Towards the appropriate use of effective and safe TMCAM therapies of good quality

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Dr Torkel FalkenbergLeader, Centre for Studies
of Complementary MedicineDeputy head, Division
of International Health (IHCAR) Lecturer in
Complementary Medicine Karolinska Institutet
Towards the appropriate use of effective and
safe TM/CAM therapies of good quality
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• Pharmaceutical Sector RD
• Laos, Vietnam, Thailand, Boliva, Peru, Uganda,
  Zambia, Bosnia, WHO World Bank
• Complementary Medicine RD
• Utilisation
• Policy development
• Integrative medicine
• Education

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Traditional and complementary medicine is widely
and increasingly used in all regions of the world
Sources Eisenberg DM et al. 1998 Fisher P
Ward A, 1994 Health Canada, 2001 World Health
Organization, 1998 and government reports
submitted to WHO.
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USA

• 427 million visits 1990 vs 628 million 1997 (385
  million visits to primary care physicians)
• More than 21 billion USD spent on visits 1997
• Top four chiropractic, acupuncture, hypnosis,
  massage
• 70 did not inform their doctor about the visit

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China

• TM hospitals increased from 678 in 1980 to 2522
  in 1995
• Staff increased from 73458 in 1980 to 353375 in
  1995
• Approximately 200 miljon patients treated at TM
  hospitals/wards per year
• Herbal medicines constitute 30 of total pharma
  market in 1995

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Laos

• Stratified two-stage sampling procedures were
  performed for selecting 600 households from one
  lowland, (Pakse) and one mountainous, (Paksong)
  district.
• The number of interviewees that had ever used
  traditional medicine was 460 (77 ) of which 233
  were women.
• 87 medicinal plants 8 sauna 3.5 massage
  2.8 acupuncture 16 other methods.

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The herbal medicines market
Million USD
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TM/CAM

• Increase in utilisation world-wide
• Consumer movement
• Lack of regulations
• Free market situation
• Unlimited market growth

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Common risks associated with TM/CAM where
patients may

• See unqualified practitioners
• Risk missed or delayed diagnosis
• Stop or refuse effective conventional treatment
• Waste money on ineffective treatments
• Experience dangerous adverse effects from
  treatments including unwanted interactions

Derived from Zolleman and Vickers, ABC of
Complementary Medicine, Brittish Medical Journal
Books, 2000
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Towards the appropriate use of effective and safe
TM/CAM therapies of good quality

• increase patient saftey
• affordable alternative to pharmaceuticals
• improve patient satisfaction
• provide cost-effective care

Developmental goals
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WHO Traditional Medicine Strategy 2002-2005
Policy

• integrate TM/CAM with national health care
  systems

Safety, efficacy and quality
provide evaluation, guidance and support for
effective regulation
Access
ensure availability and affordability of TM/CAM,
including essential herbal medicines
Rational use
promote therapeutically-sound use of TM/CAM by
providers and consumers
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Evidence Based Medicine (EBM)Different levels
and types of evidence Challenges

• Holistic systems (body, mind, spirit)
• Commonly many active components and unspecific
  effects
• The clinical RCT approach effective in assessing
  specific effects but limited in assessing
  unspecific effects

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RCT EVIDENCE
Source Research into complementary/alternative
medicine an attempt to dispel the myths. Ernst
E. Int J Clin Pract 2001 55(6)376-379
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RCT COSTS
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Who pays for research?

• No industry backing
• Who will sponsor RD in the area of acupuncture,
  massage, reflexology, yoga, etc?
• Despite popularity only 0.08 of NHS budget in
  the UK goes to CAM research
• To support evidence-based CAM it is crucial to
  find adequate funds for research

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RESEARCH ISSUES

• Policy research
• Setting research outcome priorities
• cost-effectiveness vs clinical efficacy
• Selecting and complementing appropriate EBM
  evaluation designs circular approach
• RCT, randomization by group, singel case,
  qualitative methods, etc
• Method development
• Earmarked financing

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Towards the appropriate use of effective and
safe TM/CAM therapies of good quality
RESEARCH TRIANGULATION

• HEALTH SYSTEMS RESEARCH

CARING RESEARCH
RCT
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• RESEARCH

• Bridging gaps between public and traditional
  health care sectors testing a model to improve
  quality of STI/HIV/AIDS care in sub-saharan
  Africa.
• Towards integrative medicine a pilot project
  exploring a collaborative model between primary
  health care providers and complementary therapy
  providers.
• Best and worst case series Exploring exceptional
  experiences of complementary and alternative
  therapies in patients with cancer.
• Comparative analysis of national polices for
  Traditional, Complementary and Alternative
  Medicine a global survey.

Elisabeth Faxelid, David Finer, Johanna Hök,
Jeremy Halpin, Ulf Leander, Marie-Louise Munzing,
Suzanne Schönström, Tobias Sundberg, Carol
Tishelman, Anders Warenmark