CHAPTER 1 Botanical Medicines, CAM, and Integrative Medicine: Definitions and Use Prevalence
The U.S. medical care system is self-validating. Biomedicine is rarely viewed as a historical and cultural byproduct, but rather is considered to be entirely factual, scientific, and universal. Furthermore, many powerful groups have an interest in the maintenance of existing approaches. Nonetheless, several problems have been identified with this medical care delivery system, including issues of access, quality of care, quality of life, technology use, and costs. The conservative, self-validating nature of biomedicine places severe limits on our ability to rethink our approach to medicine and deepen innovative and viable solutions to these problems. Alternative health care systems exist as a rich readily accessible resource for testable ideas about the practice and organization of medical and health care. By virtue of their popular nature, they seem generally to be well-received, low technology, and low-cost approaches to health problems. The potential contribution of these systems to solutions for the medical care problems we face would seem to be great.
WHAT IS COMPLEMENTARY AND ALTERNATIVE MEDICINE?
The National Institutes of Health (NIH) National Center for Complementary and Alternative Medicine (NCCAM) defines complementary and alternative medicine (CAM) as “a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.”2 Complementary medicine is considered to be those therapies used in conjunction with conventional medicines, whereas alternative medicine is considered to be those therapies used in lieu of conventional medicine, for example, the use of a specific herb to reduce perimenopausal symptoms in lieu of hormone replacement therapy (HRT).2
CAM therapy includes traditional Chinese medicine (TCM), Ayurvedic medicine, botanical medicine, nutritional supplements, physical therapies (i.e., massage, acupressure), homeopathy, and mind–body therapies. Spiritual practices, especially prayer, are also commonly listed among CAM therapies. “CAM therapies…share common principles. Unifying themes among CAM practices include individualized treatment plans; belief in the healing power of nature; union of mind, body, and spirit; and often, more time spent with patients.”3 The term alternative medicine creates a sharp distinction between the worlds of nonconventional therapies and conventional medicine in an either/or dichotomy, whereas the term complementary medicine may be “closer to describing what many people in reality really do; they combine the two worlds.…”3 Indeed, over 80% of the US public uses nonconventional practices and complementary medicines adjunctive to conventional medical care.4 As CAM therapies are proved safe, they may be integrated into conventional health care approaches, and thus the list of what is considered to be a CAM therapy changes constantly.
WHERE DO BOTANICAL MEDICINES FIT INTO CAM?
NCCAM divides CAM therapies into five distinct categories. Herbal remedies fall under the classification “biologically based therapies,” which refers to substances found in nature, including herbs, foods, and vitamins. These substances are broadly classified as dietary supplements. The term dietary supplement is specifically defined by the Dietary Supplement Health and Education Act (DSHEA), enacted in 1994, as a product, other than tobacco, taken by mouth, and intended to supplement the diet, including vitamins, minerals, herbs, and a number of other nutritional supplement products. Forms in which dietary supplements may be sold include extracts and concentrates, tablets, capsules, gel caps, liquids, and powders. Herbal medicines are amongst the most frequently used CAM therapies. 5 6 7
HOW WIDESPREAD IS CAM USE?
Globally, it is estimated that 70% of all health care is provided by traditional, nonconventional medicine.8 The World Health Organization (WHO) Traditional Medicine Fact Sheet states “countries in Africa, Asia and Latin America use traditional medicine to help meet some of their primary health care needs. In Africa, up to 80% of the population still relies on traditional medicine for primary health care.”9 One of the most commonly used forms of traditional medicine worldwide is botanical medicine.
Surveys indicate that as many as 50% (or more) of all Americans acknowledge using CAM therapies. 10 11 12 13 The actual rate of use is likely higher than reported in the United States, suggested by the fact that as many as 50% of patients do not report CAM use to their conventional doctors.8,14 Surveys typically exclude non–English-speaking respondents, thereby eliminating from the statistical pool those demographic pockets of Americans whose use may be even higher that in the average population; for example, large numbers of Hispanic Americans in certain locales regularly use herbs and spiritual healing practices.7
David Eisenberg’s seminal surveys on CAM use by Americans, conducted between 1990 and 1997, revealed a 45% increase in the use of CAM therapies during that period with estimated out-of-pocket expenses of up to $27 billion in 1997—up from $14 billion in 1990.7 American patients’ visits to CAM practitioners have been estimated at $600 million per year, exceeding the sum of all visits to primary care physicians.3, 5 6 7 8,14,15 Because these visits are mostly out of pocket, fewer individuals might currently use CAM therapies than if they were fully reimbursed by insurance or deductibles were lower. It is likely that there will be a significant increase in CAM use as more coverage is available from insurance companies, and as greater numbers of conventional practitioners integrate their practices to include a broader range of therapies or increase their number of referrals to a wider range of complementary therapists, such as acupuncturists, naturopathic physicians, and herbalists.
WHO USES COMPLEMENTARY AND ALTERNATIVE MEDICINE?
The average US CAM user is a well-educated health consumer, generally with at least a college education and an annual income of $50,000 or greater. Most are women between 30 and 59 years of age.6,8,14 Individuals whose personal values include a holistic approach to health, environmentalism, feminism, or a desire for personal spiritual growth are more than twice as likely to use CAM therapies.6,7,14 Additionally, members of numerous ethnic communities, such as Hispanics, African Americans, Asian Americans, and Native Americans, incorporate traditional cultural practices, including the use of herbal medicines, into their healing practices. Having a chronic disease is also an independent predictor of CAM use. 14 15 16
WHY ARE PATIENTS TURNING TO CAM?
According to Wayne Jonas, MD, former director of NCCAM, “Complementary and alternative medicine (CAM) is a health phenomenon that is largely driven by the public, and this is rather unique in medicine.”5 What is it, in this age of life-saving antibiotics, surgeries, and other seemingly miraculous medical therapies that causes so many individuals to seek therapies outside of conventional medicine? Ostensibly, there are many answers to this question.
CAM therapies are generally seen by Americans as desirable for the prevention of common chronic illnesses, including heart disease, obesity, cancer, and numerous other widespread conditions. In the past 10 years, there has been a dramatic rise in awareness of the benefits of preventative health measures, both by health practitioners and the general public. This awareness is summarized in the following statement: “Preventive health measures, including education, good nutrition, and appropriate use of safe nutritional supplements will limit the incidence of chronic diseases, and reduce long-term health care expenditures…healthful diets may even mitigate the need for expensive medical procedures.”17 This message has been reinforced by cancer and heart disease prevention societies, and the multibillion-dollar-a-year nutritional supplements industry. In response, Americans have turned to the health food store as their pharmacy, self-medicating with dietary supplements—which categorically include herbal products. Too often, individuals are getting health information from the Internet, friends and family, magazines and other popular media, and product manufacturers, rather than from well-trained CAM professionals.
A desire for safer products also leads patients to turn to CAM. Consumers place a strong belief in the high margin of safety of dietary supplements, with 53% of 1027 US adults in a survey commissioned by the Dietary Supplement Education Alliance (DSEA) stating they feel that some dietary supplements offer benefits that are not matched by conventional drugs. Fifty-six percent of respondents stated that some dietary supplements offered benefits comparable with those of drugs but with fewer side effects.13 According to Jonas, concern about the adverse effects of convention medicines is the third most commonly stated reason for turning to CAM.5 Many individuals maintain the sometimes erroneous belief that “natural” means safer and gentler.
Numerous patients hold a simple pragmatic reason for using CAM therapies—they’ve seen many doctors and tried many medications, and they are still sick. Jonas states, “In such circumstances, it is logical that patients search for something else that works. So they seek out other alternatives without necessarily abandoning conventional care.”5 Conventional medicine may be at its best when treating acute crises, but for the treatment of chronic problems it may fall short of offering either cure or healing, leading patients to seek out systems of treatment that they perceive as addressing the causes of their problem, not just the symptoms. Many prefer palliative solutions that seem safer and less invasive than the medical options with which they may be presented.
High costs of conventional medical care are also a factor. “Studies indicate that consumers are placing increased reliance on the use of non-traditional health care providers to avoid excessive costs of traditional medical services and to obtain more holistic consideration of their needs.”17 Although high-quality professional herbal products are not inexpensive, there may be hidden costs to conventional therapies, including more side effects than many herbal medicines. In one study comparing St. John’s wort with a typical tricyclic antidepressant drug, both proved close to equally effective in treating depression, although the St. John’s wort cost one-fourth the price of the drug and caused one-tenth the side effects of the conventional medication.5 Cost-effectiveness studies comparing medical interventions with CAM interventions are scarce, and should be conducted more widely.
The desire for a holistic approach, as well as for increased participation in their care may be one of the most significant forces driving the desire for complementary medicine. “Patients increasingly do not want to be treated simply as a body with a kidney, blood pressure, or blood sugar problem. Rather they want the accompanying social and psychological aspects of their ailments addressed as well.”5 Many patients simply feel that using alternative and complementary therapies more accurately reflects their personal belief systems.8,18,19
Interestingly, dissatisfaction with conventional medicine is not an independent predictor of CAM use, with greater than 95% of Americans still regularly relying on conventional medical doctors.14,20
