Integrative Medicine Aaron J Michelfelder M D FAAFP

Integrative Medicine Aaron J. Michelfelder, M. D. , FAAFP, FAAMA Vice-Chair and Predoctoral Director, Family Medicine Associate Professor of Family Medicine, and Bioethics & Health Policy Board Certified Medical Acupuncturist

Objectives • By the end of this presentation, you should be able to. . . – Define “Integrative Medicine” – Understand how Integrative Medicine relates to Modern Medicine – Prepare to practice Integrative Medicine in the future

Presentation Outline • • Definitions Why Should We Care About CAM? What Do Patients Want? What Can We Provide to Meet the Demand?

Real Patient 54 year-old female presents with peripheral neuropathy, shoulder tendonitis, and carpal tunnel syndrome about 15 months after completing chemotherapy for breast cancer. She is believed to be in complete remission currently. She states that she is exercising, doing physical therapy, taking a multi-vitamin and following all of the recommendations of her physicians, but feels like she could be doing more for her issues. What more do you want to know? What options would come to mind for you? How would you find information about those options?

“Imagine a world - oriented toward healing rather than disease, where physicians believed in the natural healing capacity of human beings, and emphasized prevention above treatment. In such a world, doctors and patients would be partners working toward the same ends. ”

Definitions “Complementary and Alternative Medicine is a Group of Diverse Medical and Health Care Systems, Practices, and Products That are Not Presently Considered Part of Conventional Medicine” National Center for Complementary and Alternative Medicine

Definitions • “Complementary Medicine is Used Together With Conventional Medicine. ” With • “Alternative Medicine is Used in Place of Conventional Medicine. ”

Definitions “Integrative Medicine Combines Mainstream Combines Medical Therapies and CAM Therapies for Which There is Some High-Quality Scientific Evidence of Safety and Effectiveness. ” NCCAM

5 Domains of CAM Alternative Medical Systems Ayurveda, Chinese, Native American, Aboriginal, African, Middle Eastern, Tibetan, Central and South American cultures, Homeopathy, Naturopathy Mind-Body Interventions cognitive-behavioral approaches, meditation, hypnosis, dance, music, art therapy, prayer, mental healing Biological Based Therapies dietary supplements, herbs, orthomolecular (varying concentrations of chemicals, such as, magnesium, melatonin, and mega-doses of vitamins), individual biological therapies (use of laetrile, shark cartilage, bee pollen). Manipulative And Body. Based Methods chiropractic, osteopathic manipulation, massage Energy Therapies Qi gong, Reiki, therapeutic touch, bioelectromagnetic-based therapies (pulsed fields, magnetic fields, or alternating current or direct current fields) As Defined by NCCAM

Why Should We Care? • 30, 000 herbs on the market currently • Estimates of $30 -40 billion dollars spent annually Eisenberg D. et al, JAMA, Nov 11, 1998(18) 1569 -1575 • Estimates of 42% of population use CAM currently Eisenberg D. et al, JAMA, Nov 11, 1998(18) 1569 -1575 • Sales of Metabolite 356 approached $1 billion in 1999 Alternative Medicine Alert, January 2000 • Relacor $23 Million; 900, 000 bottles by July 06

Overall Supplement Use

Why Should We Care? • 600 Million Visits a Year to CAM Providers – More Than to Primary Care Providers • Why? What is Mainstream Medicine Not Offering to Our Patients? Eisenberg D. et al, JAMA, Nov 11, 1998(18) 1569 -1575

Have We Missed the Boat? • Dissatisfaction with health care providers and medical outcomes • Side effects of drugs and treatments • High health costs • Technology • Lack of control in their own health care practices • Time spent with practitioner Stephen Strauss, M. D. , NCCAM Director

Have We Missed the Boat? • • Looking for “cures” Want to use “natural” products Patient feels empowered Focus on spirituality and emotional wellbeing • Health Care Provider provides the 3 T’s: touch, talk, time Stephen Strauss, M. D. , NCCAM Director

What about communication? • Between 40 and 70% of CAM users do not disclose their use to their physician. WHY? Eisenberg 2001

Why do patients not tell their physician about their CAM use? • 60% - “My doctor never asked. ” • 60% - “It wasn’t important for my doctor to know. ” • 20% - “My doctor wouldn’t understand. ” • 14% - “My doctor would disapprove. ” • 70% of patients see their Physician before or concurrent with their visits to a CAM provider Eisenberg DM. Ann Int Med 2001; 135(5): 344 -51

Why would patients not trust us? • • • Avandia Kills – FDA Black Box Warning Ketek Kills – taken off the market Rezulin Kills – taken off the market Trovan Kills - taken off the market Vioxx Kills – taken off the market

PRESS RELEASE: • Medication errors are among the most common medical errors, harming at least 1. 5 million people every year, says a new report from the Institute of Medicine of the National Academies. The extra medical costs of treating drugrelated injuries occurring in hospitals alone conservatively amount to $3. 5 billion a year, and this estimate does not take into account lost wages and productivity or additional health care costs, the report says. - IOM July 2006

Why Would We Not Trust CAM? “Doctors concerned because several cases reported of liver failure with Kava, a widely used natural remedy for anxiety”

Government Not Helping Us? • DSHEA 1994 – www. consumerlabs. com • New FDA Regulations – 8 -24 -07 – Interim Final Rule – Identity, Purity, Strength, and Free from Harmful Contaminants – Food, Drug and Cosmetic Act

Are Our Patients Reading This?

Or This?

Evidence Based Medicine • Difficulties With CAM Research – Sham Acupuncture – Non Standardized Herbal Formulations – Difficult to Blind Patients and Practitioners – Treatments Very Individualized – Difficult to Formulate Protocols

RCCT • • Gleevec Albuterol Acupuncture Chinese Herbal Therapies • How Can This Stand the Test of Time?

Comparison • Mainstream Medicine – Large Double Blind Placebo Controlled Trials • Many Exclusions Such As Multiple Medicines, Other Illnesses, Female, Pregnant, Children, Race • “Placebo Effect” Discounted • Apply These Narrow Results to The Individual – Integrative Medicine • Very Individualized • “Placebo Effect” Not Discounted

Licensing Issues CAM MODALITY Chiropractors Massage ther. LICENSURE All states 27 states Naturopaths 13 states Homeopaths 3 states Acupuncturists 32 states

• Patients are choosing integrative and alternative medicine, but what about physicians?

Where Are We Today? • Clinical Fellowships: – University of Arizona (Founding Program) – University of Michigan – University of Maryland – University of Wisconsin – Maine Medical Center – Cooper Health System (NJ) – Lawrence MA – Beth Israel Medical Center – UCLA • Academic Fellowships (Research) – – – Harvard University Tufts Boston University Stanford Duke • Residencies in Integrative Medicine – Oregon Health Sciences University – Montefiore Medical Center (NY)

Where Are We Today?

CAHCIM Members • • • • • Albert Einstein/Beth Israel Columbia University Duke University George Washington Georgetown Harvard Laval University Mayo Clinic OHSU Stanford University Yale University Wake Forest University of Alberta University of CA/Irvine Thomas Jefferson UMDNJ University of Arizona University of Calgary University of Hawaii University of Washington • • • • • University of California/LA University of California/SF University of Colorado University of Connecticut University of Kansas University of Maryland University of Massachusetts University of New Jersey University of New Mexico University of North Carolina-Chapel Hill University of Michigan University of Minnesota University of Pennsylvania University of Pittsburgh University of Texas-Galveston University of Vermont University of Wisconsin

Loyola Integrative Medicine Physician Faculty • Mariadas Chinthagada, M. D. , Anesthesiology, Acupuncture • Youngran Chung, M. D. , Peds Pulmonology, Acupuncture, Hypnosis • Chuck Dumont, M. D. , Peds GI, Acupuncture, Herbal Therapies, Homeopathy, Hypnosis • Marypat Fitzgerald, M. D. , Urogynecology, Acupuncture • Aaron Michelfelder, M. D. , Fam Med, Acupuncture, Herbal Therapies, Hypnosis • Kit Lee, M. D. , Fam Med, Acupuncture • Bo Rana, M. D. , Anesthesiology, Acupuncture • Nila Vora, M. D. , IM, Ayurvedic Medicine

Loyola CAM Providers • Amy Wu, L. Ac. , Acupuncture, Chinese Herbal Therapies • Karen Wagner, RD, LD, Nutritionist • Linda Moore, MT, Visceral, Pregnancy, Deep Tissue, Muscular Massage • Eva Mc. Cormick, PT, Biofeedback • Marilyn Moore, Guided Imagery • Thomas J. Rostafinski, Ph. D. , Hypnosis

Medical Students • Integrative Medicine Curriculum Demanded by Students • Integrative Medicine Interest Group • “Integrate Chicago” http: //www. integratechicago. com/index. html

The Future of Integrative Medicine • Definition of Integrative Medicine From the CAHCIM “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 to achieve optimal health and healing. ”

The Future of Integrative Medicine • The Term “Integrative Medicine” Will Die – Our Patients Will Demand Integrative Medicine From All of Us – Training Will Be Demanded by Medical Students – Training Will Be Demanded by Residents

The Future of Integrative Medicine • Integrative Medicine Will Be A Skill Set Added on Just Like: – Electronic Health Records – New Medications – New Procedures

The Future of Integrative Medicine • What Cannot Be Added On is Empathy and Open-mindedness • 600 Million Visits a Year to Alternative Practitioners

The Future of Integrative Medicine The Future Is Sometimes Curing, But Always Caring

Real Patient 54 year-old female presents with peripheral neuropathy, shoulder tendonitis, and carpal tunnel syndrome about 15 months after completing chemotherapy for breast cancer. She is believed to be in complete remission currently. She states that she is exercising, doing physical therapy, taking a multi-vitamin and following all of the recommendations of her physicians, but feels like she could be doing more for her issues. What more do you want to know? What options would come to mind for you? How would you find information about those options?

Integrative 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

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 therapeutic relationship and makes use of all appropriate therapies, both conventional and alternative. www. integrativemedicine. ariazona. edu PIM – U of Arizona

How do We Add On These Skills? • Build your database. • Build a referral team. • Ask your patients whom they see. • Look for summaries of available data. • Have an open dialogue with your patients.

5 Domains of CAM Alternative Medical Systems Ayurveda, Chinese, Native American, Aboriginal, African, Middle Eastern, Tibetan, Central and South American cultures, Homeopathy, Naturopathy Mind-Body Interventions cognitive-behavioral approaches, meditation, hypnosis, dance, music, art therapy, prayer, mental healing Biological Based Therapies dietary supplements, herbs, orthomolecular (varying concentrations of chemicals, such as, magnesium, melatonin, and mega-doses of vitamins), individual biological therapies (use of laetrile, shark cartilage, bee pollen). Manipulative And Body. Based Methods chiropractic, osteopathic, manipulation, massage Energy Therapies Qi gong, Reiki, therapeutic touch, bioelectromagnetic-based therapies (pulsed fields, magnetic fields, or alternating current or direct current fields) As Defined by NCCAM

Unsafe/Proven Safe/Proven Unsafe/Unproven Safe/Unproven

The Future of Integrative Medicine • Nutrition • Exercise • • • Lycopene Glucosamine Peppermint Oil Fish Oil Soy

The Future of Integrative Medicine • Epocrates Rx Pro • Micromedex • Commission E • Plus Many Other Databases

http: //nccam. nih. gov/

Resources • Commission E – Germany – Ranks Quality of Evidence – Evaluates Benefits and Risks

Integrative Medicine • Donald Novey, M. D. – Lutheran General Hospital – Evidence Based Review of Each Modality

Integrative Medicine • David Rakel, M. D. , University of Wisconsin – Instructions on how to put CAM into your own medical practice

Resources • National Center for Complementary and Alternative Medicine – http: //nccam. nih. gov/ • Agency for Healthcare Research and Quality – http: //www. ahrq. gov/clinic/epcindex. htm

Resources • American Academy of Medical Acupuncture – www. medicalacupuncture. org • Online Resource – http: //www. altmedicine. com

Where Should We Go for Information? • Product claims – www. quackwatch. com – www. snopes. com • Product quality assurance – www. consumerlab. com • Product ingredients – Natural Medicines Database www. naturaldatabase. com • Product safety and efficacy – www. cfsan. fda. gov/~dms/ds-ind. html – www. naturaldatabase. com – The Natural Pharmacist www. iherb. com or www. consumerlab. com

Summary • • • Dialogue with your patients Build your database Build your referral base Develop patient care teams Consider all available options Be open-minded • Above all: caring, concern and compassionate

THANK YOU!