Transcript Integrative Medicine Complementary and Alternative Medicine

Integrative Medicine
Complementary and Alternative
Medicine
Ma. Stephanie Fay S. Cagayan, MD
Associate Professor
Objectives
• By the end of this presentation, you should be
able to...
– Define “Integrative Medicine” and other terms
– Describe the difference between traditional and
western medicine
– Describe the different types of CAM
– Understand how Integrative Medicine (especially the
use of herbal medicine) relates to Modern Philippine
Medicine and therapeutics
– Prepare to practice Integrative Medicine in the future
Presentation Outline
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Definitions
Why Should We Care About CAM?
What Do Patients Want?
What Can We Provide to Meet the Demand?
35 year-old female
• peripheral
neuropathy,
shoulder
tendonitis, and carpal tunnel syndrome
about 15 months after completing
chemotherapy for cancer.
• in complete remission
• Currently exercising, doing physical
therapy, taking a multi-vitamin and
following all of the recommendations of
her physicians
What more do you want to know?
What options would come to mind foryou?
How would you find information about
those options?
Health and Wellness
“Imagine a world - oriented toward healing rather than
disease, where physicians believed in the natural healing
capacity of human beings, and emphasized prevention
above treatment.
In such a world, doctors and patients would be partners
working toward the same ends.”
How do we practice medicine
Oriental/Traditional
Western
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”
National Center for Complementary and Alternative Medicine
Definitions
• “Complementary Medicine is Used Together
With Conventional Medicine.”
• “Alternative Medicine is Used in Place of
Conventional Medicine.”
Definitions
“Integrative Medicine Combines Mainstream
Medical Therapies and CAM Therapies for Which
There is Some High-Quality Scientific Evidence of
Safety and Effectiveness.”
NCCAM
5 Domains of CAM
5 Domains of CAM
Alternative
Medical
Systems
Ayurveda, Chinese, Native American, Aboriginal, African,
Middle Eastern, Tibetan, Central and South American cultures,
Homeopathy, Naturopathy
Mind-Body
Interventions
cognitive-behavioral approaches, meditation, hypnosis, dance,
music, art therapy, prayer, mental healing
Biological
Based
Therapies
dietary supplements, herbs, orthomolecular (varying
concentrations of chemicals, such as, magnesium, melatonin, and
mega-doses of vitamins), individual biological therapies (use of
laetrile, shark cartilage, bee pollen).
Manipulative
And BodyBased Methods
chiropractic, osteopathic manipulation, massage
Energy Therapies
Qi gong, Reiki, therapeutic touch, bioelectromagnetic-based
therapies (pulsed fields, magnetic fields, or alternating current
or direct current fields)
As Defined by NCCAM
Why Should We Care?
• 60% of Filipinos still lack access to doctors
• Majority of Filipinos are below poverty level
and cannot afford cost of health care
Why Should We Care?
• 600 Million Visits a Year to CAM Providers – More Than
to Primary Care Providers
• Why? What is Mainstream Medicine Not Offering to
Our Patients?
33%
15% 40%
25%
25-50%
50-75%
60%
40%
>90%
75%
>80%
~60%
55%
>80%
>80%
60-70%
40-70%
60-80%
~50%
70%
Eisenberg D. et al, JAMA, Nov 11, 1998(18) 1569-1575
www.WHO.org
Have We Missed the Boat?
• Dissatisfaction with health care
providers and medical outcomes
• Side effects of drugs and treatments
• High health costs/No choice
• Technology
• Lack of control in their
own health care practices
• Time spent with
practitioner
Stephen Strauss, M.D., NCCAM Director
Have We Missed the Boat?
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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
• No choice
Stephen Strauss, M.D., NCCAM Director
What about communication?
• Between 40 and 70% of CAM users do
not disclose their use to their
physician.
WHY?
Eisenberg 2001
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.”
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70% of patients see their Physician before or concurrent
with their visits to a CAM provider
Eisenberg DM. Ann Int Med 2001;135(5):344-51
Why would patients not trust us?
Why Would We Not Trust CAM?
- quackery
“Doctors concerned because several cases
reported of liver failure with Kava Kava, a
widely used natural remedy for anxiety”
Are Our
Patients
Reading
This?
Historical Developments: Global
• World Health Organization (WHO): 1978 Alma
Ata Declaration on Primary Health Care (PHC):
Integration of Traditional Medicine in PHC
• 1999: US Congress established the National
Center for Complementary and Alternative
Medicine (NCCAM) in the National Institutes
of Health (NIH) Bethesda, Maryland.
Worldwide perspective
• Complementary
• Alternative
• Traditional
Primary medical care
Treatment of minor
ailments
Health maintenance
www.WHO.org
Goals of Use/Treatment with CAM
1. Promotion and maintenance of
health
2. Prevention of disease and injury
3. Relief of pain and suffering
4. Cure of curable diseases and
illnesses
5. Care of people who are ill
6. Avoidance of premature death
7. Peaceful death
Regulations
• Varied from stringent to
none
• Canada
– Federal and provincial
regulations
• 2004 National Health
Products Regulations
• European Union
– Directive to register and
license products
• Mexico
– Traditional birth attendants,
homeopathic practitioners,
chiropractors licensed
– Registry of traditional
practitioners
• China and India
– Integrated with allopathic
medicine, regulated
Philippine Experience in Integrative
Medicine 1972-2008
• Mid-70’s: Private physicians
started training in
acupuncture in China
• Early 1980’s: DOH physicians
trained acupuncture in
China; herbal medicine
production started
• 1993-95: DOH established
the Traditional Medicine
Unit which promoted the
use of medicinal plants,
acupuncture and therapeutic
massage
Integrative Medicine Policy and
Practice in the Philippines
• 1995 -De La Salle University inaugurated the
Center for Indigenous Medicine in Dasmarinas,
Cavite -the 1st Philippine university to do so.
• 1997 -Republic Act 8423 established the
Philippine Institute for Traditional and
Complementary Health Care (PITAHC) in as an
attached agency of the Department of Health
(DOH).
What is Traditional and Alternative
Medicine as defined by R.A. 8423 ?
• The scope of alternative health care
modalities as other forms of non-allopathic,
occasionally non-indigenous or imported
healing methods, though not necessarily
practiced for centuries nor handed down from
one generation to another.
• 1999-2000 Filipino physicians
have organized the Philippine
Association of Medical
Acupuncturists Inc (PAMAI) and
the Philippine College for the
Advancement of Medicine
(PCAM) to promote the practice
of Integrative Medicine.
• 2001 -The UP College of
Medicine started an elective
course on Integrative Medicine
in both graduate and
undergraduate courses. The UPPhilippine General Hospital
inaugurated the Traditional and
Integrative Medicine Clinic.
• 2008 -The Philippine Institute of Traditional
and Alternative Medicine (PITAHC) started the
accreditation of acupuncturists practicing in
the Philippines, both for medical and nonmedical practitioners.
World View of Health in Filipino
Traditional Medicine
• Theory of macrocosm and
microcosm (“kalawakan” at
“sangkatauhan”)
• The balance, synergy and
harmony:
– Between Humankind and the
Universe
– Between Humankind and
Nature
– Between and Amongst people
– Within his body, mind and
spirit
World View of Health in Filipino Traditional
Medicine
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Theory of nature elements
fire (kalikasan ng apoy)
earth (kalikasan ng lupa)
water (kalikasan ng tubig)
air (kalikasan ng hangin)
Theory of body humours
Init (hot) and lamig (cold)
Wet (basa) at Dry (tuyo)
• Belief in nature spirits/guardians of nature and spirit ancestors
Folk or Traditional Medicine
• 80% of Third World countries utilize folkloric
medicine
• Formal training vs apprenticeships vs
observation, imitation, practice
– Skill may be inherited
• Range of remedies
– prayer, touch, charms, rituals, teas, tinctures,
poultice, etc
• All cultures
Herbal Medicine in the Philippines
• 8,000 to 12,000 flowering plants
• 1,500 species actively utilized by
traditional healers
– About 40% of medicinal plants
used in indigenous communities
have not been documented
• There are about 250,000
traditional medical practitioners
in the Philippines
Issues on the Use of CAM/Herbal
Medicine
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
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
Challenges to the Filipino Community
1. Majority of Philippine medicinal plants remain
CAM MODALITY
LICENSURE
undocumented
and untapped.
2. Scientific
studies supporting Philippine
Chiropractors
All states
traditional medicine practices is still in the
Massage
ther.
early phase
and full
potential 27
hasstates
not been
explored.
Naturopaths
13 states
3. Lack of collaboration among research
Homeopaths
institutions,
private sector and3 states
academe
*NIRPROMP
Acupuncturists
32 states
National Integrated Research Program on
Medicinal Plants
• A multidisciplinary research team established in
1976 under the Department of Science and
Technology
• Tasked to validate scientifically certain folkloric
uses of medicinal plants and to propagate the use
of herbal medicines rationally by the majority of
the people (for example, sambong has a folkloric
use for cough but upon scientific validation, it is
now used as a diuretic)
4.Lack of investments in research and
development, raw material production, post
harvest processing and herbal manufacturing.
5.Low level of scientific technology in herbal
medicine research and manufacture among
small and medium enterprises.
6. Low support for traditional medicine research
in the academic community.
7. Need for market and government incentives
like the ones given to rice, corn, coconut,
sugar, bananas, pineapples and mangoes.
8. Need for standardized procedures/
accreditation/recognition in Filipino
traditional medicine/herbal medicine
practices.
Answers to Challenges
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A wareness raising
N etworking among groups
T echnical capacity building
I nformation exchange/monitoring
D eepening of understanding
O rganizing concerned people
T ransformative action
E mpowerment of people
• Awareness, understanding and appreciation of
resources
• Capability for a relevant and self-reliant research and
development program
• Recognition and respect of community rights and
indigenous knowledge
• Strong national policies and laws to protect
indigenous resources
• Active defense against immediate threats to
biodiversity (mining, deforestation)
• Preventive action against potentially destructive
technologies/activities (developmental aggression)
• Confronting structural causes of unsustainable use
(political system)
• Patients are choosing
integrative and
alternative medicine,
but what about us,
physicians?
35 year-old female
• peripheral
neuropathy,
shoulder
tendonitis, and carpal tunnel syndrome
about 15 months after completing
chemotherapy for cancer.
• in complete remission
• Currently exercising, doing physical
therapy, taking a multi-vitamin and
following all of the recommendations of
her physicians
What more do you want to know?
What options would come to mind foryou?
How would you find information about
those options?
The Future of Integrative Medicine
The Future Is Sometimes Curing,
But Always Caring
Integrative Medicine
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requires a paradigm shift from
the disease-centered approach of conventional
biomedicine
to
an approach in which patient values and
participation of patients are central.
Maizes 1999
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.”
The Future of Integrative Medicine
• The Term “Integrative Medicine” Will Die
– Our Patients Will Demand Integrative Medicine
From All of Us
– Training Will Be Demanded by Medical Students
– Training Will Be Demanded by Residents
The Future of Integrative Medicine
• Integrative Medicine Will Be A Skill Set Added
on Just Like:
– Electronic Health Records
– New Medications
– New Procedures
How do We Add On These Skills?
• Build your database.
• Build a referral team.
• Ask your patients whom
they see.
• Look for summaries of
available data.
• Have an open dialogue
with your patients.
Resources
• National Center for Complementary and
Alternative Medicine
– http://nccam.nih.gov/
• Agency for Healthcare Research and Quality
– http://www.ahrq.gov/clinic/epcindex.htm
Resources
• American Academy of Medical Acupuncture
– www.medicalacupuncture.org
• Online Resource
– http://www.altmedicine.com
Where Should We Go for Information?
• Product claims
– www.quackwatch.com
– www.snopes.com
• Product quality assurance
– www.consumerlab.com
• Product ingredients
– Natural Medicines Database www.naturaldatabase.com
• Product safety and efficacy
– www.cfsan.fda.gov/~dms/ds-ind.html
– www.naturaldatabase.com
– The Natural Pharmacist www.iherb.com or www.consumerlab.com
The Future of Integrative Medicine
• What Cannot Be Added On is Empathy, Openmindedness and Respect for Other People’s
Beliefs
Summary
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Know what integrative medicine is
Dialogue with your patients
Build your database
Build your referral base
Develop patient care teams
Consider all available options
Be open-minded
Be an agent of change in your community
• Above all: be caring, concerned and
compassionate