomechanical, bioenergetic
• Consider using selfadministered questionnaires
Remember your ethical framework
for advice
Effective
Yes
Safe Yes Use/Recommend
No
Monitor closely
No
Tolerate
Advise against
Remember your resources
•
•
•
•
AAP
NIH NCCAM
NIH NLM Medline Plus
Natural Standard, NMCD,
ConsumerLabs
• Academic Centers
• Professional Journals (PIR,
Contemporary Pediatrics)
Opportunities for fellowship
training
Complementary and
Alternative Research and
Education Program
• CARE (Edmonton, Alberta)
• http://www.care.ualberta.ca/
• University of Arizona
(Tucson) – not pediatric
oriented, but many
pediatricians have done it.
http://www.integrativemedicin
e.arizona.edu/index.html
A Short History of Medicine
2000 B.C.
1000 A.D.
1850 A.D.
1940 A.D.
1985 A.D.
2000 A.D.
Here, eat this root
That root is heathen.
Here, say this prayer.
That prayer is superstition.
Here, drink this potion.
That potion is snake oil.
Here, swallow this pill.
That pill is ineffective.
Here, take this antibiotic.
That antibiotic is artificial.
Here, eat this root.