integrative medicine: what the health? lisa w. corbin, md, facp medical director, integrative...

Integrative Medicine: What

the Health?

Lisa W. Corbin, MD, FACPMedical Director, Integrative Medicine

University of Colorado Hospital and Health Sciences Center

Associate Professor, Rehabilitation and Internal Medicine

ObjectivesAfter this talk, you should be able to:

– Define “CAM”, “Integrative Medicine”– Discuss the basic background, risks, and

benefits* of some common CAM therapies– Discuss CAM with your doctor / patient– Identify qualified CAM practitioners – List resources for finding more information– Describe the Integrative Medicine program at

UCDHSC

What is Integrative Medicine?

What is Integrative Medicine?

Real Definitions Please…• CAM

– Complementary / Alternative Medicine– Therapies not usually associated with

hospitals or medical schools• Acupuncture, Massage Therapy, Chiropractic…

• Integrative Medicine – CAM therapies coordinated with conventional

medical treatments

Integrative Medicine

• Reaffirms patient / practitioner relationships

• Considers the “whole” person

• Is informed by evidence

• Considers all appropriate therapies, practitioners, and disciplines

• Promotes “optimal wellness”From Consortium of Academic Health Centers for Integrative Medicine(www.imconsortium.org)

Who Uses CAM Therapies?

Barnes PM. www.cdc.gov/nchs/data/ad/ad343.pdf

Adults, 2002 incidence of CAM use:

•Over 80% also using conventional medicine•Less than 35% discuss with physician – why?

CAM: Potential Risks

• Directly harmful treatment• Indirectly harmful treatment

– Reducing efficacy of conventional treatment

– Replacing curative conventional care

• Cost

CAM: Potential Benefits

• Symptom control– Reduce use of medications

with side effects – Better tolerance of curative

conventional care

• Empowering to patient• Less cost• Less risk

Balancing Risks and Benefits• Discuss CAM openly

– Enhance doc / patient relationship– Improve health

• Dissuade from harmful practice

• Encourage beneficial treatments

• Integrate care with all providers– Take ownership of your health and health care

• Be informed about specific risks and benefits

CAM Considerations

• Avoid harmful practices

• Use evidence-based, safe therapies

• Consider plausible, safe modalities

Sugarman J, Burk L. Physicians’ ethical obligations regarding alternative medicine. JAMA 1998;280(18):1623-1625.

Hippocrates : “First, do no harm”

Harmful CAM Therapies• Colonic enemas• Chelation therapy• IV therapies• Restrictive diets• Megavitamins• Some herbs / supplements

– Direct toxicity– Indirect: drug interactions– Stimulate tumor growth, immune system

• Anything used IN PLACE OF proven, curative, conventional treatments

Therapies to Highlight

• Mind / body techniques– Sleep– Exercise

• Acupuncture

• Massage

• Chiropractic

• Herbs and supplements

Why Mind-body?• Perception of pain requires processing by the

mind; mind-body therapies can alter perception• Stress / anxiety perceived as a threat,

processed by the mind as equivalent to pain• Insomnia worsens pain• Mind-body therapies are generally safe

– Caution with “blame the victim”

Mind-body Therapies• Cognitive Behavioral Tx• Relaxation techniques• Breathing techniques• Stress management• Biofeedback / heart math• Art, music, pet therapy• Mindfulness / Meditation• Imagery / visualization• Yoga / tai chi• Hypnosis

Mind-body Details• Typically meet with therapist 5 – 10 visits

• Patient needs to practice at home

• Not all therapists comfortable with all methods

• Often covered by insurance• Workbook:

– Caudill, Margaret. Managing Pain Before It Manages You, Revised Edition (Paperback)

Mind-body: Highlighted Uses• Stress reduction

• Anxiety, depression, insomnia

• Grieving / acceptance

• Behavior change

• Symptom management– Pain (FM, muscle pain, HA)– Dyspnea (COPD, VCD)– Nausea

Get Some Sleep!• Restorative sleep improves pain, fatigue, and mood• Sleep deprived “normals” develop chronic pain• Links: breast cancer, weight gain• Behavioral approaches:

– Don’t eat, drink, exercise just before bed– Avoid late day caffeine , too much alcohol– Get consistent exercise earlier in the day– Pay attention to room environment– Establish consistent sleep times– Get out of bed if not tired– Don’t nap

Exercise: Highlighted Uses• Improves sleep, depression, anxiety -

improving overall health• Duh – cholesterol, weight, BP, DM• Wow!

– Decreased pain in arthritis– Decreased hot flashes– Improvement in BMD– One of the cornerstone treatments for

fibromyalgia and chronic fatigue– Dramatic reduction of breast CA recurrence– Improvement in immune function

• Too much – decreased immunity

Exercise Instruction: FIT• F requency

– Exercise every day

• I ntensity– Break a sweat; increase difficulty of exercise

• T ime– Start with 5 minutes daily, increase by 1 minute

daily each week; goal 30 minutes / day

AcupunctureChinese Medicine Background

– Health = balance of yin and yang– Qi = energy force created by interaction

of yin and yang– Meridians = channels that carry qi throughout the body;

each corresponds with a specific organ– Excess, deficiency, or stagnant flow of qi results in

disease– Examples of TCM diagnoses:

• Yin deficiency and yang predominance with reduced kidney qi• Stomach qi rebelling

AcupunctureWestern Medicine Background

– Osler, 19th century “best treatment for lumbago”

– James Reston, China, 1971 – Biological effects

• Local nerve activation• Endorphins, ACTH, endogenous opiods (reversal of

analgesia with naloxone)– SPECT scanning: increased activity and reversal of

asymmetry in chronic pain patients in thalamic and prefrontal cortex during acupuncture over baseline

Han JS. Neurosci Lett 2004;361(1-3):258-61.

Newberg AB et al. J Neuroimaging 2005;15(1):43-9

Mayer (1977) Brain Res

General Advice: Acupuncture• Acupuncture is generally safe

– Adverse events: minor or rare (pain, bleeding, fatigue)– Disposable needles, alcohol wipes to avoid infection

• Practitioners – State to state variability (www.acupuncture.com/statelaws)– TCM: National Certification Commission for Acupuncture and Oriental

Medicine (www.nccaom.org)– MD: American Academy of Medical Acupuncture

(www.medicalacupuncture.org)• Costs

– Initial / follow up: $80 (MD $175) / $55 (MD $100)– Covered by some insurances

Acupuncture: Highlighted Uses• WHO - Chronic pain of any etiology

– Fibromyalgia / myofascial pain – Low back, neck pain– Headaches– Carpal tunnel – Osteoarthritis

• IBS• Depression / anxiety • Fertility / menstrual irregularity• Nausea (chemo, pregnancy, post op)

Acupuncture. NIH consensus statement 1997;15(5):1-34.

Massage Therapy• Developed by almost

all cultures• Many different forms• Emphasis on

improving circulation, releasing muscle tension, calming and relaxing patient

General Advice: Massage• Generally safe. Use caution with:

– Congestive heart failure– Infections– Blood clots / bleeding disorders– Osteoporosis or bone metastases– Pregnancy

• A license is NOT required in Colorado– Look for “CMT” or “LMT”– Look for involvement in AMTA (www.massagetherapy.org)

• $60+++ / hour, occasionally covered

Massage Therapy: Highlighted Uses

• Relaxation, improved QOL

• Post-operative wound healing

• Lymphedema treatment

• Pain management– Musculoskeletal complaints– Tension headaches– Fibromyalgia

Chiropractic• “Manipulation” referenced by

Hippocrates; Galen• Daniel David Palmer, 1895

– “Normalization of the nervous system” is key to health

• CAM vs. subspecialty

•Manipulation; often exercises, fitness, general health advice; acupressure, supplements•Practice styles, practice philosophies vary

Chiropractic: General Advice• Safety

– Generally safe– Local discomfort, headache, fatigue– Excessive xrays from some DCs– Stroke, dislocation, fracture rare but possible

• Risk of serious complication estimated at 6.39 per 10 million cervical manipulations (3.2 per 1000 for NSAIDS)

• Avoid high velocity neck manipulation

– Caution: cerebrovascular disease, osteoporosis, rheumatoid arthritis, metastatic cancer, bleeding disorders

Chiropractic: General Advice• Practitioners

– 4 year accredited school– Philosophies and styles vary widely – Licensing required in 50 states; scope of practice

variable

• Costs / reimbursement– Initial / follow-up $35 - 150 / $25 - 50– OMT usually covered; chiropractic often covered

Chiropractic: Highlighted Uses

• Back pain

• Neck pain

• Headaches

• Other msk complaints

Herbs and Supplements• Three types of medicines:

– Prescription (Rx)– Over-the-counter (OTC)– Dietary Supplements

• Unlike Rx and OTC, supplements:– Are not required to prove safety or efficacy

• Burden of proof on FDA to show unsafe

– Are not required to enforce quality control• GMP to be required by 2008

– Can vary in concentration of ingredients

• Natural safe

• Use extra caution when taking prescriptions– Herb / drug interactions may be dangerous

• Use trustworthy resources for information

• If you choose to take or recommend supplements:– Look for well-labeled brands– Avoid combination products, MLM sales products– Tell your health care providers / ask your patients

General Advice: Supplements

Supplements to Avoid

• Vitamin E– No proof of benefit, meta-analysis with concerns of

toxicity

• St. John’s wort– Too many drug interactions, ? DNA damage

• Pre-op– Blanket statement – stop all products 2 weeks

prior to surgery / upon hospital admit• Beware of metabolic / pharmacokinetic implications

Supplements to Consider• Multivitamin

– But latest data doubts benefit; good diet better

• Calcium (women)– 1500 mg / day total

• Vitamin D– Most Americans deficient– Cancer prevention, muscle pain

• Fish oil (Omega 3 FA)– Heart disease, TG, HTN, HA, weight

loss, depression, cancer prevention

Supplements to Consider• Probiotics

– Infectious diarrhea, IBD, IBS, antibiotic associated diarrhea

• Coenyme Q10– Deficiencies: beta blockers,

statins, CHF– Helps statin-associated muscle

pain, reduces doxirubicin cardiac toxicity

Finding a Good Practitioner

• Training and licensure

• Experience with symptom

• Risks

• Costs / reimbursement

• Time frame / progress assessment

• Ability to work with conventional physicians

What the Health!• Integrative medicine coordinates CAM

with conventional care

• Don’t use harmful CAM therapies

• Use beneficial, safe therapies

• Consider TCFIM at the University of Colorado Hospital as a resource

University of Colorado Hospital Anschutz Medical Campus• 720-848-1090• www.uch.edu/integrativemed

The Center for Integrative Medicine

Conception • Group of interested faculty presented

proposal to UCH/HSC administration, late 1990’s

• Administrator hired March, 2001• Steering committee drawn from all 4

UCHSC schools• “Clinical first, then education / research”• First clinical services December, 2001

General Assessment / Oversight• Lisa Corbin, MD

Traditional Chinese Medicine• Daisy Dong, L.Ac • Mel Drisko, L.Ac

Massage therapy• Rose Patch, CMT• Molly Monahan, CMT• Ann Mathews, CMT

Nutritional Counseling• Colleen Gill, RD• Pamela Ham, RD

Pharmaceutical / Herbal Consults• Susan Paulsen, Pharm D

Chiropractic• Brian Enebo, DC

Behavioral Medicine / Biofeedback• Bennett Leslie, PsyD• Denise McGuire, PhD

Clinical Care

Access to Services• Referrals

– Self referred– UCH physician or provider referred– Outside physician or provider referred

• Insurance / authorizations checked• Visits scheduled

– With specific practitioner, and / or– With Medical Director to explore all options and

make a personalized plan

Integration of Care

• Notes for each visit available in EMR

• Referral letter written to physicians, other providers, and patient

• Formal case reviews– Integrates the care from within TCFIM– Further integration with other care providers

• www.imconsortium.org

• 39 member schools in US, Canada

• Collaboratively working to promote Integrative Medicine care, education, and research

• Resource to learn from each other

Education: UCHSC• Resident elective (est. 1999)• Medical student elective (2003)• Medical student required lectures

– Herbal pharmacology / small groups– Chiropractic theory and practice– Advising patients on use of CAM

• Formal classroom teaching in PT and Pharmacy Schools (required courses)

• Lectures in CHA/PA training

Education

• Other medical professionals / CME

• Public education – support groups

• School of Nursing, Metro – separate courses

• Half-day shadowing experiences

Research

• CAMPUS group

• REST study

• Demographic descriptive articles

• Reviews

Clinical Care• Expand outpatient services• Develop satellite programs

Education• CME conferences, lectures• Hands-on time

Future directionsResearch• Participate in campus-

wide projects• Fund small grants• Follow treatment-

specific clinical outcomes data