Complementary and Alternative Medicine, Dietary Supplements, and Medications

Complementary and Alternative Medicine, Dietary Supplements, and Medications

اسلاید 1: 1www.tabaye.ir

اسلاید 2: 2 Complementary and Alternative Medicine, Dietary Supplements, and Medications

اسلاید 3: 3Learning ObjectivesTo define complementary and alternative medicine (CAM) in relationship to conventional medicine.To discuss characteristics of CAM users and practitioners and their implications for primary care clinicians.

اسلاید 4: 4Learning ObjectivesTo review research in progress on CAM modalities for common problems.To discuss issues CAM use raises for primary care clinicians related to communication and liability.

اسلاید 5: 5Complementary and Alternative Medicine (CAM)a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine (1)healing therapies that typically fall outside the Western biomedical model of disease, diagnosis, and treatment (2)(1) Eisenberg 1993; (2) Drivdahl 1998

اسلاید 6: 6Complementary and Alternative Medicine (CAM)The list of what is considered to be CAM changes continuallyas those therapies that are proven to be safe and effective become adopted into conventional health care and as new approaches to health care emerge. NCCAM 2003

اسلاید 7: 7Major Domains of CAM Alternative medical systemsMind-body interventionsBiologically-based treatmentsManipulative and body-based methodsEnergy therapiesNCAAM 2003

اسلاید 8: 8Who uses CAM?Surveys show marked increase in past 50 years in US and other industrialized countries (1).Between 1990 to 1997, increase from 34% to 42% of US households reporting CAM use (2).In 1997 in US, more visits to CAM practitioners than to all primary care providers (2).(1) Kessler 2001; (2) Eisenberg 1998

اسلاید 9: 9Who uses CAM?Surveys of primary care clinic populations show 28-47% utilization of CAM.21% of patients in primary care practices reported using CAM for the same health problem for which they sought conventional care on that visit. Palinkas 2000

اسلاید 10: 10Who uses CAM?Herbal therapy is used by 12-14% of the US population, up from 2.5% in 1990.16-18% of patients taking prescription medications also take herbal remedies. Kaufman 2002

اسلاید 11: 11Why do people use CAM?Desire for health and wellness (1)PreventionPainMusculoskeletal pain accounted for 1/3 of all CAM use among primary care patients (2).Between 60 and 94% of rheumatic disease patients use CAM (3).Wolsko 2002; (2) Palinkas 2000; (3) Ramos-Remus 1999

اسلاید 12: 12Why do people use CAM?Very few individuals rely exclusively upon alternative modalities (1). Most individuals who use CAM do so because of preference, related to the perception that the combination of CAM and conventional treatments are superior to either alone (2).(1) Astin 1998; (2) Eisenberg 2001

اسلاید 13: 13Who practices CAM?Wide variation in background and approachDiversity in training programsBarrett 2000

اسلاید 14: 14Who practices CAM?No standardization of approach to accreditation and licensureControversies about regulationChez 1999

اسلاید 15: 15Who practices CAM?Some common beliefs and valuesThe body has self-healing potential.Body mind and spirit are all important.Therapy must be individualized.People are responsible for their own healing.Curtis 2003

اسلاید 16: 16Who practices CAM?More nonphysicians than physicians practice CAMIncreasing numbers of dual-trained MDsAmerican Board of Medical AcupunctureAmerican Board of Holistic Medicine

اسلاید 17: 17Who practices CAM?How did I get to be a “dual-trained MD”?

اسلاید 18: 18What about communication?Between 40 and 70% of CAM users do not disclose their use to their physician.WHY?Patients usually say that they do not report because they are not asked.Eisenberg 2001

اسلاید 19: 19Why does this matter?The substantial overlap between use of prescription medications and herbal supplements raises concerns about unintended interactions.Patient use of CAM is often a clue to values and preferences that need to be acknowledged.Kaufman 2002

اسلاید 20: 20How can we communicate?Always ask! “What else are you doing for your health?”Be open and nonjudgmental.Consider patient preferences and values.Encourage self-monitoring of results. Eisenberg 1997

اسلاید 21: 21How can we communicate?5. Coordinate care as appropriate.6. Be honest about your lack of knowledge and open to education.7. Monitor safety and efficacy, arrange follow-up.8. Document all discussions and advice.Eisenberg 1997

اسلاید 22: 22 EBM and CAMWhile some scientific evidence exists regardingsome CAM therapies, for most there are key questions that are yet tobe answered through well-designed scientific studies—questions such as whether they are safe andwhether they work for the diseases or medical conditions for which they are used. NCCAM 2003

اسلاید 23: 23Where are we now?There is an urgent need for more and better trials of CAM therapies!There may be hope:OAM funding FY 1992: $2 MNCCAM funding FY 2003: $113.2 M.

اسلاید 24: 24Research in ProgressNCCAM funded Research Centers Program12 Centers for CAM Research, each with focus on a particular condition4 Centers for Dietary Supplements ResearchMany clinical trials in progress, for example18 on acupuncture 16 on cancerwww.nccam.nih.gov/clinicaltrials

اسلاید 25: 25Research in ProgressBiologically-based therapiesSafety of “natural” productsEfficacy of glucosamine and/or chondroitin for pain of osteoarthritisNIH-GAIT www.nihgait.orgwww.nccam.nih.gov/clinicaltrials

اسلاید 26: 26Research in ProgressMind-body approachesSome now mainstream Clinical hypnosisCognitive therapyBiofeedbackMeditation for fibromyalgiaTranscendental meditationMindfulness meditationRelaxation responseHadhazy 2000

اسلاید 27: 27Research in ProgressManipulative therapies: chiropracticMost accepted professional therapyGood review of safety Current trials of effectiveness forChronic neck painLow back painStevinson 2002

اسلاید 28: 28Research in ProgressManipulative therapies: massageLow back painComparison with acupuncture & self-care (1)Combined with education and exercise (2)(1) Cherkin 2001; (2) Furlan 2002

اسلاید 29: 29Research in ProgressAlternative medical systems: Traditional Chinese Medicine (TCM)Current trials of acupuncture forFibromyalgiaKnee osteoarthritisRepetitive stress disorderTMJ painwww.nccam.nih.gov/clinicaltrials

اسلاید 30: 30Research in Progress“Frontier Medicine Program”NCCAM initiative to encourage research on widely used CAM practices for which there is “no plausible biomedical explanation” Energy therapiesHomeopathyPrayerSpiritual healingwww.nccam.nih.gov/clinicaltrials

اسلاید 31: 31Where does this leave us?Many conventional treatmentshave been adopted without good quality researchare costlyare invasiveare likely to have adverse effectsAND often provide inadequate relief.

اسلاید 32: 32Where does this leave us?CAM interventions generallyare low costare low-riskare free of serious side effectsAND are widely used.

اسلاید 33: 33Advising patients about CAMUse evidence forefficacy safetyto place therapy on continuumrecommendaccept discourageWeiger 2002

اسلاید 34: 34Towards IntegrationLiability Risks Based on EvidenceSupport for safety and efficacySupport for safety, inconclusive for efficacySupport for efficacy, inconclusive for safetyIndication of serious risk or inefficacyCohen 2002

اسلاید 35: 35Framework for approaching CAM in clinical situationsProtect against dangerous practices.Permit practices that are harmless and that may help.Promote and use practices that are safe and effective.Partner with patients and encourage communication about CAM.Jonas 2000

اسلاید 36: 36Framework for approaching CAM in clinical situationsQuestion:Is “permit” the right word here?Do physicians have the power to “permit” practices that their patients choose?

اسلاید 37: 37Integrative Medicinea combination of mainstream medical therapies and CAM therapies for which there is high-quality scientific evidence of safety and effectivenessNCCAM 2003

اسلاید 38: 38Integrative 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

اسلاید 39: 39Towards IntegrationThe satisfaction that patients report from relationship-centered and individualized CAM therapies serves to remind us: We can never know with certainty what therapy- alternative or otherwise- will work for an particular patient, no matter what randomized controlled clinical trials indicate.

اسلاید 40: 40Towards IntegrationOur patients’ use of CAM invites usto ask and listen to our patients,to contribute what evidence based medicine offers, to advocate for better evidence-based research, and at the same timeto acknowledge the existence of other types of information that may be more relevant to a given individual or for a particular situation.

اسلاید 41: 41Framework for approaching CAM in clinical situationsProtect against dangerous practices.Permit practices that are harmless and that may help.Promote and use practices that are safe and effective.Partner with patients and encouragecommunication about CAM.Jonas 2000

اسلاید 42: 42Partner with patients and communicate about CAMASK!“Build” a history that includes CAM use. (Don’t “take” one.)When patients tell, LISTEN!Haidet 2003

اسلاید 43: 43Integrative Medicine an opportunity to bring together strengths and balance weaknesses of different systems of health care“a coming together of heart, head, and hand”Owen 2001

اسلاید 44: 44Integrative Medicine“Could this be a healing process in itself”?Owen 2001

اسلاید 45: 45 An Integrative Approach to Complementary and Alternative Medicine in Primary Care SettingsMaureen A. Flannery MD, MPHDepartment of Family PracticeUniversity of Kentucky College of Medicine