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The CAM in UME Project
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URL: The CAM in UME Project does not warrant or assume any legal liability or responsibility for the accuracy, completeness, or usefulness of any information presented herein. CAM in UME at DALHOUSIE 2006
Jana Sawynok, PhD
Dept. Pharmacology, Dalhousie University (902)494-2596
What is CAM?
Health-related systems, treatments, practices, and products which do not
currently have widespread acceptance within Canadian health care
e.g. herbal remedies, chiropractic, massage therapy
acupuncture, homeopathy, naturopathy meditation, relaxation, visualization (see Typologies)
Why teach CAM?
- widespread use by patients
- lack of discussion about CAM use
- knowledge lacking amongst medical students, physicians
- both groups want more CAM in UME
• Physicians must know about and educate patients about potential adverse effects including drug interactions • Some CAM therapies improve health outcomes, and patients should not be denied the option of these potentially helpful therapies
Healing-oriented medicine that takes into account the whole person;
Emphasizes the therapeutic relationship, and makes use of all appropriate
therapies (conventional, CAM).
Overview of session

Utilization of CAM prevalence, who uses CAM and why sources of information methodological issues central themes for CAM Natural health products (NHPs)*, acupuncture*, chiropractic*, bodywork, naturopathy*, homeopathy*, mind-body work*, energy therapies (identified by NWG) ____________________________________________________________ CAM BASICS (2 hrs) Presentation by Dr. J. Sawynok, PhD; Dept. Pharmacology Appendix I Table of contents of recommended CAM resources Timeline of events relevant to CAM development CAM PRACTICE (2 hrs) Presentations by invited CAM practitioners; with Q and As (Naturopath, Chiropracteur) Dal Faculty, Dr. E. Gold, MD, CCFP, FCFP; Dept. Family Medicine currently President CCMA (Canadian Complementary Medical Assocn) ___________________________________________________________ Note: This is an initial step towards attaining goals identified in Appendix I. Typologies


1. Biologically based therapies
use substances found in nature, such as herbs, special diets,
or vitamins (doses outside use in conventional medicine)
e.g. dietary supplements, herbal products ____________________________________________________________

2. Manipulative and body-based therapies
are based on manipulation or movement of one or more body parts

3. Mind-body interventions
use a variety of techniques designed to enhance the mind’s
ability to affect bodily function and symptoms
e.g. relaxation, meditation, guided imagery, hypnosis, cognitive behavioural therapy, expressive therapies ____________________________________________________________

4. Energy therapies
involve the use of energy fields and biofields
(as reflected in meridians, chakras)
e.g. acupuncture, homeopathy Qi gong, Reiki, therapeutic touch energy psychotherapies (e.g. TFT, EFT) ____________________________________________________________

5. Alternative medical systems
are built upon complete systems of theory and practice.
Often, these systems have evolved apart from, and earlier
than, the conventional medical approach used in the US
e.g. naturopathy, homeopathy Traditional Chinese Medicine (TCM), Ayurvedic Medicine ____________________________________________________________ B. Utilization of CAM

Trends in Alternative Medicine Use in the United States,
1990-1997. Results of a follow-up National survey

Eisenberg et al (1998) JAMA 280:1569 Telephone based survey of 1539 adults in 1990, 2055 in 1997. 1993 NEJM study reported: 34% used CAM; 72% did not disclose; out-of-pocket expenditures comparable to hospitalization. ____________________________________________________________ _________________________________________________________________________________________________________ Back problems ____________________________________________________________________________________ Allergies ____________________________________________________________________________________ Fatigue ____________________________________________________________________________________ Arthritis ____________________________________________________________________________________ Neck problems ____________________________________________________________________________________ High blood pressure ____________________________________________________________________________________ Sprains/strains ____________________________________________________________________________________ Insomnia ____________________________________________________________________________________ Lung problems ____________________________________________________________________________________ Skin problems ____________________________________________________________________________________ Digestive problems ____________________________________________________________________________________ Depression ____________________________________________________________________________________ Anxiety ____________________________________________________________________________________
Why patients use CAM
Significant predictors of CAM use
(Astin, 1998):
(1) Education
Holistic philosophy (body/mind/spirit) or cultural creative (interest in environment, personal growth) (3) Health status (particularly chronic conditions) (the more health problems, the more likelihood of use) Why patients use alternative medicine
Other factors involved in CAM use (nccam website):
Thought CAM with conventional medicine would help Conventional medical professional suggested it ____________________________________________________________ Note: Reasons identified vary according to nature of survey C. Evidence

[Note: Table of contents listed in Appendix II]

INTEGRATIVE MEDICINE David Rakel (2003) Saunders INTEGRATIVE MEDICINE. PRINCIPLES FOR PRACTICE Kligler and Lee (2004) McGraw Hill HERBAL-DRUG INTERACTIONS AND ADVERSE EFFECTS An Evidence-Based Quick Reference Guide Richard Philip (2004) McGraw Hill Websites: National Centre for Complementary and Alternative Medicine Databases: PubMed, Cochrane Library Evidence Based Medicine:
Series of case studies (observational trials) Limitation of model:
Provides information of effectiveness over a population, BUT
does not provide information on the outcome in an individual
Central themes for CAM:
Emphasizes the INDIVIDUAL (involves individualized interventions; lesion vs suseptibility theory of disease) (problems understood as interconnections between systems; emotions, stress contribute to health) (body has innate ability to heal itself, need to remove impediments to healing) reconceptualization of body (ENERGY systems) (role of meridians, chi or qi, in pathogenesis and healing) Note: CAM is amenable to investigation using evidence-based principles,
provided careful design features are used.
1. Different study questions require different methodologies/analysis
2. Results of observational studies can inform the design of trials
3. Existing procedures are robust for alternative therapies and

complementary systems
4. Complex systems can be studied as “gestalts”
Levin et al. Quantitative Methods in Research on CAM:
Methodological Manifesto. Med Care (1997) 35:1079-1094

D. Specific
Main modalities identified by the NWG on CAMinUME as requiring exposure in the medical curriculum ________________________________________________________ Natural Health Products (NHPs) Acupuncture/Traditional Chinese Medicine Homeopathy Mind-body practices Therapeutic bodywork Energy therapies Expressive therapies _________________________________________________________ Acupuncture
• originated in China over 5000 years ago
• health is determined by a balanced flow of QiQi courses along 14 major meridian systems • over 1000 acupuncture points in meridian system • needles inserted into acupoints (manual, electrical stimulation; also pressure, lasers, heat via moxibustion) • Western interest in acupuncture developed during 1970s (endorphin mechanism; NIH reviewed efficacy; FDA reclassified acupuncture needles from “experimental” to “medical device”) • different forms of acupuncture exist (Chinese, Korean, THE WEB THAT HAS NO WEAVER. UNDERSTANDING CHINESE MEDICINE (2000) Ted Kaptchuk CLINICAL ACUPUNCTURE (2001) Stux, Hammerschlag CONTEMPORARY CHINESE MEDICINE and ACUPUNCTURE (2002) Monod Cassidy Science of Acupuncture
Meridian system does not correspond to conventional structures,
BUT it has been “visualized” in a number of ways, and plausible
mechanisms have been invoked.
Conductivity mapping reveals acupoints have higher
electrical conductivity than non-points

Reveals differences (highs/lows) along a meridian system, and singular points and separatrices in surface mapping. Organizing centres (play role in development, morphogenesis) have high electrical conductivity, and high density of gap junctions; has led to Morphogenetic Singularity Theory, in which meridian system originates from a network of organizing centres. Brain imaging reveals that stimulation of acupoints evokes
activity in corresponding areas
fMRI study reveals that needle stimulation of UB67 (lateral foot;
used to treat eye disorders) leads to activation of visual cortex. [Cho
et al (1998) PNAS USA 95:2670]
fMRI study reveals laser acupuncture of GB43 (between 4th and 5th
toe; used for hearing problems) leads to activation of cortical and
subcortical sites involved in processing sound and language
[Siedentopf et al (2005) Lasers in Medical Science 20:68]

Endorphins (endogenous opioids) mediate aspects of analgesia
and antiemetic effects of acupuncture

Studies in animals and/or humans reveal that naloxone (opioid
receptor antagonist) can block acupuncture analgesia, and antiemetic

Does Acupuncture Work?

Conclusive data for P6 (PC6, pericardium meridian)

for nausea of chemotherapy, pregnancy, surgery (PONV)

good paradigm, as P6 is a standard point; the outcome is clear; short time course is evaluated ____________________________________________________________ • Systematic review: Vickers (1996) J R Soc Med 89:303
27/29 studies provide positive evidence for P6 (manual, electrical stimulation, acupressure or via Seabands) Meta-analysis: Lee and Done (1999) Anesth Analg 88:1362
19 trials; Acupuncture of P6 equivalent to antiemetic drugs in preventing PONV (post-op nausea and vomiting) Recent high quality trial: Gan et al (2004) Anesth Analg 99:1070
Compared electroacupuncture stimulation of P6 (A),
ondansetron (O), sham control (P) (placement of electrodes)
(25 per group, breast surgery; PONV outcomes at 2 and 24 hrs)
complete response (no N,V, or rescue medication)
* more effective than drug, lower cost * Acupuncture and Pain
Issues in acupuncture research:

adequacy of blinding (hollow-headed needle, laser on or off) (non-acupoint shams can produce effects) role of placebo (needle is exotic, slightly invasive, produces mild pain, balance of energy appealing concept) adequacy of treatment (choice and number of sites, number of treatments, standard vs individual sites) ____________________________________________________________
Recent high quality trials with placebo:
He et al (2004) Effect of acupuncture on chronic neck pain in sedentary
female workers: a 6-month and 3-year follow-up study. Pain 109:299

AP for 3-4 weeks provides significant benefit during
treatment, and long-term benefits remaining at 3 years
De Hoyas et al (2004) Randomized trial of long term effect of acupuncture for shoulder pain. Pain 112:289 AP for 7 weeks leads to reduction in pain compared to placebo at 7 weeks, 3 months and 6 months
“Pragmatic trial” concept:
Vickers et al (2004) Health Technol Assess 8:1-50
401 patients with chronic headache, mainly migraine, in Eng/Wales
12 AP treatments over 3 mo, vs usual care, outcomes 3 and 12 mo
AP lower than controls at 12 mo (22 fewer headache days) 15% less drugs, 25% fewer GP visits, 15% fewer sick days Acupuncture and Osteoarthritis
Berman et al (2004) Ann Intern Med 141:901-910 Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: a randomized, controlled trial Large trial (570 patients); acupuncture (8wk+taper) vs sham and educational controls; adequate duration (26 wks) Outcomes: • significant WOMAC decreases at 8wk and 26 wk • effect size similar to NSAIDs, acetaminophen • useful as adjunctive therapy See also: (1) Witt et al (2005) Lancet 366:136 N=150; acupuncture for 8 weeks vs minimal acup vs wait list AP for 8 weeks vs minimal AP vs wait list Reveals sham AP has effect compared to wait list, (2) Pariente et al (2005) NeuroImage 25:1161 Expectancy and belief modulate the neuronal substrates of pain treated by acupuncture Belief that acupuncture is being given leads to activation of neuronal substrates of pain which are similar to those activated by real acupuncture Homeopathy ____________________________________________________________ • founded late 18th century by Samuel Hahnemann (1755-1843) “Like • remedies from plants, animals and minerals • differs from herbal remedies, as involves extractions AND dilutions • US FDA recognizes homeopathic remedies as drugs, regulates manufacturing, labeling and dispensing (DIN-HM) Homeopathic Pharmacopoeia • widely used in Europe (used 20-40% physicians) • 3000 medical doctors and licensed health care providers practice __________________________________________________________ Ten most common diagnoses of patients seeking care using Homeopathic
Medicine compared with physicians using Conventional Medicine

Homeopathic Medicine (n=1177)

Conventional Medicine (n=11614)
Arch Fam Med (1998) 7:537-540
______________________________________________________________________ Like cures like (Law of Similars)
(homois “similar” – pathos “suffering”) The more a remedy is diluted, the greater its potency
(Law of Infinitesimal Dose)
- X, C and M potency; 10X, 100X, 1000X
- ultra-low dose (microdose) therapy
- after 24X potency, no molecular trace remains
(raises the question of plausibility; see below) Illness is specific to individual
e.g.1: migraine has >20 symptom patterns and remedies
e.g. 2: cold with tears, eye irritation, thin, clear nasal discharge
treated with onion extracts; cold with thick, yellow nasal discharge and
loss of thirst treated with purple cone flower
Activates self-regulatory mechanisms that are protective NMR (nuclear magnetic resonance) imaging of remedies reveals some distinct readings (electromagnetic frequency Mechanism not well understood, but remedies activate endogenous energy systems (vibrational medicine) See: ENERGY MEDICINE. THE SCIENTIFIC BASIS. Oschman JL (2000) Edinburgh, Churchill Livingstone Does Homeopathy work? • History of use (>200 years); widespread use in Europe • Accounts of patients and doctors support practice _________________________________________________________________ Lancet (1997) 350:834 Are the clinical effects of homeopathy placebo effects? A meta analysis of placebo controlled trials Results of meta-analysis (119 trials) are not compatible with the hypothesis that the clinical effects of homeopathy Lancet (2004) 366:726-732 Are the clinical effects of homeopathy placebo effects? Comparative study of placebo-controlled trials of homeopathy and allopathy Compared 110 homeopathic trials with 110 matched conventional medicine trials. Weak evidence for specific effect of homeopathic remedies, but strong evidence for specific effects on conventional interventions. Findings compatible with clinical effects of homeopathy being due _______________________________________________________ E. Implications for practice

John’s herbal dilemma
Canadian J CME (Jan 2004) 117-124
Complementary medicine: What you should know
John, 67, had a myocardial infarction and was placed on
ramipril, metoprolol, acetylsalicylic acid (ASA) and pravastatin.
A few weeks later, after an uneventful recovery, he was feeling
quite tired, had difficulty with erections, and had memory loss.
He believed this came from the medications and he decided to
stop his pills. He then visited a naturopath who suggested he
take St. John’s Wort, garlic, and ginko biloba. He returns to see
you and his blood pressure is 160/95 mmHg. He is feeling much
better since stopping the medications and taking herbal remedies.
He would like to continue taking them, but also wants to stay on
the ASA.
What would you say and do?
John could benefit from blood pressure control and medicine to
prevent another heart attack. However, he felt unwell, and so discontinued
all his medications. Perhaps John is depressed.
Educate him about the risks and benefits of conventional therapy.
Negotiate that he take some of the medications, and perhaps drop
the beta blocker, and see if the erectile dysfunction and tiredness
wane. He cannot take ginko and ASA together because of the risk
of spontaneous bleeds. Explain the risk benefit of both treatments
and let him decide which to take. Staying on the St. John’s Wort
may help with his depression. Give John a number of follow up visits,
making sure he is making well-informed choices.

CASE EXAMPLE 2 ____________________________________________________ Mike’s case Canadian J Diagnosis (Mar 2004) 81-84
Needling the facts: An evidence-based review of acupuncture
Mike, a 35-year-old tennis player, was experiencing lateral
epicondyle pain for approximately three months. His initial
treatment consisted of naproxen (500 mg twice daily, for
two weeks), and conventional physical therapy for two months.
These treatments were unsuccessful in alleviating his pain.
Mike was then referred for cortisone injections. The diagnosis
of lateral epicondylitis was confirmed on examination. The patient
was given the option of cortisone injections or acupuncture. After potential
adverse effects were discussed, he expressed concerns
with the cortisone injections, and opted for acupuncture.
Treatment consisted of five electroacupuncture sessions within
three weeks (once or twice weekly). After the treatments, Mike’s
epicondylar pain abated, and he was able to play tennis at the same level
as prior to pain onset. He has yet to seek further treatment.
Appendix I
CAM Learning objectives
National Working Group on Complementary and Alternative Medicine
(CAM) in Undergraduate Medical Education (UME) project, a national
initiative to teach CAM in UME in Canada, led by Dr. Marja Verhoef
(University of Calgary), with representatives from most medical schools in
Canada (Nov 2003 report).
K1 Definitions,
classification schemes, prominent practices List/describe CAM therapies used in certain prominent conditions Identify safety issues, interactions with conventional medicine Identify reliable sources for evidence, evaluate evidence Understand regulation and credentialing of common CAM practitioners in student’s province Discuss CAM in a professional manner (history, listening respectfully, informing) Locate, understand, evaluate and communicate information regarding safety and efficacy of CAM therapies Communicate effectively with CAM practitioners Describe beliefs regarding CAM, identify how these may affect practice Demonstrate respect for beliefs and choices of those who use CAM Appendix II
Contents of some recommended CAM resources

(2003) Ed. D. Rakel; Saunders
Part I: Integrative Medicine
Ch 1 Philosophy of integrative medicine
Part II: Integrative Approach to Disease
Ch 3 Depression
Ch 7 Migraine/Tension Head Ch 8 Peripheral Neuropathy Ch 10 Parkinson’s Disease Ch 11 Otitis Media Ch 13 Upper Resp Infection Ch 14 HIV Disease Ch 36 Recurring Abdominal Ch 37 Fibromyalgia Ch 48 Benign Prostatic Hyp Ch 49 Urolithiasis Part III: Disease Prevention
Ch 65 Prevention of Breast Cancer
Ch 76 Preventing Age-Related Macular Degen Ch 79 Prevention of Urinary Tract Infect Part IV: Tools for Your Practice
Ch 81 Food Allergy
Ch 82 Elim Diet and Food Hypersensitivities
Appx II (cont’d)

Ch 93 Journaling
Ch 99 Strain/Counterstrain Manipulations Ch 101 Acupuncture for Nausea/Vomiting Ch 102 Spiritual Assessment and Care Ch 103 Therapeutic Homeopathy ____________________________________________________________________________

INTEGRATIVE MEDICINE. Principles for Practice

(2004) B. Kligler, R. Lee; McGraw-Hill
PART 1: Basic Principles
Ch 1 Integrative Medicine: Basic Principles
Ch 2 Psychosocial Determinants of Health and Illness: Reintegrating Mind, Body and Spirit
Ch 3 Mind-Body Medicine
Ch 4 A New Definition of Patient Centered-Care PART II: Therapeutic Modalities
Ch 5 Botanical Medicine: Overview
Ch 6 Issues Concerning the Safety of Herbs Ch 11 Movement/Body-Centred Therapies Ch 12 Homeopathy Ch 13 Physical Activity and Exercise Ch 16 Selected Issues in Environmental Medicine PART III: Integrative Approaches (IA) to Specific Conditions
Ch 17 IA (*) to Allergy
Ch 29 IA to Rheumatology
Part IV: Integrative Approaches Through the Life Cycle
Ch 30 IA to the Care of Children
Part V: Legal and Ethical Issues
Ch 36 Legal and Ethical Issues in Integrative Medicine
Part VI: Selected Cases in Integrative Medicine
Ch 37 Selected Cases in Integrative Medicine
* Note: IA indicates Integrative Approach
Appx II (cont’d)


Evidence-Based Quick Reference Guide
(2004) R.B. Philip, McGraw Hill
SECTION 1: Overview and General Principles
SECTION 2: Alphabetical Listing of Herb and Nutriceutical Monographs
(contains 262 pages listing 2-3 pages each for individual agents, with sections on Sources/
Description/Use, Pharmacology, Adverse Effects/Interactions, References for each agent)
Appendix I
Documented and Potential Interactions Between Botanicals/Nutriceuticals and
Anticoagulant/Platelet-inhibiting Drugs
Appendix II
Confirmed and Theoretical Interactions (Potentiative or Additive) Between Herbs/Nutriceuticals
and Psychotropic/Other Centrally Acting Drugs
Appendix III
Herbs/Botanicals That May Cause Hepatotoxicity
Appendix IV
Herbs and Foods That May Contain Phytoestrogens and/or Phytoprogestins
Appendix V
Herbal Preparations That May Cause Adverse Reactions When Used Systemically, Topically for
skin Conditions, or in Cosmetics
Appendix VI
Botanicals That May Alter Drug Biotransformations
Appendix VII
Botanicals that can Affect Cardiovascular Function / Lower Serum Lipids
Appendix VIII
Herbal Remedies and Nutriceuticals With Anti-inflammatory and Antirheumatic Properties
Appendix IX
Members of the Compositae (Daisy or Asteraceae) Family, Including Wild and Garden Flowers
Appendix X
Herbal and Other Alternative Remedies Purported to Have Hypoglycemic or Antidiabetic
Appendix XI
Herbs and the Kidney: Diuretic and Nephrotoxic Herbs
Appendix XII
Herbs/Botanicals and Cancer (Herbs Shown to be Carcinogenic in Laboratory Studies/ Herbs
Shown to be Antineoplastic in Laboratory Studies)
Appendix XIII
Psoralen-containing Botanicals Capable of Causing Phytophotodermatitis
Appendix XIV
Some Useful Websites
Appendix III
Selected readings
Chapter 1 of INTEGRATIVE MEDICINE listed in Appendix II.

Results of a Follow-up National Survey
Eisenberg et al (1998) JAMA 280:1569

Astin (1998) JAMA 279:1548

SYSTEM AND THE IMMUNE SYSTEM Ader et al (1995) Lancet 345:99-103
MOLECULES Sternberg (1997) Nature Medicine 3:264-267

Astin et al (2003) J Am Board Fam Pract 16:131-147
This REVIEW considers the effectiveness of mind-body therapies (relaxation,
meditation, guided imagery, hypnosis, biofeedback, cognitive behavioral therapy,
psychoeducational approaches) in diverse medical conditions.

(2001) Esther Sternberg, MD
This BOOK addresses the connections between the immune system and the brain, providing a construct for how stress and emotions contribute to health. It has an interesting historical section. FROM DOCTOR TO HEALER. THE TRANSFORMATIVE JOURNEY (1998) Robbie Davis-Floyd and Gloria St. John, Rutgers University Press This BOOK explores multiple health paradigms, from biomedical to humanistic to holistic. It also contains interviews with physicians who use holistic approaches, and addresses the issue of paradigm shift. Appendix IV
Timeline of events relevant to CAM development
CAM teaching in Medical Schools in Canada Mainstream medical journals publish CAM articles (New Eng J Med, J Am Med Assoc or JAMA) NCCAM (National Centre for Complementary and Alternative Medicine) evolves from OAM Eisenberg review of CAM use (NEJM) (or Psychoneuroimmunoendocrinology, PNIE) Nervous system-immune-endocrine system connections Neuropeptides identified in these systems Endogenous opioids implicated in acupuncture Opiate receptor, and endorphins discovered China invades Tibet, Dalai Lama goes into exile RCTs developed; “Powerful placebo” acknowledged


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