COMPLEMENTARY AND ALTERNATIVE MEDICINE ^225 ^588 ^647

Complementary and alternative medicine (CAM) can be defined as those systems, practices, interventions, modalities, professions, therapies, appli­cations, theories, or claims that are currently not an integral part of the dominant or conventional medical system (known as allopathy in North America).

In 2007, 38.3% of Americans used some form of CAM over the previous 12 months, spending $33.9 billion out of pocket. This trend of increased CAM use will continue as it is reinforced and supported by continuing media attention; intense commercial efforts by providers of CAM products and services, including proprietary pharmaceutical companies; third-party reimbursement for some CAM practices and products; and the increasing over-the-counter access to CAM products in drugstores and supermarkets.

Types of Therapy

The spectrum of CAM encompasses more than 350 different techniques and treatments. These can be classified into the following major categories, with some overlap.

Mind-Body Practices

Mind-body practices typically focus on intervention strategies that are believed to promote health and well-being and include yoga, relaxation­response techniques, meditation, tai chi, hypnotherapy, spirituality, sup­port groups, visual imagery, and biofeedback. This field views illness as an opportunity for growth and transformation.

Whole Medical Systems

Whole medical systems use multiple modalities when promoting health and treating illness and are exemplified by traditional Chinese medicine. Other approaches in this category include homeopathy, Ayurveda, natu­ropathy, chiropractic medicine, Native-American medicine, and the various forms of acupuncture.

Biologically Based Practices

Biologically based practices include, but are not limited to, the use of botanicals, animal-derived extracts, vitamins, minerals, fatty acids, amino acids, proteins, whole diets, functional foods, and probiotics.

Nutrition-based and diet-based practices encompass the use of vitamins, minerals, and nutritional supplements, in general, and cancer and cardio­vascular disease diets, in particular. Dietary supplements that have gained popularity in Western culture include the use of glucosamine for arthritis, of echinacea for upper respiratory infections, and of fish oil for cardio­vascular disease. Other diet-based and nutrition-based treatments include megadosing, elimination of or excessive intake of certain foods, vegetarian and macrobiotic diets, and diets associated with various physicians (see also the “Fitness” section earlier in Part 3).

Functional foods are components of the usual diet that may have bio­logically active components (eg, fish oils and polyphenols). Specific examples include dark chocolate, soy, and nuts. Sales of functional foods are explod­ing, thanks in part to the ability of manufacturers to advertise directly to consumers.

Probiotics are defined by the World Health Organization and the Food and Agriculture Organization of the United Nations as “live microorgan­isms, which, when administered in adequate amounts, confer a health benefit on the host.” Probiotics are enjoying increasing popularity, par­ticularly among women. These bacteria, often used to promote digestion, are similar to bacteria found normally in the gut, either lactobacillus or bifidobacterium species. Of interest to the obstetrician-gynecologist are women who use probiotics to treat irritable bowel syndrome or infections of the female urinary or genital tract. Probiotics are available in foods and dietary supplements and in some other forms as well. In probiotic foods and supplements, the bacteria may have been present originally or added during preparation. Examples of foods that contain probiotics include yogurt, fermented and unfermented milk, miso, tempeh, and some juices and soy beverages.

Manipulative and Body-Based Practices

Manipulative and body-based practices focus mainly on the structures and systems of the body, including the bones and joints, the soft tissues, and the circulatory and lymphatic systems. These are among the most widely accepted and commonly used CAM therapies. Examples include massage and chiropractic and osteopathic manipulation.

Energy Medicine

Energy medicine describes a domain of CAM that uses two types of energy to affect health: 1) veritable, which is of specific measurable wavelengths or frequencies, and 2) putative (or biofield), which has so far eluded measure­ment. Veritable energy medicine includes the use of magnets to treat mus­culoskeletal and neurologic pain; of low-frequency thermal waves for deep tissue heat treatment (or diathermy); of pulsed electromagnetic waves to treat bone fractures; of transcutaneous electrical nerve stimulation for pain relief; and of light to treat conditions such as seasonal affective disorder. Putative energy medicine is based on the concept that humans are infused with subtle forms of energy. Examples include the use of qi in acupuncture, Reiki, therapeutic touch, Ayurveda, and distant healing.

Safety Concerns

Safety is the critical issue when a patient asks about the merit of using a CAM product or intervention. The potential can exist for direct and indi­rect risks. These risks can include patient delay in or avoidance of seeking appropriate conventional treatment, a misdiagnosis, toxic reactions from ingested substances, and interference with the mechanism of action of a prescribed drug or treatment.

Over-the-counter herbal preparations and dietary supplements, such as those marketed to relieve menopausal symptoms, may be of particular concern to the obstetrician-gynecologist. There can be uncertainty as to the identity of the active ingredient and its potency. Also, the chemical com­position may vary from manufacturer to manufacturer and by lot number, and there may be adulteration without this being identified on the label.

Concerns about safety can be tempered for some CAM modalities. For instance, it is unlikely that homeopathic preparations, acupuncture, biofeedback, or prayer will be associated with direct adverse effects. In contrast, intravenous hydrogen peroxide, chelation therapy, and mega­dosing of supplements can be toxic and dangerous. Accordingly, when informed that a patient is using CAM, her clinician can advise her if there is supporting published research, warn her about real or potential dangers, ascertain whether the CAM method can be continued in conjunction with conventional treatment, and monitor her treatment for positive and nega­tive effects over time.

Addressing Patient Use and Interest

Most patients who use CAM are self-referred and do not tell their phy­sicians about their use of CAM treatments. Thus, their medical record is incomplete, and the possibility of medical risk cannot be addressed. Inquiring about the patient’s interest in, or use of, CAM and providing information on safety and effectiveness can be integral to the physician’s role as a patient advocate. Patients can be asked questions such as, “Have you used or have you been considering other kinds of treatment or medi­cations for relief of your symptoms or to maintain wellness?” Follow-up questions to a positive answer can include asking when she decided to use CAM, what results she was expecting, how she chose the method, and how it has worked for her.

Some patients will request a referral to a local alternative care provider. Any such referral should be made only to a state-licensed provider. All states license chiropractors, but not all license other CAM providers, such as natu­ropathic physicians, acupuncturists, or massage therapists. Physicians should be aware of possible liability consequences of such referrals. If the referral itself is negligent because it is inconsistent with generally accepted standards of medical practice, the referring physician may be exposed to liability if the patient is injured by the subsequent treatment. Also, liability may arise if the referring physician supervises the CAM care, jointly treats the patient, or knows (or should have known) that the CAM provider is unlicensed.

It can be anticipated that patients will continue to use CAM with or without physician referral. Accompanying this use is the public’s expec­tation that health insurance plans will reimburse for CAM treatment. A growing number of third-party payers have responded by doing so under a variety of clinical guidelines. This willingness can result in conflict between physicians and CAM providers if important operational issues are not addressed. These issues include the creation of protocols and plans of care for specific diagnoses, procedures for monitoring and follow-up with finite clinical endpoints, evidence for safety and effectiveness, and identified cri­teria for referral to conventional care.

Health Care Provider Education

Each physician can determine to what extent he or she wishes to learn more about various aspects of CAM. There are a number of ways to obtain information. Clinical studies in peer-reviewed, conventional medical journals now appear on a regular basis. In addition to continuing medical education courses, there are peer-reviewed medical journals, textbooks, and newsletters devoted to the subject. Computer databases and web pages specifically oriented to CAM now are accessible by physicians and patients (see Bibliography and Resources).

In the coming years, it is likely that there will be a continued blending of conventional medicine with various CAM therapies as evidence-based research data support clinical decision making in patient care. This com­prehensive approach is known as integrated medical care.

Bibliography

Barnes J, Anderson LA, Phillipson JD. Herbal medicines. 3rd ed. London: Pharma­ceutical Press; 2007.

Blumenthal M, editor. The complete German Commission E monographs: Therapeutic guide to herbal medicines. Austin (TX): American Botanical Council; 1998.

Blumenthal M. Herbal medicine: expanded Commission E monographs. 1st ed. Newton (MA): Integrative Medicine Communications; 2000.

Jonas WB, Levin JS, editors. Essentials of complementary and alternative medicine. Philadelphia (PA): Lippincott Williams & Wilkins; 1999.

Mayo Clinic. Herbal supplements: what to know before you buy. Available at: http://www.mayoclinic.com/health/herbal-supplements/SA00044. Retrieved July 24, 2013.

Nahin RL, Barnes PM, Stussman BJ, Bloom B. Costs of complementary and alterna­tive medicine (CAM) and frequency of visits to CAM practitioners: United States, 2007. Natl Health Stat Report 2009;(18):1-14. [PubMed]

National Center for Complementary and Alternative Medicine. National Institutes of Health. Available at: http://nccam.nih.gov. Retrieved July 24, 2013.

National Institutes of Health. Alternative medicine: expanding medical horizons: a report to the National Institutes of Health on alternative medical systems and prac­tices in the United States. Bethesda (MD): NIH; 1995.

PDR for herbal medicines. 4th ed. Montvale (NJ): Medical Economics Co.; 2007.

Segen JC. Dictionary of alternative medicine. Stamford (CT): Appleton & Lange; 1998.

Resources

American Botanical Council. Available at: http://abc.herbalgram.org. Retrieved July 24, 2013.

Center for Complementary and Integrative Medicine. Weill Cornell Medical College. Available at: http://weill.cornell.edu/ccim. Retrieved July 24, 2013.

National Cancer Institute. Complementary and alternative medicine. Available at: http://www.cancer.gov/cancertopics/cam. Retrieved July 24, 2013.

National Center for Complementary and Alternative Medicine. Herbs at a glance.

Available at: http://nccam.nih.gov/health/herbsataglance.htm. Retrieved July 24, 2013.

National Center for Complementary and Alternative Medicine. Resources for health care providers. Available at: http://nccam.nih.gov/health/providers. Retrieved August 20, 2013.

National Library of Medicine. Available at: http://www.nlm.nih.gov. Retrieved July 24, 2013.

Office of Dietary Supplements. National Institutes of Health. Available at: http:// ods.od.nih.gov. Retrieved July 24, 2013.