Integrative MedicineComplementary and Alternative Medicine

Ma. Stephanie Fay S. Cagayan, MDAssociate Professor

Objectives

• By the end of this presentation, you should be able to...– Define “Integrative Medicine” and other terms– Describe the difference between traditional and

western medicine– Describe the different types of CAM– Understand how Integrative Medicine (especially the

use of herbal medicine) relates to Modern Philippine Medicine and therapeutics

– Prepare to practice Integrative Medicine in the future

Presentation Outline

• Definitions• Why Should We Care About CAM?• What Do Patients Want?• What Can We Provide to Meet the Demand?

35 year-old female • peripheral neuropathy, shoulder

tendonitis, and carpal tunnel syndrome about 15 months after completing chemotherapy for cancer.

• in complete remission • Currently exercising, doing physical

therapy, taking a multi-vitamin and following all of the recommendations of her physicians

What more do you want to know?What options would come to mind

foryou?How would you find information about

those options?

Health and Wellness

“Imagine a world - oriented toward healing rather than disease, where physicians believed in the natural healing

capacity of human beings, and emphasized prevention above treatment.

In such a world, doctors and patients would be partners working toward the same ends.”

How do we practice medicine

Oriental/Traditional Western

Definitions

“Complementary and Alternative Medicine is a Group of Diverse Medical and Health Care Systems, Practices, and Products That are Not Presently Considered Part of Conventional Medicine”

National Center for Complementary and Alternative Medicine

Definitions

• “Complementary Medicine is Used Together With Conventional Medicine.”

• “Alternative Medicine is Used in Place of Conventional Medicine.”

Definitions

“Integrative Medicine Combines Mainstream Medical Therapies and CAM Therapies for Which There is Some High-Quality Scientific Evidence of Safety and Effectiveness.”

NCCAM

5 Domains of CAM

AlternativeMedicalSystems

Ayurveda, Chinese, Native American, Aboriginal, African,Middle Eastern, Tibetan, Central and South American cultures,Homeopathy, Naturopathy

Mind-BodyInterventions

cognitive-behavioral approaches, meditation, hypnosis, dance,music, art therapy, prayer, mental healing

BiologicalBased Therapies

dietary supplements, herbs, orthomolecular (varying concentrations of chemicals, such as, magnesium, melatonin, and mega-doses of vitamins), individual biological therapies (use of laetrile, shark cartilage, bee pollen).

Manipulative And Body-Based Methods

chiropractic, osteopathic manipulation, massage

Energy Therapies Qi gong, Reiki, therapeutic touch, bioelectromagnetic-basedtherapies (pulsed fields, magnetic fields, or alternating currentor direct current fields)

5 Domains of CAM

As Defined by NCCAM

Why Should We Care?

• 60% of Filipinos still lack access to doctors• Majority of Filipinos are below poverty level

and cannot afford cost of health care

Why Should We Care?• 600 Million Visits a Year to CAM Providers – More Than to

Primary Care Providers• Why? What is Mainstream Medicine Not Offering to Our

Patients?

Eisenberg D. et al, JAMA, Nov 11, 1998(18) 1569-1575

60-80%

50-75%

25-50%

>80% ~50%

~60%>80%

75%

55%

40%

60%

70%

40%33%

25%15%

60-70%

40-70%

>80%>90%

www.WHO.org

Have We Missed the Boat? • Dissatisfaction with health care

providers and medical outcomes• Side effects of drugs and treatments• High health costs/No choice• Technology• Lack of control in their own health care practices• Time spent with practitioner

Stephen Strauss, M.D., NCCAM Director

Have We Missed the Boat?

• Looking for “cures”• Want to use “natural” products • Patient feels empowered• Focus on spirituality and emotional well-being• Health Care Provider provides the 3 T’s: touch,

talk, time• No choice

Stephen Strauss, M.D., NCCAM Director

What about communication?

• Between 40 and 70% of CAM users do not disclose their use to their physician.

WHY?

Eisenberg 2001

Why do patients not tell their physician about their CAM use?

• 60% - “My doctor never asked.” • 60% - “It wasn’t important for my doctor to

know.”• 20% - “My doctor wouldn’t understand.”• 14% - “My doctor would disapprove.”•

70% of patients see their Physician before or concurrent with their visits to a CAM provider

Eisenberg DM. Ann Int Med 2001;135(5):344-51

Why would patients not trust us?

Why Would We Not Trust CAM?

- quackery“Doctors concerned because several cases

reported of liver failure with Kava Kava, a widely used natural remedy for anxiety”

Are Our Patients Reading This?

Historical Developments: Global

• World Health Organization (WHO): 1978 Alma Ata Declaration on Primary Health Care (PHC): Integration of Traditional Medicine in PHC

• 1999: US Congress established the National Center for Complementary and Alternative Medicine (NCCAM) in the National Institutes of Health (NIH) Bethesda, Maryland.

Worldwide perspective

• Complementary• Alternative• Traditional

Primary medical careTreatment of minor ailmentsHealth maintenance

www.WHO.org

Goals of Use/Treatment with CAM

1. Promotion and maintenance of health

2. Prevention of disease and injury 3. Relief of pain and suffering 4. Cure of curable diseases and

illnesses 5. Care of people who are ill 6. Avoidance of premature death 7. Peaceful death

Regulations

• Varied from stringent to none• Canada

– Federal and provincial regulations

• 2004 National Health Products Regulations• European Union

– Directive to register and license products

• Mexico– Traditional birth attendants,

homeopathic practitioners, chiropractors licensed

– Registry of traditional practitioners

• China and India– Integrated with allopathic

medicine, regulated

Philippine Experience in Integrative Medicine 1972-2008

• Mid-70’s: Private physicians started training in acupuncture in China

• Early 1980’s: DOH physicians trained acupuncture in China; herbal medicine production started

• 1993-95: DOH established the Traditional Medicine Unit which promoted the use of medicinal plants, acupuncture and therapeutic massage

Integrative Medicine Policy and Practice in the Philippines

• 1995 -De La Salle University inaugurated the Center for Indigenous Medicine in Dasmarinas, Cavite -the 1st Philippine university to do so.

• 1997 -Republic Act 8423 established the Philippine Institute for Traditional and Complementary Health Care (PITAHC) in as an attached agency of the Department of Health (DOH).

What is Traditional and Alternative Medicine as defined by R.A. 8423 ?

• The scope of alternative health care modalities as other forms of non-allopathic, occasionally non-indigenous or imported healing methods, though not necessarily practiced for centuries nor handed down from one generation to another.

• 1999-2000 Filipino physicians have organized the Philippine Association of Medical Acupuncturists Inc (PAMAI) and the Philippine College for the Advancement of Medicine (PCAM) to promote the practice of Integrative Medicine.

• 2001 -The UP College of Medicine started an elective course on Integrative Medicine in both graduate and undergraduate courses. The UP-Philippine General Hospital inaugurated the Traditional and Integrative Medicine Clinic.

• 2008 -The Philippine Institute of Traditional and Alternative Medicine (PITAHC) started the accreditation of acupuncturists practicing in the Philippines, both for medical and non-medical practitioners.

World View of Health in Filipino Traditional Medicine

• Theory of macrocosm and microcosm (“kalawakan” at “sangkatauhan”)

• The balance, synergy and harmony:– Between Humankind and the

Universe– Between Humankind and Nature – Between and Amongst people– Within his body, mind and spirit

World View of Health in Filipino Traditional Medicine

• Theory of nature elements Theory of body humours• fire (kalikasan ng apoy) Init (hot) and lamig (cold)• earth (kalikasan ng lupa) Wet (basa) at Dry (tuyo)• water (kalikasan ng tubig) • air (kalikasan ng hangin)

• Belief in nature spirits/guardians of nature and spirit ancestors

Folk or Traditional Medicine

• 80% of Third World countries utilize folkloric medicine

• Formal training vs apprenticeships vs observation, imitation, practice– Skill may be inherited

• Range of remedies– prayer, touch, charms, rituals, teas, tinctures,

poultice, etc• All cultures

Herbal Medicine in the Philippines

• 8,000 to 12,000 flowering plants • 1,500 species actively utilized by

traditional healers – About 40% of medicinal plants

used in indigenous communities have not been documented

• There are about 250,000 traditional medical practitioners in the Philippines

Issues on the Use of CAM/Herbal Medicine

Evidence Based Medicine

• Difficulties With CAM Research– Sham Acupuncture– Non Standardized Herbal Formulations– Difficult to Blind Patients and Practitioners– Treatments Very Individualized – Difficult to

Formulate Protocols

Comparison

• Mainstream Medicine– Large Double Blind Placebo Controlled Trials

• Many Exclusions Such As Multiple Medicines, Other Illnesses, Female, Pregnant, Children, Race

• “Placebo Effect” Discounted• Apply These Narrow Results to The Individual

– Integrative Medicine• Very Individualized• “Placebo Effect” Not Discounted

CAM MODALITY LICENSURE

Chiropractors All states

Massage ther. 27 states

Naturopaths 13 states

Homeopaths 3 states

Acupuncturists 32 states

Challenges to the Filipino Community

1. Majority of Philippine medicinal plants remain undocumented and untapped.

2. Scientific studies supporting Philippine traditional medicine practices is still in the early phase and full potential has not been explored.

3. Lack of collaboration among research institutions, private sector and academe

*NIRPROMP

National Integrated Research Program on Medicinal Plants

• A multidisciplinary research team established in 1976 under the Department of Science and Technology

• Tasked to validate scientifically certain folkloric uses of medicinal plants and to propagate the use of herbal medicines rationally by the majority of the people (for example, sambong has a folkloric use for cough but upon scientific validation, it is now used as a diuretic)

4.Lack of investments in research and development, raw material production, post harvest processing and herbal manufacturing.

5.Low level of scientific technology in herbal medicine research and manufacture among small and medium enterprises.

6. Low support for traditional medicine research in the academic community.

7. Need for market and government incentives like the ones given to rice, corn, coconut, sugar, bananas, pineapples and mangoes.

8. Need for standardized procedures/ accreditation/recognition in Filipino traditional medicine/herbal medicine practices.

Answers to Challenges

• A wareness raising • N etworking among groups • T echnical capacity building • I nformation exchange/monitoring • D eepening of understanding • O rganizing concerned people • T ransformative action • E mpowerment of people

• Awareness, understanding and appreciation of resources • Capability for a relevant and self-reliant research and

development program • Recognition and respect of community rights and indigenous

knowledge • Strong national policies and laws to protect indigenous

resources • Active defense against immediate threats to biodiversity

(mining, deforestation) • Preventive action against potentially destructive

technologies/activities (developmental aggression) • Confronting structural causes of unsustainable use (political

system)

• Patients are choosing integrative and alternative medicine, but what about us, physicians?

35 year-old female • peripheral neuropathy, shoulder

tendonitis, and carpal tunnel syndrome about 15 months after completing chemotherapy for cancer.

• in complete remission • Currently exercising, doing physical

therapy, taking a multi-vitamin and following all of the recommendations of her physicians

What more do you want to know?What options would come to mind

foryou?How would you find information about

those options?

The Future of Integrative Medicine

The Future Is Sometimes Curing, But Always Caring

Integrative Medicine

requires a paradigm shift from • the disease-centered approach of conventional

biomedicine to

• an approach in which patient values and participation of patients are central.

Maizes 1999

The Future of Integrative Medicine

• Definition of Integrative Medicine From the CAHCIM

“Integrative medicine is the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches to achieve optimal health and healing.”

The Future of Integrative Medicine

• The Term “Integrative Medicine” Will Die– Our Patients Will Demand Integrative Medicine

From All of Us– Training Will Be Demanded by Medical Students– Training Will Be Demanded by Residents

The Future of Integrative Medicine

• Integrative Medicine Will Be A Skill Set Added on Just Like:– Electronic Health Records– New Medications– New Procedures

How do We Add On These Skills?

• Build your database.• Build a referral team.• Ask your patients whom

they see.• Look for summaries of

available data.• Have an open dialogue

with your patients.

Resources

• National Center for Complementary and Alternative Medicine– http://nccam.nih.gov/

• Agency for Healthcare Research and Quality– http://www.ahrq.gov/clinic/epcindex.htm

Resources

• American Academy of Medical Acupuncture– www.medicalacupuncture.org

• Online Resource– http://www.altmedicine.com

Where Should We Go for Information?

• Product claims– www.quackwatch.com– www.snopes.com

• Product quality assurance– www.consumerlab.com

• Product ingredients– Natural Medicines Database www.naturaldatabase.com

• Product safety and efficacy– www.cfsan.fda.gov/~dms/ds-ind.html– www.naturaldatabase.com– The Natural Pharmacist www.iherb.com or www.consumerlab.com

The Future of Integrative Medicine

• What Cannot Be Added On is Empathy, Open-mindedness and Respect for Other People’s Beliefs

Summary• Know what integrative medicine is • Dialogue with your patients• Build your database• Build your referral base• Develop patient care teams• Consider all available options• Be open-minded • Be an agent of change in your community

• Above all: be caring, concerned and compassionate