Integrating Integrative Medicine

“The doctor of the future will give no medicine, but will interest his patients in the care of the human frame, in diet, and in the cause and prevention of disease.”
— Thomas Alva Edison

What Is Integrative Medicine?

The National Institutes of Health National Center for Complementary and Alternative Medicine (NIH NCCAM) defines integrative medicine as conventional care used in combination with complementary and alternative medicine (CAM) therapies for which there is high-quality scientific evidence of safety and effectiveness, such as using acupuncture/acupressure for postoperative nausea (1). Conversely, alternative medicine is used in place of conventional medicine, such as using a special diet to treat cancer instead of undergoing surgery, radiation, or chemotherapy that has been recommended by a conventional doctor. Integrative medicine is thus more than a therapy; it is the context, rationale, and communication surrounding therapies from various perspectives.

Other definitions that expand on this theme and principles of integrative medicine have been developed by the Consortium of Academic Health Centers for Integrative Medicine and the University of Arizona’s Arizona Center for Integrative Medicine as noted in figure 1.

Figure 1: Integrative Medicine Definition and Principles

"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, healthcare professionals, and disciplines to achieve optimal health and healing."
— Consortium of Academic Health Centers for Integrative Medicine

"Integrative Medicine is healing-oriented medicine that takes account of the whole person (body, mind, and spirit), including all aspects of lifestyle. It emphasizes the therapeutic relationship and makes use of all appropriate therapies, both conventional and alternative."
— Arizona Center for Integrative Medicine, University of Arizona

Key Principles

• Patient and practitioner are partners in the healing process.
• All factors that influence health, wellness, and disease are taken into consideration.
• Appropriate use of both conventional and alternative methods facilitates the body’s innate healing response.
• Effective interventions that are natural and less invasive should be used whenever possible.
• Integrative medicine neither rejects conventional medicine nor accepts alternative therapies uncritically.
• Good medicine is based in good science. It is inquiry-driven and open to new paradigms.
• Alongside treatment, health promotion and prevention are paramount.
• Practitioners of integrative medicine should exemplify its principles.

— Arizona Center for Integrative Medicine, University of Arizona

How Common Is CAM?

According to a 2007 NHIS survey, approximately 38 percent of U.S. adults and 12 percent of children have used some form of CAM at least once. This represents a 2.3 percent increase from 2002 as noted in figure 2 (2,3).

Figure 2: CAM Use by U.S. Adults and Children

• Adults (2002): 36.0%
• Adults (2007): 38.3%
• Children (2007): 11.8%

Source: Barnes PM, Bloom B, Nahin R. CDC National Health Statistics Report #12. Complimentary and Alternative Medicine Use Among Adults and Children: United States, 2007. December 2008.

Complementary therapies are categorized into four domains: mind-body medicine, biologically based practices, manipulative/body-based practices, and energy medicine. NCCAM also recognizes Traditional Chinese Medicine as a whole medical system.

The most common types of complementary therapies utilized by adults in the United States are natural products, deep breathing, meditation, chiropractic, and massage. Dietary supplements are the most commonly used form of CAM at 17.7 percent (see figure 3). It is important to note that the use of these therapies varies widely, with dietary supplements, for example, being used by up to approximately 70 percent of the population based on the population and survey methodology utilized (4).

Figure 3: 10 Most Common CAM Therapies Among Adults, 2007

• Natural Products: 17.7%
• Deep Breathing: 12.7%
• Meditation: 9.4%
• Chiropractic & Osteopathic: 8.6%
• Massage: 8.3%
• Yoga: 6.1%
• Diet-based Therapies: 3.6%
• Progressive Relaxation: 2.9%
• Guided Imagery: 2.2%
• Homeopathic Treatment: 1.8%

Source: Barnes PM, Bloom B, Nahin R. CDC National Health Statistics Report #12. Complimentary and Alternative Medicine Use Among Adults and Children: United States, 2007. December 2008.

Therapies With Significant Increases Between 2002 and 2007 Are:

• Deep Breathing — 2002: 11.6% • 2007: 12.7%
• Meditation — 2002: 7.6% • 2007: 9.4%
• Massage — 2002: 5.0% • 2007: 8.3%
• Yoga — 2002: 5.1% • 2007: 6.1%

Pain is the most common condition treated with CAM (see figure 4). The top 10 include headache pain as well as more common conditions, including back, neck, and joint pain. Part two of this article describes an integrative model for headache treatment.

Figure 4: Diseases/Conditions for Which CAM Is Most Frequently Used Among Adults, 2007

• Back Pain: 17.1%
• Neck Pain: 5.9%
• Joint Pain: 5.2%
• Arthritis: 3.5%
• Anxiety: 2.8%
• Cholesterol: 2.1%
• Head or Chest Cold: 2.0%
• Other Musculoskeletal: 1.8%
• Sever Headache or Migraine: 1.6%
• Insomnia: 1.4%

Source: Barnes PM, Bloom B, Nahin R. CDC National Health Statistics Report #12. Complimentary and Alternative Medicine Use Among Adults and Children: United States, 2007. December 2008.

Barriers to Implementing Integrative Medicine

It is important to point out that nearly all patients ideally wish to pursue an integrative approach to their healthcare with less than 5 percent attempting an alternative-only approach. When surveyed about the motivation for use of CAM, the most typical response (54.9 percent) in the 2004 version of the CDC/NIH survey was that CAM combined with conventional medicine would help. Unfortunately, several barriers often make this attempt fragmented, including financial/insurance coverage, knowledge base, discussion, and coordination of care.

The less-than-optimal level of clinician/patient discussion regarding CAM was best exemplified by the 2006 NIH/AARP report on CAM (5). Overall, 77 percent did not discuss CAM use with their doctors, with reasons given for non-discussion including:

• Physicians never asked (42 percent).
• Patients didn’t know they should talk with their doctors (30 percent).
• Lack of time (19 percent).
• Don’t think doctor knows the topic (17 percent).
• Doctor would have been dismissive or told you not to do it (12 percent).

In a survey of more than 700 physicians, Corbin and colleagues confirmed that 84 percent felt uncomfortable discussing CAM with their patients. The authors noted that the physicians wanted to learn more about CAM to adequately address patient concerns and concluded that education may help alleviate the discomfort physicians have when answering patients’ questions about CAM (6).

These barriers may stand in the way of truly integrative care. As a starting point, simply bringing up the topic in an open and nonjudgmental manner can be highly effective in overcoming several of the more common reasons for nondisclosure, as well as creating a conducive environment for discussion. Additionally, several resources and evidence-based tools can be accessed to provide point-of-care answers to improve the level of comfort and discussion (see table 1).

A New Model of Healthcare

Integrative medicine is on the rise in hospitals throughout the country. In 2005, the Institute of Medicine conducted a survey and found that 25 percent of U.S. hospitals offer CAM. That represents a 17.3 percent increase since 1999. The most common complementary therapies offered by hospitals are massage, music therapy, healing touch, guided imagery, relaxation techniques, and acupuncture.

To illustrate this trend, a total of 44 highly respected academic medical centers such as Duke, Yale, Harvard, Johns Hopkins, Mayo Clinic, and Beth-Israel now belong to the Consortium of Academic Health Centers for Integrative Medicine, which is dedicated to advancing the principles and practices of integrative healthcare within academic institutions. These medical centers all have integrative medicine programs that provide a broad spectrum of integrative services to their patients.

Next Steps

It is important for physicians to have access to scientifically validated information about complementary therapies and best-practice applications. To that end, Scripps Center for Integrative Medicine offers several continuing medical education conferences and grand rounds lectures on integrative medicine topics designed for healthcare providers. For more information, please contact Scripps Conference Services and CME at (858) 652-5400. To access integrative medicine resources online, see table 1.

Table 1: Evidence-based Internet Resources for Integrative Medicine

Free Access

• National Institutes of Health:
  • National Center for Complementary and Alternative Medicine*
• Time to Talk Program
• Topics A–Z
• Herbs at a Glance
  • Office of Dietary Supplements
• Dietary Supplement Fact Sheets
• International Bibliographic Information on Dietary Supplements Database (IBIDS)
• Computer Access to Research on Dietary Supplements Database (CARDS)
• CAMline
• MD Anderson Cancer Center

Subscription Required

• DynaMed*
• Natural Medicines Comprehensive Database*
• Natural Standard*

Asterisk (*) denotes AAFP-recognized source of evidence-based information.

Conclusion

Integrative medicine is a recognized model of care that offers a whole-person approach to improving health outcomes while empowering patients as partners in the healing process. To overcome barriers to implementing integrative medicine into clinical practice, physicians need access to accurate and timely information about evidence-based approaches.

References:

1. Lee A, Fan LTY. Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD003281.
2. Barnes PM, Bloom B, Nahin R. CDC National Health Statistics Report #12. Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007. December 2008.
3. Barnes P, Powell-Griner E, McFann K, Nahin R. CDC Advance Data Report #343. Complementary and Alternative Medicine Use Among Adults: United States, 2002. May 27, 2004.
4. Timbo BB, Ross MP, McCarthy PV, Lin CT. Dietary supplements in a national survey: Prevalence of use and reports of adverse events. J Am Diet Assoc. 2006 Dec;106(12):1966-74.
5. Complementary and Alternative Medicine: What People 50 and Older Are Using and Discussing with Their Physicians. The 2006 NIH/AARP report.
6. Corbin W et al. Physicians want education about CAM to enhance communication with their patients. Arch Intern Med. 2002 162 (10): 1176-81.