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The Function of Complementary and Alternative MedicineWho Uses CAM and What is UsedExploitation of the mind body connection is often considered part of the arsenal of complementary and alternative medicine (CAM). CAM is an array of heterogeneous health and medical systems, practices, and products that are not currently accepted parts of conventional medicine. Conventional medicine is practiced by M.D.s, D.O.s, and allied health professionals such as nurses, psychologists, and physical therapists. Conventional medicine practitioners may also practice CAM. When CAM therapies are used as an alternative to conventional medicine, they are called alternative. When they are used in conjunction with conventional treatments, they are called complementary. Although an argument can be made in dividing nonconventional medicine into a mainstream CAM category and an ethnocentric or parochial category, we will lump the two for most of the discussions unless otherwise specified (). For the record, the splitters divide CAM into professional groups, layperson-initiated popular health reform movements, alternative psychological therapies, New Age healing, and non-normative scientific enterprises. Their parochial category includes religious healing, folk medicine, and ethnomedicine Based on the results of a nationally representative telephone survey of 2,055 adults, it was estimated that in 1997, Americans made 629 million visits to CAM practitioners, exceeding the total visits to all primary-care physicians in the USA (). CAM followers spent at least $21.2 billion dollars, with conservatively $12.2 billion of that out of their own pockets for professional alternative medicine. This exceeds the total amount of out-of-pocket expenses for all hospitalizations in the same year. And, the total out-of-pocket expenses for all forms of alternative therapies were at least $27 billion, which is comparable to all of the out-of-pocket expenses for all physician services in the USA. An estimated 44% of the population of the USA used at least one CAM therapy in 1997 (). An estimated 52% of those 44% saw a CAM provider in that same period. Approximately 8.9% of the total USA population accounted for 75% of the visits to CAM providers. Of those who saw a CAM provider, the following factors were independently associated:
Analysis of data from the nationally representative 1997 telephone survey found that of the 311 of the 2,055 respondents who were 65 or older, 30% used CAM in the preceding year (). This has been extrapolated to mean about 10 million Americans. In addition, 19% visited CAM providers, extrapolated to 63 million visits. Chiropractic and herbs were the most commonly used therapies. As the studies authors point out, these can cause problems in older folks. CAM therapies used for diabetes in 1997-1998 were reported in 57% of 95 diabetic respondents to a national survey (n = 2,055) (). This is about the same as the rest of the population. Of those, 35% used a CAM therapy specifically for diabetes. Solitary prayer/spiritual practices were 28%, herbal remedies were 7%, commercial diets were 6% and folk remedies were 3% of those therapies. As of 2002, the most common forms of CAM sought out by cancer patients were dietary modification and supplementation, herbal products and other biological agents, acupuncture, massage, exercise, and psychological and mind-body therapies (). According to a 1997 convenience sample of 401 working folks at an urban outpatient rehabilitation center, physically disabled folk are more likely than the population as a whole in the USA to use CAM (57.1% vs. 34%) and their providers (22% vs. 9%) (). They are more likely to be referred by their physicians and be reimbursed by the health insurance. They are more likely to have more chronic pain (14% vs. 8%), and depression (14% vs. 8%), and lower amount of severe headaches (9.2% vs. 13%). There is a positive correlation with education and income, and no correlation with race, gender, or age. CAM was chosen over conventional treatment for pain (51.8% vs. 33.9%), depression (33.9% vs. 25%), anxiety (42.1% vs. 13.1%), insomnia (32.3% vs.16.1%), and headaches (51.4% vs. 18.9%) Telephone interviews with 289 HIV positive patients in 1998, at a university-based teaching hospital in Boston, showed that 67.8% used herbs, vitamins, or dietary supplements, 45% used a CAM provider, and 23.9% used medical marijuana in the past year (). CAM therapies were reported to be very helpful for 81% of those using supplements, 65.5% of those seeing a CAM provider, 87% of those using marijuana. Sixty-three pairs of twins discordant for chronic fatigue syndrome (CFS) were surveyed about their use of CAM (). They found that 91% of the twins with CFS and 71% of the twins without CFS used CAM at least once in their lifetime. A large percent of all the twins reportedly found the CAM useful. Overall, a twin with CFS was more likely than a twin without CFS to use megavitamins, relaxation or meditation, homeopathy, herbs, guided imagery, energy healing, biofeedback, self-help groups, and religious healing. Only 42% of the twins who had CFS and 23% of the twins without CFS discussed their use of alternative therapy with their physician. Results of a national USA survey of 831-adult patients who saw a medical doctor and used CAM therapies in 1997 shows that use of CAM therapy is not primarily the result of dissatisfaction with conventional care (). Of the patients that used CAM therapies at the same time as they saw their medical doctor, 79% thought the combination was superior to either alone. Of those who saw a medical doctor and a CAM practitioner at the same time, 70% saw a medical doctor before or concurrent with the CAM practitioner. And 15% saw the CAM provider before they saw the medical provider. Confidence in CAM providers and medical providers were about equal. Don’t ask, don’t tell is inappropriate for medicine. Yet it seems that in spite of widespread use, patients are reluctant to speak with their physicians about their use of CAM; and physicians are reluctant to bring up or discuss the subject of CAM with their patients. CAM followers tend to be concerned principally with their physician’s ability to understand or incorporate CAM therapy into their medical management rather than their disapproval. Of the 63% to 72% of patients who did not disclose to their physicians their use of CAM,
What Works?Following a comprehensive review, evidence on the safety and efficacy of these therapies relative to cancer progression and palliation, but not cancer prevention, was published in 2002 by researchers at Harvard Medical School et al. (). They considered two categories of efficacy: 1) possible effects on disease progression and survival, and 2) potential palliative effects. Two types of risks were identified: 1) risk for direct adverse effects, and 2) risk for interactions with conventional therapy. This article would be good to read for those who would like to see a comprehensive review. Briefly, their findings are as follows: CAM therapies that may be accepted with monitoring by conventional medicine:
Credentialing is a source of debate. On one side is the desire to protect us from unscrupulous practitioners and potentially dangerous treatments; on the other side is the desire to allow patients freedom of choice (). Hopefully, information such as provided by the Harvard group will help in providing patients with evidence-based, accountable advice. As patients, should we expect less from our physicians or ourselves before we seek alternative treatments? Bona Fide Sources for CAMWhat are the best sources for information on CAM? Well, our tax dollars have paid for The National Center for Complementary and Alternative Medicine (NCCAM), a part of the National Institutes of Health. Congress appropriated $104,644,000 for NCCAM for use in the 2002 fiscal year. NCCAM’s predecessor, the Office of Alternative Medicine, was established in 1992. NCCAM was established in October of 1998. It is the definitive source for CAM clinical trials. Their web site is www.nccam.nih.gov. NCCAM’s mission is:
Why Is CAM so Popular?What is the driving force behind use of and considerable expense of alternative therapies even though most of them seem to be patently useless, dangerous, or have not been tested? One possibility is the misperception that something ineffective actually is effective. This may be a result of seeming improvement linked in time to the therapy when in reality the malady may have simply run its natural course. Or it may be a result of misdiagnosis, spontaneous remission, or the placebo effect. Another possibility is psychosocial or cultural bias. This may take the form of a belief in superiority of “natural” products, anti-scientific attitudes and New Age mysticism. Or it may be the result of being conned by aggressive marketing and outlandish claims, wishful thinking, suspending judgment, or logical thinking errors. Over the last few decades, patients have switched from a passive role in their medical treatment and begun to demand full information and a partnership with their healthcare providers (, , ). Witness the burgeoning of medical and health oriented internet sites (although sadly the quality of information is often pathetic). Until the last few decades, our demigods have often been the doctors or the priests. With increasing malpractice and sex abuse scandals, now they are seen as human only. When we lose faith in our human gods, we need to find other sources for our hope. During times of illness, this includes looking inward to ourselves, outward to others who we hope know more than we do, or to a power that is beyond our ken. There may be many reasons why we use CAM therapies. It could be our distrust of authority arising from our understanding of human weakness. It may be our attempt to take charge of our health, to feel empowered. It may be our reaction to depersonalized managed care, or desperation when we feel that conventional medicine has not helped us. It may be anger at long waits in the doctor’s office or frustration when we do get to see our physicians: a reaction to feeling too rushed, or that the doctor is not connected to us as an individual. Do we need to feel more of a participant in our care, or need greater self-identity (), or authenticity when illness threatens us? Maybe we need to strengthen our spirituality. Maybe it is our only way to keep from succumbing to the twin despairs of helplessness and hopelessness. |
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