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Integrative Medicine: What the Health

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Acupuncture, Massage Therapy, Chiropractic... Integrative Medicine ... Massage Therapy. Developed by almost all cultures. Many different forms ... – PowerPoint PPT presentation

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Title: Integrative Medicine: What the Health


1
Integrative Medicine What the Health?
  • Lisa W. Corbin, MD
  • Medical Director, Integrative Medicine
  • University of Colorado Denver Anschutz Medical
    Campus
  • Associate Professor, Internal Medicine

2
Objectives
  • After 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 patients (or self!)
  • Identify qualified CAM practitioners
  • List resources for finding more information

3
What is Integrative Medicine?
4
What is Integrative Medicine?
5
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6
Real Definitions
  • 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

7
Who Uses CAM Therapies?
Adults, 2002 incidence of CAM use
  • Over 80 also using conventional medicine

Barnes PM. www.cdc.gov/nchs/data/ad/ad343.pdf
8
Why Discuss CAM in the SOP?
  • Pharmacists viewed by public as among the most
    trusted, accessible HCP
  • Pharmacists report being asked about CAM
    therapies by patients
  • 68 of senior students at UMinn SOP hoped to be
    able to have CAM therapies available in their
    practices

9
Why Discuss CAM in the SOP?
  • U Minn SOP survey 83 of students wanted CAM
    education
  • 73-86 of SOP offer some CAM in curriculum, but
    mostly electives, focus on natural product

10
  • CAM Potential Risks
  • CAM Potential Benefits
  • Directly harmful treatment
  • Indirectly harmful treatment
  • Reducing efficacy of conventional treatment
  • Replacing curative conventional care
  • Cost
  • Symptom control
  • Reduce use of medications with side effects
  • Better tolerance of curative conventional care
  • Empowering to patient
  • Less cost
  • Less risk

11
Balancing Risks and Benefits
  • Discuss CAM openly
  • Normalize the behavior
  • Why?
  • Enhance HCP / patient relationship
  • Improve health
  • Dissuade from harmful practice
  • Encourage beneficial treatments
  • Integrate care with all providers
  • Be informed about specific risks and benefits

12
CAM Considerations
  • Avoid harmful practices
  • Use evidence-based, safe therapies
  • Consider plausible, safe modalities

Hippocrates First, do no harm
Sugarman J, Burk L. Physicians ethical
obligations regarding alternative medicine. JAMA
1998280(18)1623-1625.
13
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

14
Therapies to Highlight
  • Mind / body techniques
  • Sleep
  • Exercise
  • Acupuncture
  • Massage
  • Chiropractic
  • Herbs and supplements
  • Chinese Herbs

15
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

16
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

17
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)

18
Mind-body Highlighted Uses
  • Stress reduction
  • Anxiety, depression, insomnia
  • Grieving / acceptance
  • Behavior change
  • Symptom management
  • Pain (FM, muscle pain, HA)
  • Dyspnea (COPD, VCD)
  • Nausea

19
Get Some Sleep!
  • Restorative sleep improves pain, fatigue, and
    mood
  • Sleep deprived normals develop chronic pain
  • Links breast cancer, weight gain
  • Behavioral approaches
  • Dont 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
  • Dont nap

20
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

21
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

22
Acupuncture
  • Chinese 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

23
Acupuncture
  • Western 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 2004361(1-3)258-61.
Newberg AB et al. J Neuroimaging
200515(1)43-9 Mayer (1977) Brain Res
24
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25
General Advice Acupuncture
  • Acupuncture is generally safe
  • Adverse events minor or rare (pain, bleeding,
    fatigue)
  • Disposable needles, alcohol wipes to avoid
    infection
  • Practitioners
  • Must have a license in CO (LAc) scope of
    practice for MD, DO, DC
  • 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

26
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27
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
199715(5)1-34.
28
Massage Therapy
  • Developed by almost all cultures
  • Many different forms
  • Emphasis on improving circulation, releasing
    muscle tension, calming and relaxing patient

29
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30
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.o
    rg)
  • 60 / hour, occasionally covered

31
Massage Therapy Highlighted Uses
  • Relaxation, improved QOL
  • Post-operative wound healing
  • Lymphedema treatment
  • Pain management
  • Musculoskeletal complaints
  • Tension headaches
  • Fibromyalgia

32
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

33
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

34
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

35
Chiropractic Highlighted Uses
  • Back pain
  • Neck pain
  • Headaches
  • Other msk complaints

36
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37
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 beginning in 2008
  • Can vary in concentration of ingredients

38
General Advice Supplements
  • Natural ? safe
  • Use extra caution when taking prescriptions
  • Herb / drug interactions may be dangerous
  • Use trustworthy resources for information
  • If you choose recommend supplements
  • Look for well-labeled brands
  • Avoid combination products, MLM
  • Ask all patients about use!

39
Manufacturers More Likely to Produce Quality
Products
  • Natures Way
  • Natures Made
  • Natures Bounty
  • Costco
  • Phytopharmica
  • Puritans Pride

Susan Paulsen, PharmD, personal communication -
2007
40
Supplements to Avoid
  • Vitamin E
  • (No) benefit, meta-analysis revealed toxicity at
    higher doses
  • St. Johns wort
  • Too many drug interactions, ? DNA damage
  • Phytoestrogens in women with breast cancer risk
  • No evidence they are any safer
  • All supplements - pre-op
  • Blanket statement stop all products 2 weeks
    prior to surgery / upon hospital admit
  • Beware of metabolic / pharmacokinetic implications

41
Supplements to Consider
  • Multivitamin
  • But latest data doubts benefit good diet likely
    better
  • Calcium (women)
  • 1000 - 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

42
Supplements to Consider
  • Probiotics
  • Infectious diarrhea, IBD, IBS, antibiotic
    associated diarrhea
  • Coenyme Q10
  • Deficiencies beta blockers, statins, CHF
  • May help statin-associated muscle pain, reduces
    doxirubicin cardiac toxicity

43
Chinese Herbals
  • Traditional Chinese Medicine (TCM) uses
    acupuncture, cupping, diet, exercise and Chinese
    Herbal Medicines (CHM)
  • In TCM theory, herbs are always given as
    mixtures, with emperor (main) herbs and
    helper herbs the mixtures are thought to be
    more effective and also with less side effects
  • Because of the use of mixtures, CHM is more
    complicated and patients should avoid
    self-medicating with these products

44
Chinese Herbals
  • Common adverse reactions
  • GI intolerance (diarrhea, gas, bloating)
  • Headaches,
  • Insomnia
  • Pruritis
  • More serious adverse reactions
  • Anaphylactic shock
  • Liver or kidney failure
  • Miscarriage
  • To help assure safety when using CHM
  • Consult with professionals educated in CHM
  • Intermittent use (1-2 week break every 3-6
    months)
  • Periodic self assessment
  • Seeking reputable manufacturers (GMP)
  • Exercise caution with liver and kidney
    dysfunction, other meds

45
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46
Finding a Good Practitioner
  • Training and licensure
  • Experience with symptom
  • Risks
  • Costs / reimbursement
  • Time frame / progress assessment
  • Ability to work with conventional physicians

47
What the Health!
  • Integrative medicine coordinates CAM with
    conventional care
  • Dont use harmful CAM therapies
  • Use beneficial, safe therapies
  • Consider plausible, safe therapies
  • Talk to your patients
  • Throw them a bone approach
  • Find good practitioners
  • Use reliable information sources

48
The Center for Integrative Medicine
  • University of Colorado Hospital
  • Anschutz Medical Campus
  • 720-848-1090
  • www.uch.edu/integrativemed

49
  • General Assessment / Oversight
  • Lisa Corbin, MD
  • Traditional Chinese Medicine
  • Daisy Dong, L.Ac
  • Mel Drisko, L.Ac
  • Massage therapy
  • 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
50
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

51
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

52
  • 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

53
Education UCD-AMC
  • 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

54
Education
  • Other medical professionals / CME
  • Public education support groups
  • School of Nursing, Metro separate courses
  • Half-day shadowing experiences

55
Research
  • CAMPUS group
  • REST study
  • Demographic descriptive articles
  • Reviews

56
Future directions
  • Clinical Care
  • Expand outpatient services
  • Develop satellite programs
  • Education
  • CME conferences, lectures
  • Hands-on time
  • Research
  • Participate in campus-wide projects
  • Fund small grants
  • Follow treatment-specific clinical outcomes data
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