Sharlene M. Weiss, RN, PhD
In 1993, an estimated 60 million Americans used
alternative medical therapies in 1990 at an estimated cost of $13.7 billion.
The estimated number of annual visits to providers of alternative medicine
(425 million) exceeded the number of visits to all US primary care physicians
(388 million); and more than 70% of the patients who acknowledged using
alternative therapy never mentioned this information to their physicians.
Complementary and alternative therapies are now in
demand by health consumers throughout the developed world. They have had
an impact on every facet of the health care system and all specialties
of medicine. They are now available to the general public through every
known means of communication including the Internet, which has become a
primary source of information for many individuals. In 1995, the National
Library of Medicine (NLM) expanded its number of keywords and now includes
five journals related to alternative and complementary practices. The NLM
currently contains more than 60,000 citations on alternative and complementary
medicine.
The Office of Alternative Medicine
at the National Institutes
of Health
In 1992, Congress established the Office of Alternative
Medicine (OAM) within the Office of the Director, National Institutes of
Health (NIH) to facilitate the full scientific evaluation of alternative
therapies that could improve health and well-being. OAM was also mandated
to establish an information clearinghouse for the exchange of information
about alternative medicine and to support research training in topics related
to alternative medicine that are not typically included in the training
curriculum of mainstream health professionals. The mandate of the OAM is
not to support any particular alternative medicine treatment, but rather
to advocate for full scientific evaluation of alternative therapies that
have the potential to improve the health and well-being of a significant
number of people. The OAM also maintains ongoing interest in the alternative
medicine research projects funded by all of the NIH. Virtually every NIH
institute has funded (and continues to support) studies concerning alternative
therapies.
Definition
The current definition used by the OAM is as follows:
"Complementary and alternative medicine (CAM) is a broad domain of healing
resources that encompasses all health systems, modalities, and practices
and their accompanying theories and beliefs, other than those intrinsic
to the politically dominant health system of a particular society or culture
in a given historical period. CAM includes all such practices and ideas
self-defined by their users as preventing or treating illness or promoting
health and well-being. Boundaries within CAM and between the CAM domain
and the domain of the dominant system are not always sharp or fixed."
The changing usages of the words alternative
and complementary reflect an evolving public and professional consciousness.
Alternative has most recently been used to suggest substitution,
an either/or relationship, implying modalities used instead of conventional
medicine, while complementary suggested modalities used together
with or to complement conventional medicine. Rather than trying to define
the component terms separately, the OAM defines the combined term as a
significant domain of health-related activity.
Fields of Practice
The OAM NIH has grouped
alternative therapies
into seven categories:
1. Mind-body interventions refer to the interest
in the mind’s role in the cause and course of illness. This role has been
substantially stimulated by the discovery of the complex interactions between
the mind and the neurological, hormonal, and immune systems. Mind-body
interventions often help patients experience and express illness in new,
clearer ways. The placebo response is one of the most widely known examples
of mind-body interaction, yet it is also one of the most undervalued and
neglected assets in medical practice. Psychotherapy, support groups, meditation
and imagery, hypnosis and hypnotic suggestion, biofeedback, yoga, dance/movement
therapy, music therapy, art therapy, prayer, and mental healing are examples
of these therapies.
2. Bioelectromagnetic applications in medicine
(BEM) is an emerging science that studies how living organisms interact
with electromagnetic fields. The most important BEM modalities in alternative
medicine are nonthermal applications of nonionizing radiation. Major new
applications of nonthermal, nonionizing BEM fields are bone repair, nerve
stimulation, wound healing, treatment of osteoarthritis, electroacupuncture,
tissue regeneration, and immune system stimulation.
3. Traditional and folk remedies is a category
that includes the following:
• Traditional oriental medicine refers to
acupuncture, herbal medicine, acupressure, gigong, and oriental massage.
• Ayurveda is India’s traditional natural
system of medicine practiced for more than 500 years. It includes lifestyle
interventions (meditation and yoga), natural therapies, and herbal preparations.
• Homeopathic medicine involves remedies made
from naturally occurring plant, animal, or mineral substances that are
recognized and regulated by the FDA. Basic research in homeopathy involves
investigations into chemical and biological activity of highly diluted
substances.
• Naturopathic medicine integrates traditional
natural therapies (eg, botanical medicine, clinical nutrition, homeopathy,
acupuncture, oriental medicine, hydrotherapy, and naturopathic manipulative
therapy) with modern scientific medical diagnostic science and standards
of care. This practice, which has more than 1,000 licensed naturopathic
doctors, is 100 years old in the United States.
• Environmental medicine traces its roots
to the practice of allergy treatment and recognizes that illness can be
caused by a broad range of substances, including food and chemicals found
at home and in the workplace and chemicals in the air, water, and food.
4. Manual healing methods are based on the
concept that dysfunction of a part of the body affects secondarily the
function of other discrete, not necessarily directly connected body parts.
• Chiropractic therapy investigates the relationship
between structure (primarily of the spine) and function (primarily of the
nervous system). Chiropractic physicians use manual procedures and interventions,
not surgery or chemotherapy.
• Massage therapy is defined as the scientific
manipulation of soft body tissues to return those tissues to their normal
state.
• Biofield therapeutics refers to laying on
of hands on or near a patient’s body and is also known as healing touch,
therapeutic touch, and shen therapy.
5. Pharmacological and biological treatments
refers to the use of an assortment of drugs and vaccines not yet accepted
by mainstream medicine, including antineoplastons, cartilage products,
ethylene diamine tetracetic acid (EDTA), immunoaugmentive therapy, coleys
toxins, neural therapy, apitherapy, iscador, and biologically guided chemotherapy.
6. Herbal medicine includes the use of plants
and plants products found in the folk medicine traditions found in all
cultures. The World Health Organization estimates that four billion people
-- 80% of the world’s population -- presently use herbal medicine for some
aspect of primary health care.
7. Diet and nutrition in the prevention and treatment
of chronic disease is an alternative to the Federal government’s approach
to dietary intervention. The government’s strategy is formulated by boards
of scientists and generally does not recommend supplementing the typical
American diet with vitamins or nutrients beyond the recommended daily allowance
(RDA) and does not suggest that some foods never be eaten. In contrast,
many alternative dietary approaches contend that no amount of manipulation
of the typical American diet is enough to promote optimum health or prevent
eventual chronic illness. These alternative approaches represent a continuum
of philosophies ranging from the concept that supplementing the typical
American diet lies somewhat beyond the RDA necessary to promote optimum
health, to the concept that supplementation well beyond the RDA is often
required to reverse the effects of long-term deficiencies.
• Orthomolecular medicine is the therapeutic
use of high-dose vitamins to treat chronic disease. It promotes improving
health and treating disease by using the optimum concentration of substances
normally present in the body.
Growth in Alternative Medicine
More than two dozen medical schools and hospitals have
developed programs or departments for the study of alternative therapies.
At least 30 medical schools in the United States offer courses on alternative
medicine, and many others provide lectures or ongoing informal programs.
At least five journals devoted to alternative medicine intended for physicians
and other health professionals were launched in 1995. The OAM now funds
10 Alternative Medicine Centers at US universities, which represent the
major research effort of their office. The $13 million budget for FY98
for the OAM is proposed to be spent on the Centers to cofund investigator-initiated
grants and to collaborate with the National Cancer Institute in evaluating
the science and efficacy of unconventional cancer therapies, joint initiatives
with other NIH institutes and centers, and intramural research training.
Insurance companies have now begun to offer plans
that reimburse alternative practitioners. Some plans now allow subscribers
access to acupuncturists, homeopaths, or wellness plans that use naturopathic
physicians. Some plans cover licensed psychologists, nutritionists, biofeedback
therapists, and massage therapists.
Advising Patients Who Seek Alternative Medical Therapies
A step-by-step strategy has been developed for clinicians
to proactively discuss alternative therapies with their patients that emphasizes
patient safety, the need for documentation in the patient record, and the
importance of shared decision making. Patients may not initiate conversations
about alternative therapies, but one can safely assume that many, if not
most, patients are using or contemplating the possibility of trying an
alternative therapy. It is vital that physicians be aware of what therapies
their patients are using outside of mainstream medicine in order to guide
patients away from potentially harmful therapies (eg, overdoses of vitamins
or minerals) and toward potentially useful complementary techniques (eg,
acupuncture or relaxation therapy).
Health professionals must address the challenge of
learning more about the variety of alternative therapies and discussing
these with patients when appropriate. Ending the "don’t ask, don’t tell"
approach that characterizes communication between many physicians and their
patients not only will provide opportunities for shared decision making
and relationship-centered care, but also will benefit both patients and
their health care providers.
References
Cassileth BR, Chapman CC. Alternative and complementary cancer therapies.
Cancer. 1996;77:1026-1034.
Eisenberg DM. Advising patients who seek alternative medical therapies.
Ann Intern Med. 1997;127:61-69.
Alternative Medicine: Expanding Medical Horizons. Washington,
DC: National Institutes of Health, Office of Alternative Medicine, US Govt
Printing Office; 1994.