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 It appears that most Americans seek to supplement rather than supplant traditional medical care.8 According to Brokaw et al., “Clearly, CAM is offering something that many patients want but are not getting from conventional medical services.”19
Some see the use of CAM therapies as an act of self-empowerment and an opportunity to take their health more into their own hands, perhaps a response to the days when “doctors made the decisions; patients did what they were told.”6,21 Dr. Atul Gawande, in his compelling and best-selling book, Complications: A Surgeon’s Notes on an Imperfect Science, states that “little more than a decade ago…doctors did not consult their patients about their desires and priorities, and routinely withheld information—sometimes crucial information, such as what drugs they were on, treatments they were being given, and what their diagnosis was. Patients were even forbidden to look at their own medical records: it wasn’t their property. They were regarded as children, too fragile and simpleminded to handle the truth, let alone make decisions…and they suffered for it. And they missed out on treatments they might have preferred.”22
Chambliss observes, “Poor physician–patient communication may increase the chance that a patient will turn to alternative medicine. Conventional physicians sometimes alienate patients by minimizing the connection between the mind and the body.”8 Snyderman and Weil, in Integrative Medicine: Bringing Medicine Back to Its Roots, observe that the marked improvements in medical understanding that have been the hallmark of the scientific model have been accompanied by “an unexpected and unintended erosion of the patient–physician relationship.… Burgeoning medical knowledge has created specialties and subspecialties, all of which are necessary; however it has created a dizzying array of practitioners, who generally focus their attention on small pieces of the patient’s problem.… Managed care, capitation, increased need for documentation and productivity, and major constraints in health care funding have further eroded the patient–physician relationship and, at times, have forces physicians into positions of conflict with patients’ needs.… Physicians simply do not have the time to be what patients want them to be: open-minded, knowledgeable teachers and caregivers who can hear and understand their needs.”10 Table 1-1 compares a conventional medical consultation and a CAM consultation.
TABLE 1-1 CAM Consultations vs. Conventional Medicine Consultations
| CAM | CONVENTIONAL MEDICINE | |
|---|---|---|
| Time | More | Less |
| Touch | More | Less |
| History taking | Holistic | Specific |
| Language used |
Adrian Furnham, PhD, of the Department of Psychology at University College, London, researches the difference between CAM consultations and conventional consultations. His observations suggested these differences.
Presented in the report, Can Alternative Medicine Be Integrated into Mainstream Care? From the NCCAM-Royal College of Physicians Symposium, January 23–24, 2001, London.
Linda Hughes, MD, of the University of California, San Francisco, suggests that “Complementary and alternative medicine is attractive to many people because of its emphasis on treating the whole person, its promotion of good health and well-being, the value it places on prevention, and its often more personalized approach to patient concerns.”14 Many CAM practitioners and researchers corroborate this view.* David Spiegel, MD, professor of medicine and biochemistry at Stanford University School of Medicine, described the current state of health care delivery in the United States as having turned doctors into “biomechanics” and “providers.” “They are drowning in paperwork,” he said, “especially when it comes to reimbursement for CAM modalities.… They haven’t been good in helping people reconstitute a relationship with their body and deal with the emotional effects of their disease.”24
In summary, complementary and alternative medicine use is increasing because in many aspects, it “fills patients’ needs.”23
HOW OFTEN DO WOMEN SEEK CAM THERAPIES AND WHY?
Women seek medical care overall more frequently than men, and also follow more preventative health measures.25 Therefore, it is no surprise that one of the largest subgroups of CAM users is women. Specifically, they are college-educated, employed women of reproductive age, between 30 and 59 years old.6,8,11 Women are up to 40% more likely to use CAM therapies than are others.6
Although not all women who use CAM define themselves as feminist, in a study by Astin, feminism was cited as one of the three most common personal values contributing to CAM use, with twice as much CAM use likely by women who identified themselves as feminist.6 This may be a reflection of CAM use as a tool of self-empowerment. The Consumer Healthcare Products/Roper 2001 survey reported that 60% of women, versus 46% of men, were regular dietary supplement users.25 This pattern of increased use by women is likely to continue. In 1998, the US Surgeon General predicted that gender would be the greatest contributing factor to people’s health over the next century, with women predicted to experience significant increases in health-related problems, particularly as baby boomers move into their menopausal years.25
The need for personal connection and relationship with health care providers may be a motivating factor for women seeking care from integrative or alternative practitioners. According to feminist theory on gender, communication, and models of learning, women thrive better in environments emphasizing connection.26 The rampant perception of the depersonalization of medicine and disregard for subjective experience leaves many women feeling alienated. Noted childbirth educator and author, Sheila Kitzinger states: “There remains a deep-seated suspicion of women’s own accounts, which are often dismissed as mere anecdote…female experience, [particularly in relation to childbearing] is often ignored or trivialized because it does not match with ‘observable facts’ or because it does not match with [‘expert’] perceptions of the same event or process.”27 This phenomenon is recognizable in the cases of PMS and postnatal depression, now acknowledged medical syndromes, but for which women were historically dismissed or pathologized. Models of objectivity and distrust of the experiential in favor of evidence-based may be contrary and counterintuitive to women, who may place more value on intuition and personal experience as valid means of “knowing.”26 CAM therapies, typically patient-centered in their philosophies, are inherently more inclusive of the subjective voice—of the “intuitive and personalized.”26
The absence of the feminine voice in our health institutions may also be a primary contributing factor to women seeking health care outside of these institutions and returning to traditional healing methods, such as the use of herbal therapies. There is a need for inclusion of the emerging feminist perspective, known in academic circles as ‘women’s ways of knowing,’ into the discussion of potential new paradigms for women’s medicine. Jeanne Achterberg, in Woman as Healer: A Panoramic Survey of the Healing Activities of Women from Prehistoric Times to the Present, states insightfully that
The dissonance between women’s talents and women’s fate bears close attention as it reflects the evolution of institutions that lack the feminine voice. The absence of balance in these institutions has perpetuated a crisis that now extends alarmingly through all levels of health—from the health of tissues, mind, and relationships, to the health of the environment upon which life itself is dependent.28
Women also have significant concerns over the safety of some of the therapies specifically prescribed for women’s health. For example, recent back-pedaling by the medical and pharmaceutical establishments on the actual safety and efficacy of HRT has led many women to lose confidence in a range of pharmaceutical interventions. Turning to herbs and nutritional supplements for the symptomatic relief of menopausal complaints, and even the prevention of cardiovascular disease, seems to many a practical and relatively safe response to the HRT confusion. Erosion of confidence in conventional care makes women increasingly vulnerable to “natural product” marketing schemes by pharmaceutical and nutraceutical companies.
WHAT PATIENTS DON’T TELL THEIR DOCTORS
“Most patients who are using CAM are, unfortunately, not talking with their practitioners about it,” states Ellen Hughes, MD, in Integrating Complementary and Alterative Medicine into Clinical Practice.20 Statistics vary, but research indicates that 20% to 72% of all patients do not inform their physicians of their use of herbs, nutritional supplements, and other CAM therapies. 6 7 8,20,23,29 In one significant example, almost 50% of patients undergoing surgery at a University of Colorado hospital never informed their doctors about using an alternative therapy within the 2 weeks prior to the surgery.8
Wendy Kohatsu, MD, in Complementary and Alternative Medicine Secrets, emphasized that it is “of great concern that two-thirds of patients do not tell their doctors about the use of CAM. Because of growing data about interactions between conventional and CAM therapies, open communication is imperative for all concerned.”3
There are several probable reasons for such nondisclosure. Two commonly cited reasons are “Doctors don’t ask because they don’t want to know and/or don’t feel they have the time; and patients feel reluctant to volunteer such information because they are afraid doctors will think less of them and/or don’t feel it’s relevant.”6 According to Hughes, among others, 61% of patients in one survey simply felt it wasn’t important to reveal to their doctors, 60% stated that their practitioner “didn’t ask,” and 31% asserted that it was none of their care provider’s business! Twenty percent felt their provider was not knowledgeable enough about CAM to make it worth mentioning, and 13% felt their physician would disapprove and discourage their use of CAM.14 In an article in U.S. Pharmacist, Michael Montagne, PhD, a professor at Massachusetts College of Pharmacy, confirms the possibility that care providers might make derogatory remarks: “words used by conventional health professionals to describe…why people choose alternative therapies tend to be pejorative, paternalistic, sarcastic, ethnocentric, or negatively biased in some way.”30 The perception that derogatory attitudes toward CAM users exist, or that physicians are just not interested in taking time to serve as advocates and educators for patients may play a dramatic role in keeping patients from talking to their doctors about CAM use.
Patients may pay the price. Recent surveys indicate that 18% (15 million) of US adults take prescription drugs concurrently with herbs or vitamins, and most are unaware of the potential risks and contraindications of the herbal remedies they use.30,31 Nondisclosure of CAM use to physicians could result in unfavorable consequences for the patient.8 For example:
Fortunately, and as a general testament to the overall safety of botanical medicines, “despite this widespread concurrent use of conventional and alternative medicines, documented drug–herb interactions are sparse.”30
Approximately 25% of Americans end up substituting herbs for prescription drugs.14 Lack of knowledge of the use of a complementary therapy may lead the practitioner to misinterpret the effects, including the benefits, of a conventional therapy.4,29 If health care providers are going to provide safe and effective therapies to their patients, they must be open-minded and knowledgeable enough about CAM therapies to have honest, meaningful, and respectful discussions with their patients, and be able to at least advise their patients about the safety and efficacy of the most common therapies, or be able to provide appropriate resources for information and referrals for competent care.
CAM EDUCATION FOR HEALTH PROFESSIONALS
Health professionals are aware of the growing need for a minimum understanding of CAM, and many physicians and medical students express a direct interest in learning to incorporate CAM practices. As many as 60% of doctors have recommended an alternative therapy to their patients at least once, and half have used them themselves.3 Yet presently, few medical professionals are fully comfortable with or knowledgeable enough about CAM therapies to actually integrate them as a part of the clinical repertoire, or to be able to thoroughly or accurately educate their patients about the benefits and risks of CAM therapies.11,14 This lack of comfort with and knowledge about CAM therapies extends to pharmacists and dieticians.32 They may be particularly concerned about the safety of herbs because they contain pharmacologically active constituents, as opposed to other therapies that may not contain measurable active constituents (i.e., homeopathy) or that are not ingested (i.e., massage therapy, aromatherapy, Reiki).11 Then again, the known potential for pharmacologic activity is exactly what makes botanical medicines of special interest.
Many medical students, aware of the growing trend for patients to use nonconventional therapies, admit that they would like to receive training in CAM therapies—particularly botanical medicine.10,11 Currently, most receive little training, if any, in the use of phytotherapy during the course of their medical education.10 There is little consensus in the conventional medical world as to what extent, or how to integrate such therapies into medical training and practice. An increasing number of conferences on CAM are a regular feature of the continuing education options available for physicians, pharmacists, nurses, and other health professionals.
As of a 1997–1998 survey of 125 medical schools in the United States, 64% of the 117 schools that responded were offering courses in CAM either as required courses or electives, with only one-third of schools requiring CAM study as part of the formal curriculum.14,19 This number doubled from 34% in 1995. Botanical medicine is a dominant topic in such courses. However, most of the courses are brief, with fewer than 20 contact hours, and in a lecture series on multiple modalities, students typically receive no more than 2 hours of lecture on any single modality; thus, they are more likely to be introductory survey courses than in depth presentations of clinically applicable information and techniques.19,29 Additionally the majority of physicians currently practicing received no training in CAM modalities.20 David Eisenberg states, “Unless medical students or physicians in practice or in training are exposed to these therapies…unless they actually see a demonstration on a patient, a volunteer, a medical colleague, or themselves, they are simply unable to prescribe it. And they are unable to appreciate the conversation that they may need to have with a patient who wants a referral.”33 Presently only one-fourth of CAM courses surveyed by Wetzel and Kaptchuk use a case-based teaching approach. Further, it is not realistic to expect physicians to be fully fluent in a wide range of alternative medicines and treatments, while under pressure to remain current on all the developments in their own fields.23 Although Hughes suggests that the number of physicians who become bilingual will be in great demand, he points to the need for a cooperative environment between physicians and alternative practitioners—in this case, skilled herbalists and naturopathic doctors—for the purpose of referrals and mutual support of the patient.20,23
TOWARD AN INTEGRATED FUTURE OF HEALTH CARE
Ben Kligler, MD, and Roberta Lee, MD, leaders in this field, define integrative medicine as
a practice that is oriented toward prevention of illness and toward the active pursuit of an optimum state of health. It is the marriage of conventional biomedicine, other healing modalities, and traditional medical systems (Chinese medicine, Ayurveda, homeopathy, and Western herbalism, among others).34 This involves an understanding of the influences of mind, spirit, and community, as well as the body. It entails developing insight into the patient’s culture, beliefs, and lifestyle that will help the provider understand how best to trigger the necessary changes in behavior that will result in improved health. This cannot be done without a sound commitment to the doctor–patient relationship.35
Medical residencies and post-doctoral fellowships in integrative medicine have arisen to meet the educational needs of physicians interested in such training, and a national organization, the Consortium of Academic Health Centers for Integrative Medicine has evolved to support the development of undergraduate integrative medical education for emerging physicians. Harvard Medical School, Yale School of Medicine, Stanford University and Johns Hopkins University are among the many schools now a part of this group. The Consortium defines integrative medicine as follows:
Integrative practitioners embrace both conventional and alternative practices critically, prioritizing therapeutic options according to the level of benefit, risk, potential toxicity, and cost to the patient. Although integrative practitioners have a wide range of modalities at their disposal, they often are not specialists in any specific modality, having gained only brief exposure to a variety of modalities in their medical training. Some integrative physicians have specialized in a specific modality outside of medical school, for example, obtaining a license in acupuncture or specific training in botanical medicine. Many work in integrative clinics that employ a variety of types of practitioners, or work in conjunction with CAM practitioners in their communities. Integrative medicine practitioners can serve as a bridge for patients seeking both conventional and alternative modalities, with the integrative physician serving as a central figure assisting the patient in orchestrating her health care options.
