complementary and alternative medicine

Complementary and Alternative Medicine

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Suzana Makowski, MD

Melissa Fischer, MD MEd

I have personally used a complementary or alternative medical therapy.

1 2

0%0%

1. Yes

2. No

I believe that most complementary and alternative therapies are effective.

1 2 3 4 5

0% 0% 0%0%0%

1. Strongly agree

2. Agree

3. Neutral

4. Disagree

5. Strongly disagree

I feel as comfortable discussing CAM therapies with patients as I do conventional western medical therapies.

1 2 3 4 5

0% 0% 0%0%0%

1. Strongly agree

2. Agree

3. Neutral

4. Disagree

5. Strongly disagree

I feel comfortable responding when a patient brings up CAM

1 2 3 4 5

20% 20% 20%20%20%1. Yes, definitely

2. Somewhat

3. I’m not sure

4. Not really

5. No way

Data re: use

1720 (41.3%) completed phone interview regarding health practices

Aromatherapy, acupuncture, chiropractic, folk remedy, herbal, diet, massage, relaxation, self-help group, yoga, spiritual healing, biofeedback, energy, homeopathy, hypnosis, imagery, megavitamin, naturopathy, osteopathy, spiritual healing

• Kessler et al. Ann Int Med. 2001;135:262-268

•Use at any time•No measure of persistence•English-speaking only

Barriers to prescribing CAM therapies by conventional western medical practitioners

Lack of knowledge of efficacy Lack of belief in efficacy Shifting basis of evidence Lack of consensus about use Lack of comfort Lack of interest in the topic

Potential harms from using CAM therapies

Physician-patient relationship strain Harm from patient rejection of proven

conventional western therapies Innate hazard

• Adams et al. Annals Int Med 2002

“even physicians who are willing to consider CAM treatments in some circumstances find it difficult to know how to responsibly and ethically advise patients in this unfamiliar realm of medicine.”

• Adams et al. Annals Int Med 2002

•==========================

•“EBM is the integration of best research evidence with clinical expertise and patient values.”Sackett, et al. Evidence-based medicine: How to practice and teach EBM. 2000

Types/Catagories of CAM

Mind-Body Herbal/Supplements Manual Energy Systems

Factors in risk-benefit of CAM vs conventional medical therapy

Severity & acuteness

Curability with conventional treatment (tx)

Invasiveness, toxicity & side effects of conventional tx

Evidence on safety & efficacy of CAM tx

Understanding of risks & benefits of CAM tx

Knowledge & acceptance of risks of CAM tx

Persistence of patient’s intention to use CAM tx

Adams et al. Annals Int Med 2002

Would you consider using lavender therapy to calm elderly demented pts?

1 2 3 4 5

20% 20% 20%20%20%

1. Yes, definitely

2. Maybe

3. I’m not sure

4. I don’t think so

5. No way

Aromatherapy

Cross-over randomized trial 70 Chinese adults with dementia (78) 3 weeks lavender inhalation (at least 1 hr

at night) Cohen-Mansfield Agitation Inventory

(CCMAI) & Neuropsychiatric Inventory (CNPI)

Lin et al, Int J Geriatr Psychiatry 2007; 22:405-410

Cochrane Review: Aromatherapy and Massage Therapy for Pts. with Cancer.

REVIEWERS' CONCLUSIONS: Massage and aromatherapy massage

confer short term benefits on psychological wellbeing, with the effect on anxiety supported by limited evidence.

Effects on physical symptoms may also occur.

Evidence is mixed as to whether aromatherapy enhances the effects of massage.

Replication, longer follow up, and larger trials are need to accrue the necessary evidence.

Would you consider using lavender aromatherapy in elderly demented pts?

1 2 3 4 5

20% 20% 20%20%20%

1. Yes definitely

2. Maybe

3. I’m not sure

4. Probably not

5. No way

Mindfulness

Randomized wait-list controlled 37 adults with chronic low back pain (74) 90 minutes x 8 weeks Pain, function and QOL questionnaires

baseline, after intervention and 3 mos later

Physical function (SF-36) 42-46 (8, 12 mos)

Pain acceptance 72-76 (75 12 mos) Continued meditation 76%, 72%

recommended to othersMorone et al. Pain 134(2008) 310-319

Depression: JAMA 2002Effect of St. John’s Wort in Major Depressive Disorder

Objective: Test efficacy & safety of St. John’s Wort in Major Depressive Disorder

Study Design: Double blind, randomized, placebo controlled trial. N=340 randomized to: (a) Sertraline (b) St. John’s Wort (c) Placebo

Conclusion: Study fails to support efficacy of St. John’s Wort in moderately severe major depression

Comments from Table 2 (results section)• “No significant differences between St. John’s Wort and placebo

(p=0.21), or between Sertraline and placebo (p=0.26).

Summary of Discussion/Conclusion

“No evidence of superior effect of St. John’s Wort relative to placebo. Neither St. John’s Wort or Sertraline could be differentiated from placebo on primary efficacy measures.”

Based on this data, “St. John’s Wort should not be substituted for standard clinical care”

But what if the standard care is Sertraline?

Respect of personal beliefs (pt s& own) Seek middle ground Time limited trial Coordination of care Abandonment Comfort in counseling without evidence

An Approach

What is the likely risk of therapy patient is considering?

Build referral relationships with local CAM providers.

Become familiar with a few possible approaches that you can recommend (i.e. Center for Mindfulness.)

I believe that complementary and alternative therapies may be effective.

1 2 3 4 5

20% 20% 20%20%20%

1. Strongly agree

2. Agree

3. Neutral

4. Disagree

5. Strongly disagree

I feel comfortable responding when a patient brings up CAM

1 2 3 4 5

20% 20% 20%20%20%

1. Yes, definitely

2. Somewhat

3. I’m not sure

4. Not really

5. No way

Lifetime use of CAM therapy increasing steadily since 1950s

English speaking only No measure of persistence

“the challenge for physicians … is to provide ethical, medically responsible counseling that respects and acknowledges patient values.”

Adams et al. Annals Int Med 2002

Experiential Session

Mindfulness Aromatherapy foot baths