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Complementary and Alternative Medicine (CAM) Resources fo

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Complementary and Alternative Medicine (CAM) Resources for the Practitioner: ... Jennifer Aniston. Ernst MJA 2006; 185 (11/12): 680-681 ... – PowerPoint PPT presentation

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Title: Complementary and Alternative Medicine (CAM) Resources fo


1
Complementary and Alternative Medicine (CAM)
Resources for the Practitioner Where to look
and Who to Trust
  • John D. Mark MD
  • Clinical Assoc Professor of Pediatrics
  • Pediatric Pulmonary Medicine
  • Lucile Packard Childrens Hospital at Stanford

2
CAM- Where is it?
  • A 14 yr old athlete with moderate, persistent
    asthma comes to clinic. He has an asthma action
    plan and has been adherent with his controller
    medication. Now he wants to try a breathing
    technique (Buteyko) so he can get off his meds.
  • A 3 yr old comes to the clinic for a well-child
    check-up. On exam you find a right otitis media.
    She is asymptomatic and you recommend watchful
    waiting. The parents would like to try a
    homeopathic remedy because they had heard that
    homeopathy worked better than placebo for
    children with an ear infection.
  • Answer Everywhere

3
CAM- every where you look
4
CAM in the News
  • Dying Woman Loses Marijuana Appeal March 14, 2007
  • Evidence Mounts That Coping Skills Can Boost HIV
    Survival March 14, 2007
  • Omega-3 in Fish Oils Might Ease Depression March
    7, 2007
  • Insomnia Alternative Medicine Popular
  • 1.6 Million Adults Use Complementary Or
    Alternative Medicine For Insomnia September 2006

5
Ernst MJA 2006 185 (11/12) 680-681
6
Complementary and Alternative Medicine (CAM)
  • Complementary and alternative medicine
  • A group of diverse medical and health care
    systems, practices, and products
  • Not considered part of conventional medicine
  • Some scientific evidence exists regarding CAM
    therapies
  • For most, questions of safety and efficacy
    persist
  • Complementary medicine is used together with
    conventional medicine. Alternative medicine is
    used in place of conventional medicine.

http//nccam.nih.gov/health/whatiscam/
7
Integrative or Holistic Medicine
  • Integrative combines mainstream medical therapies
    and CAM therapies for which there is some
    high-quality scientific evidence of safety and
    effectiveness.
  • Healing-oriented medicine that takes account of
    the whole person (body, mind, and spirit),
    including all aspects of lifestyle. It emphasizes
    the therapeutic relationship and makes use of all
    appropriate therapies, both conventional and
    alternative.

http//nccam.nih.gov/health/whatiscam/
http//www.integrativemedicine.arizona.edu/about2.
html
8
Major Classes of CAM
Enhance the minds capacity to affect
bodily function and symptoms
  • Chiropractice
  • Osteopathy
  • Massage

Alternative medical systems
Mind-body interventions
Manipulative body-based methods
Energy therapies
Biologically -based therapies
  • Homeopathic
  • Naturopathic
  • Traditional
  • Chinese and
  • Ayurvedic
  • treatments
  • Dietary supp
  • Herbs
  • Foods
  • Vitamins
  • Natural
  • substances
  • Biofield therapy
  • Bioelectro-
  • magnetic
  • therapy

http//nccam.nih.gov/
9
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10
CAM Utilization
  • Reasons for using CAM
  • Consistent with patients and families values
    natural, and empowering
  • CAM providers are patient-centered, dedicated
    to promoting health.
  • Conventional therapies are perceived to be
    emotionally or spiritually without benefit
  • Conventional therapies are not effective or are
    associated with side effects.
  • CAM use is a circular usage determines number of
    CAM practitioners

Archives of Disease in Childhood 20069196-97
11
CAM Therapies
http//nccam.nih.gov/news/camsurvey_fs1.htmdomain
12
CAM Therapies
13
Pediatric Use of CAM
  • Asthma 80 Reznik, 2003 (Bronx,
    NY)
  • Adolescents 54-69 Wilson, 2002 (NY)

    Braun, 2005 (MN)
  • Special Needs 64 Sanders, 2003
    (Tucson, AZ)
  • Rheumatology 64 Hagen, 2003
    (Toronto)
  • ADHD 54 Chan et al, 2003
    (Boston Childrens)
  • Emergency 13-45 Losier, 2005 (Ottawa)
    Lanski, 2003 (Atlanta)

14
Pediatric Use of CAM
  • Oncology 47-84 McCurdy, 2003
    (WFU)
  • Neuhouser, 2001 (Seattle)
  • Kelly, 2000 (NYC)
  • Cerebral Palsy 56 Hurvitz,
    2003
  • Ann Arbor, MI
  • IBD 41 Heuschkel, 2002
  • London, Boston, Detroit
  • Autism Spectrum 30 Levy,
    2003 CHOP, PA
  • Preoperative 29.5 Lin, 2004
  • Boston Childrens
  • Primary Care 12-21 Sawni, 2002
    (Detroit) Ottolini, 2001 (Wash D.C.)

15
Evidence Based CAM Therapies in Pediatrics
  • Effectiveness well documented
  • Acupuncture for nausea and vomiting
  • Biofeedback for constipation
  • Biofeedback for headache
  • Hypnotherapy for headache
  • Hypnotherapy for irritable bowel syndrome
  • Lemon balm for herpes simplex
  • Massage for constipation

Archives of Disease in Childhood 20069196-97
16
CAM Treatments Commonly Thought Effective in
Pediatrics
  • Effectiveness uncertain
  • Acupuncture for asthma
  • Acupuncture for hay fever
  • Acupuncture for rheumatoid arthritis
  • Chromium for diabetes
  • Echinacea for common cold prevention or treatment
  • Evening primrose for eczema
  • Effectiveness unlikely
  • Acupuncture for body weight reduction
  • Acupuncture for smoking cessation
  • Flower remedies for anxiety
  • Homeopathy for anxiety
  • Spinal manipulation for asthma
  • Spinal manipulation for infantile colic

Archives of Disease in Childhood 20069196-97
17
Use of Herbs- Evidence?
  • Alternative Health supplement of the 2002
    National Health Interview Survey data on 10
    common herbs
  • Of 30,616 adults, 19 used herbs in past 12 mo,
    57 for a specific condition
  • Approximately 2/3 used herbs (except Echinacea)
    not in accordance with evidence based indications
  • Mayo Clin Proc, May 200782(5) 561-566

18
Conventional Medicine, Evidence?
  • Most conventional physicians believe in
    unconventional medicine because it is not
    scientific
  • What is evidence-based medicine? Treatment that
    will improve patient outcomes by well-designed,
    appropriately powered, randomized, controlled
    clinical trials.
  • There is not good evidence (Grade A) that many of
    the commonly used therapies in conventional
    medicine are effective (ex heparin, aspirin, and
    warfarin).
  • The principal distinguishing characteristic of
    unconventional and conventional medicine
    therapies is the source of introduction.
  • Conventional therapies are introduced by
    mainstream Western physicians and scientists,
    whereas most unconventional modalities are
    introduced by "outsiders."
  • One of the reasons that most unconventional
    modalities are not evidence based is that the
    majority of them were introduced prior to the
    20th Century

Arch Intern Med. 19981582179-2181
19
CAM Pediatric Care
  • Evidence is lacking even for the most popular, if
    there is evidence, most is in adults
  • However, the Institute of Medicine states the
    same principles and standards of evidence of
    treatment effectiveness apply to all treatments
    whether currently labeled as conventional
    medicine or CAM.
  • Only 1/3-1/3 of patients or their parents
    reported CAM use to their doctors. Indicates a
    need to promote dialogue about CAM use between
    patients and their health care providers.

20
Physicians Attitudes
  • Survey sent to 660 physicians at the Mayo Clinic
    (233 responded)
  • Three areas utilization, familiarity and
    attitudes
  • Utilization
  • 75 had never referred to CAM practitioner
  • 44 said they would consider if available at the
    Mayo (lt46 years or female more likely)
  • Less 25 discussed benefits or risks with CAM
  • 57 thought incorporation of CAM would be have a
    positive impact on pt satisfaction

21
Physicians Attitudes
  • Familiarity
  • Biofeedback, massage, chiropractic and relaxation
    therapies were the most familiar
  • 59 were unfamiliar with energy healing, 53 with
    naturopathic medicine
  • Of the 13 herbs listed, only 3 were commonly
    listed as familiar
  • 66 were not familiar with feverfew and 52 were
    not familiar with Kava
  • 49 of the physicians felt it was difficult or
    very difficult to find reliable information about
    herbs

22
Physicians Attitudes
  • 41 of the physicians neither agreed or disagreed
    that physician knowledge had an impact on
    patients health
  • 52 felt physicians spiritual beliefs were
    important and 87 felt patients spiritual beliefs
    and practices were important
  • 67 agreed some CAM therapies hold promise but
    70 felt current practices of CAM was a threat
    to the public health
  • Most important factors in changing physicians
    attitudes were RCTs and evidence demonstrating
    mechanism
  • 70 of the physicians felt Mayo clinic should
    provide proven CAM therapies

eCAM 20063(4) 495-501
23
Federation of State Medical Board Guidelines
(excerpts)
  • Patient evaluation Includes the use of
    non-conventional methods of diagnosis and
    treatment
  • Consultation and/or referral to licensed or
    otherwise state-regulated health care
    practitioner- the Physician is responsible for
    monitoring the results
  • Medical records should also document What
    conventional medical options have been discussed,
    offered, tried, or refused
  • Education- All physicians must be "able to
    demonstrate a basic understanding of the medical
    scientific knowledge" connected with any CAM
    therapy

www.fsmb.org
24
What to do.
  • Be aware of the growing scientific evidence
    concerning the safety and effectiveness of
    relevant complementary, as well as mainstream,
    therapies.
  • Balance the risks and benefits of any therapy
    before recommending a course of action, and
    continue to monitor patients appropriately.
  • Discuss and document with patients and their
    families any information regarding treatment
    decisions, conventional or CAM.
  • Know professional guidelines including ethics

25
CAM Education in Pediatrics
  • CAM education in medical schools
  • American Academy of Pediatrics (AAP)
  • Pediatric Integrative Medicine Leadership
    Initiative and Pediatric Integrative Medicine
    Conference (PIMC)
  • International Pediatric Integrative Medicine
    Network (IPIM-N)
  • Canadian network linking pediatric CAM
    researchers educators (PedCAM)

26
CAM Education in Medical Schools
  • 1998 survey found 75 medical schools (out of 125)
    offered CAM electives or including these topics
    in required courses
  • 81 of the schools that included CAM in the
    curriculum did so by adding stand alone courses
    or electives, 41 used required courses, and 23
    had both stand-alone and in required courses
    JAMA. 1998280784-7
  • Barriers included lack of money, lack of time to
    plan and prepare, and outright animosity on the
    part of faculty.
  • unscientific, lack of mechanistic explanation or
    demonstrated clinical efficacy.if taught could
    be viewed as advocacy
  • Change is occurring
  • Harvard Division for Research and Education in
    Complementary and Integrative Medical Therapies
  • Albert Einstein, Columbia, Duke, Mount Sinai,
    Stanford, Arizona, Maryland, Pennsylvania, and
    several branches of the University of California
    have included CAM in the curriculum

27
How to Include CAM in Education
  • Teach One Medicine
  • Create Opportunities for Cross-Fertilization
  • Develop Support and Commitment from the
    Institution
  • Offer a Well-Designed Electives
  • Include an Experiential Component (acupuncture,
    massage, homeopathy, craniosacral etc)
  • Plan across the Curriculum from Undergraduate to
    Graduate and Continuing Medical Education (often
    a void during residency and fellowships)

Wetzel MS, et al. Ann Intern Med 2003 138 1916
28
Current Status - AAP
  • Provisional Section on Complementary, Holistic
    Integrative Medicine (CHIM)
  • Kathi Kemper, Chair for Holistic and Integrative
    Medicine and Professor of Pediatrics, Wake Forest
    University
  • Section will promote policies to enhance
    patient-centered care, integrating
    evidence-based, safe and effective complementary
    therapies
  • Meetings
  • Super CME Courses
  • AAP National Conference October 2007
  • Four sessions by CHIM members

29
Current status - PIMC
  • Pediatric Integrative Medicine Conference
  • Collaboration of academic faculty at multiple
    pediatric integrative medical centers in
    US/Canada
  • 1st-2000, University of Arizona, Tucson
  • 2nd-2001, University of Minnesota, Minneapolis
  • 3rd- 2005, New York Academy of Medicine, NYC
  • 4th- 2006 October, 27-29th, Chicago
  • 5th- 2007, October 26-27th, San Francisco
  • http//www.pangeaconference.com/index.asp

30
Current Status - IPIM-N
  • International Pediatric Integrative Medicine
    Network
  • List serve connecting PIM practitioners and
    organizations
  • Facilitates communication and collaboration
  • Promotes clinical, educational and research
    initiatives
  • Provides resources and links
  • Secure electronic network
  • ldrdoc_at_alum.mit.edu

31
Resource Evaluation
  • Introduction
  • Who runs this site?
  • Who pays for the site?
  • What is the purpose of the site?
  • Where does the information come from?
  • What is the basis of the information?
  • How is the information selected?
  • How current is the information?
  • How does the site choose links to other sites?
  • What information about you does the site collect,
    and why?
  • How does the site manage interactions with
    visitors?

32
A Guide for Providers Using CAM
  • Government sites
  • National Center for CAM
  • http//nccam.nih.gov/
  • Office of Dietary Supplements
  • http//ods.od.nih.gov/Research/CARDS_Database.asp
    x
  • MedWatch
  • http//www.fda.gov/medwatch
  • CAM on PubMed
  • http//www.nih.gov/news/pr/feb2001/nccam-05a.html

33
NCCAM Website
  • AcupunctureArthritisBlack CohoshCancerChelatio
    nChiropracticChondroitinDepressionDietary Supp
    lements
  • EchinaceaEphedraGinkgoGinsengGlucosamineHerbs
    at a GlanceHomeopathyMenopauseSt. John's Wort
  • Introduction to Naturopathy
  • New Herbs at a Glance Grape Seed Extract
  • AARP/NCCAM Report on Older Americans
  • Past Highlights
  • News from NCCAM 
  • Subscribe to quarterly newsletter
  • Monthly e-bulletin

34
A Guide for Providers Using CAM
  • Academic sites
  • Boston-Longwood Herbal Task Force
  • http//www.longwoodherbal.org/
  • University of Pittsburgh
  • http//www.pitt.edu/cbw/database.html
  • Beth Israel Medical Center NYC
  • http//www.healthandhealingny.org/
  • Columbia University
  • http//www.rosenthal.hs.columbia.edu/Botanicals.h
    tml
  • University of California, Berkeley Newsletter
  • http//www.wellnessletter.com/html/ds/dsSupplemen
    ts.php

35
Longwood Website
  • ABC's of Herbal Medicine Herbs Dietary
    Supplements Vitamins MineralsIn-depth
    Monographs (71) Clinician Information
    SummariesPatient Fact Sheets Articles by LHTF
    MembersInteractions and Toxicity Information
    Resources LinksAbout the LHTF  How to Support
    the LHTF

36
Courses and Websites
  • Herbs and Dietary Supplements-Wake Forest
    University
  • http//northwestahec.wfubmc.edu/learn/herbs/index.
    aspCurrDesc
  • Botanicals and Health series-University of
    Arizona
  • http//integrativemedicine.arizona.edu/online_cour
    ses/botanicals
  • Botanical Medicine in Modern Clinical Practice
    (NYC)
  • http//cait.cpmc.columbia.edu88/dept/rosenthal/Bo
    tanicals_CME.html
  • Consumer Labs
  • http//www.consumerlab.com
  • Natural Medicines Comprehensive Database
  • http//www.therapeuticresearch.net/(ctt54155qny2vs
    55ryiv2d32)/home.aspx?li0st0cssND
  • Quackwatch http//www.quackwatch.com.

37
Consumer Labs
  • ConsumerLab.com, is a provider of independent
    test results and information to evaluate health,
    wellness, and nutrition products.
  • 2.5 millions visits/year and as a certification
    company, CL enables companies of all sizes to
    have their products voluntarily tested for
    inclusion in its list of Approved Quality
    products and bear the CL Seal.
  • In the past 7 years, tested more than 1,800
    products, representing over 350 different brand
    and supplements. One-year (12 months)
    subscription is 27.00
  • Natural Products Encyclopedia and free newsletter

38
Natural Medicine Database
  • Search - enter natural product name, disease or
    condition, or drug name objective product
    information, Effectiveness Ratings, or potential
    interactions with drugs
  • Natural Product Effectiveness Checker - tells you
    the level of effectiveness for natural products
    used for various medical conditions.
  • Natural Product / Drug Interaction Checker -
    tells you potential interactions between any
    natural product and any drug.
  • Disease / Medical Conditions Search - shows you
    medical conditions, and allows you to see which
    natural products might be effective.
  • Search Colleagues Interact - shows you questions,
    answers, and comments posted by other health
    professionals.

39
Fellowships and Residencies
  • University of Arizona Associate Fellowship
  • http//www.integrativemedicine.arizona.edu/af/inde
    x.html (residential and associate)
  • Family Practice and CAM residencies
  • Albert Einstein College of Medicine
  • Maine Medical Center
  • Middlesex Hospital Family Practice Residency
    Program
  • Oregon Health Science University
  • University of Arizona College of Medicine
  • University of Wisconsin Madison

40
CAM Local Resources
  • Stanford Center for Integrative Medicine (SCIM)
  • http//www.stanfordhospital.com/clinicsmedServices
    /clinics/complementaryMedicine/default
  • Osher Center for Integrative Medicine
  • http//www.osher.ucsf.edu//
  • Five Branches Institute
  • http//www.fivebranches.edu/
  • College of Botanical Healing
  • http//www.cobha.org/
  • Ryan Ranch, Integrative Medicine
  • http//www.ryanranchmedicalgroup.com/integrative_m
    edicine.htm

41
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