As health care providers, we are certain to encounter a patient who uses some form of complementary or alternative medicine (CAM). According to the National Center for Complementary and Alternative Medicine (NCCAM), 36% of adults have used some form of CAM in the past 12 months. Most patients who use CAM do so as an adjunct to conventional medicine. The very real potential for interactions between pharmaceuticals, herbs, and nutritional supplements highlights the need for regular communication between doctors, pharmacists and patients about CAM. Understanding the appeal of CAM is the first step in facilitating such conversations.

Patients are drawn to CAM for various reasons. One way this can be characterized is in terms of “push” and “pull” factors. Patients dissatisfied with conventional medical treatments may feel “pushed” towards CAM by issues such as drug side effects, perceived lack of efficacy of traditional treatments, toxicities and poor patient-practitioner communication. On the flip side, it can be said that many CAM treatments provide “pull” factors that appeal to patients. These may include a belief that CAM treatments are “more natural,” a perception that CAM practitioners are more patient-centered and encouraging of patient participation, or the appeal of the mind-body connection that is often neglected in traditional medicine.

Professionals in all health care disciplines should familiarize themselves with the different modalities of CAM. With knowledge and a willingness to discuss these treatments with patients in a supportive, non-judgmental manner, practitioners can assist patients in making good decisions about their health care. While this article is not meant to be a complete source of information about CAM, it is designed to give some basic insights into the types of alternative treatments patients may be using.

Domains of CAM

Energy medicine uses energy fields as treatment. There are two main types. One is biofield therapies or putative energy medicine and is intended to affect the energy field that surrounds and penetrates the body. Practitioners manipulate this energy by touching or putting one’s hands through the energy field. Common names for this therapy are gi gong, reiki, and therapeutic touch. The second type of energy medicine deals with bioelectromagnetic fields. Practitioners access these fields in unconventional ways to treat the patient.

Manipulative and body-based practices use manipulation or movement of one or more body parts. These modalities include massage therapy, reflexology, and chiropractic manipulation, which is the most common CAM therapy for back pain. Chiropractics’ main principle is that joint misalignment interferes with the central nervous system and can lead to other ailments. Chiropractors will also suggest lifestyle changes such as diet and exercise to their patients. Acupuncture is the stimulation of anatomical points on the body through the use of a variety of techniques. The most studied form of acupuncture is the use of needles to penetrate the skin.

Mind-body medicine uses various techniques to enhance the mind’s ability to affect bodily function and symptoms. Some mind-body techniques that were once considered to be alternative therapies are now mainstream ideas, such as support groups and cognitive-behavioral therapy. Other techniques such as meditation, yoga and hypnotherapy are considered subsets of mind-body medicine. Prayer, often cited as the most frequently used modality of CAM, is also included here.

Biologically-based practices are the use of substances found in nature to produce desired clinical effects. When prayer is not included, this is the most frequently used domain of CAM. It is estimated that 21.9% of people will use some sort of biologically-based alternative product, including herbs, vitamins, minerals, and animal-derived products. Another practice included in this domain is special diet, such as the macrobiotic diet. Prebiotics and probiotics are also included in this domain.

The last domain of CAM is whole health systems. This domain includes homeopathy and naturopathy. The goal of homeopathy is to stimulate the body’s own healing response. One principle that homeopathy uses is the “principle of similar,” which says that substances that cause symptoms in a healthy patient will cure similar symptoms in the sick patient.

Another mainstay of homeopathy is vitalism. Homeopathic practitioners say that every person has a vital force and that when this vital force is disrupted or imbalanced, health problems can develop. A third principle of homeopathy is that malfunctions of any organ or body system can affect the entire body. Homeopathic practitioners believe that only one disease process can occur at a time and so only a single therapeutic agent is used to treat a single disease. Treatment should be individualized and based on the total picture.

Homeopathic practitioners believe that only a small stimulus is needed to start the healing processes, so serial dilution is used to prepare homeopathic remedies. It is important to note that in homeopathic remedies, the “High Potency” products are more dilute than the “Low Potency” products.

The FDA has some requirements for homeopathic remedies, requiring them to meet certain standards for strength, quality, purity and packaging. Labeling must state indications for use, ingredients, dilutions, and instructions for safe use. However, the FDA does not require pre-marketing proof of safety and effectiveness. The guidelines can be found in the Homeopathic Pharmacopoeia of the United States.

Homeopathic practitioners in the United States go through a diploma or certificate course. Currently three states (Connecticut, Arizona and Nevada) have licensing requirements for homeopathic practitioners.

A second whole health system practice is naturopathy. This method proposes a healing power in the body that establishes, maintains and restores health through treatments such as nutrition and lifestyle counseling, medicinal plants, exercise, homeopathy, and traditional Chinese medicine. Some of the basic beliefs of naturopathy include the idea that prevention is the best cure and that treating diseases, not symptoms, is the best course of action. The naturopathic physician takes the role of educator and motivator, so the patient will take control of his or her own health.

In naturopathy there are three levels of practitioners. The first type is a naturopathic physician, who goes through a four-year graduate program at a naturopathic medical school accredited by the Council on Naturopathic Education. The second type is traditional naturopaths, who are trained through correspondence courses, apprenticeships or self-learning.

The last group is conventional providers with naturopathic training. These providers can be nurses or physicians. It is important to note that for naturopaths and conventional providers trained in naturopathy, the level of education and the quality is not uniform.

Armed with the knowledge of some basic facts about CAM, health care providers can begin conversations with their patients that may reveal what other types of treatment or modalities patients are using in combination with or instead of conventional medicine. Most patients will not spontaneously disclose this information to their physician or pharmacist so it is important that the health care provider be proactive.

Questions to ask your patients:

• What other health care providers are involved in your care?
• Are you taking any over-the-counter medications, supplements or herbal remedies?
• What are you using these medications for and who recommended them?
• Have you or are you currently participating in treatments such as chiropractic, massage or meditation? How do you feel these treatments are working for you?
• How do you feel the treatments I’ve provided are addressing your medical concerns? Do you have any untreated conditions or new problems I should be aware of?

It is also essential that practitioners be able to direct patients to reliable, unbiased sources of information about CAM. The National Center for Complementary and Alternative Medicine is a well-known, thorough source of information for practitioners wishing to educate themselves and provide quality information to their patients.

References:

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