Making Your Practice More Integrative Some Tips and

Making Your Practice More Integrative: Some Tips and Tricks Adam Rindfleisch, MPhil, MD Associate Professor, University of Wisconsin Department of Family Medicine

Objectives Help you make your practice more “Integrative” 1. Define what IM is 2. Suggest a tool for evaluating therapies 3. Apply this technique to several ‘tools’ you can bring into your practice – supplements, CAM, and beyond 4. Offer tips and resources along the way

Integrative Medicine at UW

UW Health Arboretum Family Medicine

A Key Web Resource: www. fammed. wisc. edu/integrative

Some Disclosures…

NCCIH and ACIHM • • • National Center for Complementary and Integrative Health Originally created as Office of Alternative Med October 1991 Renamed 1998 under Clinton as NCCAM 2015: Became NCCIH https: //nccih. nih. gov/ • Academic Consortium for Integrative Medicine and Health – www. imconsortium. org – 69 members

What is Integrative Medicine (IM)? • 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, healthcare professionals and disciplines to achieve optimal health and healing.

What is Integrative Medicine (IM)? • Bottom line – Based on respect for communication and individuality – Evidence-based – Prevention and health-focused – Enlists “CIM” approaches

Our Medical Culture 68, 000 Codes (ICD-9 has 13, 000) W 6162 XA = V 9107 XA = Struck by a duck Burn due to water skis catching on fire

Gauging an Approach… ECHO

The ECHO Mnemonic for choosing therapies • Efficacy • Cost • Harms • Opinions 13

ECHO: Using it with Turmeric (Curcuma longa) https: //naturalmedicines-therapeuticresearch-com • • Efficacy – ‘Possibly effective’ for knee OA – 500 mg BID improved functionality Costs (variable) – $3 for 140 doses of powdered – $35 for 120 high-end caps Harms – Likely safe, up to 8 months – 6 g/day caused some flatulence and stool changes – NO reports of bleeding risk Opinions – My patients love it about 80% of the time – Good to avoid NSAID adverse effects My Conclusion: A potentially good choice 14

Other supplements and ECHO – in brief Supplement Efficacy Cost Harms Opinions L-theanine (anxiety) Less clear $$ Minimal Usually Positive Red rice yeast (cholesterol) Good $$$ Moderate Ashwagandha (adaptogen) Less clear $ Minimal Moderate Grape seed extract Good (venous insuff. ) $$ Minimal Less familiar to people St. John’s wort (depression) Good $$ Risky Varied Rhodiola (adaptogen) Less clear $$ Minimal Usually positive 15

Rhodiola Rosea (Arctic or Golden Root) Darbinyan V, et al. Clinical trial of Rhodiola rosea L. extract SHR-5 in the treatment of mild to moderate depression. Nord JPsychiatry 2007; 61: 343348.

The Microbiome VETERANS HEALTH ADMINISTRATION

Ridaura, V. K. , et al. , Gut microbiota from twins discordant for obesity modulate metabolism in mice. Science, 2013. 341(6150)

Probiotics Improve IBS Bifidobacterium bifidum MIMBb 75 • Improved global symptom score, pain, distension/bloating and stool urgency. • Adequate relief reported in 47% Tx group and 11% in placebo. (P<0. 0001) • No adverse events compared to placebo. Guglielmetti S, et al. RCT: Bifidobacterium bidfidum MIMBb 75 significantly alleviates IBS VETERANS HEALTHQOL-a ADMINISTRATION and improves DBPCS. Aliment Pharmacolo Ther. 2011. 33(10)

Probiotics also benefit Constipation Bifiobacterium lactus. “B” for Bowel Movement” Dimidi et al. The effect of probiotics on functional constipation in adults: a systematic review and metaanalysis of randomized controlled trials. Am J Clin Nutr 2014 VETERANS HEALTH ADMINISTRATION

Bailey, L. C. , et al. , Association of Antibiotics in Infancy With Early Childhood Obesity. JAMA Pediatr, Sept. 29 th, 2014.

L. rhamnosus and Mice Anxiety • Prolonged swimming in water • Less stress and depression • GABA receptor stimulation • No Δ when vagus nerve cut Bravo JA, et al. Ingestion of Lactobaccillus strain regulates emotional behavior and central GABA receptor expression in a mouse via the vagus nerve. PNAS. July, 2011 VETERANS HEALTH ADMINISTRATION

Gut Directed Hypnotherapy: The results seen at 3 months were sustained up to 1 year! Lindfors, P. , et al. , Effects of gut-directed hypnotherapy on IBS in different clinical settings-results from two randomized, controlled trials. Am J Gastroenterol, 2012. 107(2): p. 276 -85. VETERANS HEALTH ADMINISTRATION 24

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Probiotics Practice Pointers • Most commonly use Bifidobacterium or Lactobacillus • Saccharomyces boulardii, a probiotic yeast, also quite powerful – Red Star Yeast, 1 tsp daily – Helpful with Inflammatory Bowel (Crohns Dz) • Dose in colony forming units (CFU’s) – 109 or 1010 CFU’s daily a good dose – How long? – I do a few weeks • I always give them with diarrhea • I always recommend them with antibiotics • Consider in pregnancy and in kids who were born via C/S or who are bottle feeding or who’s mom needed antiobiotics prophylaxis for group B Strep. Can read more in the chapter, “Prescribing Probiotics” in the Integrative Medicine textbook. VETERANS HEALTH ADMINISTRATION 26

What about Other Approaches? VETERANS HEALTH ADMINISTRATION 27

Treatment A • 12 mth, multi-center, randomized, DB study • 228 pts with sciatica • Tx A vs saline injection • Transient benefit for Tx A at 3 weeks • Transient benefit for saline at 12 weeks • No benefit @ 6, 12, 26 & 52 wks. • Cost/QALY= $319, 130. 00 • Failed NICE threshold Treatment B • • • 24 month, multi-center, randomized, open study 241 pts with persistent low back pain Tx B vs usual care by PCP 10 -15% improvement with Tx B at 12 and 24 months vs control Cost/QALY: $8, 097. 00 Passed NICE threshold for cost effective benefit

Treatment A vs Treatment B Tx A Tx B Evidence of Benefit Cost/QALY + ++ ++++ + Patient Cost + +++ Institutional Profit Potential Harm ++++ + Practice ++++ +

How much it costs to gain one additional quality adjusted life year (QALY). Treatment Hip Replacement Cost/QALY $2, 164 Neurosurgery for malignant brain tumor Acupuncture for LBP $197, 647 Epidural Steroid Injection for Sciatica $319, 130 $8, 097 Sackett D, et al. Evidence Based Medicine. 2 nd Ed. Churchill Livingstone. 2000.

Friedly JL, et al. A randomized trial of epidural glucocorticoid injections for spinal stenosis. N Engl J Med 2014; 371: 11 -21.

References: Epidural Steroids • Arden NK, et al. A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: the WEST study. Rheumatology 2005; 44: 1399 -1406 • Price C, et al. Cost-effectiveness and safety of epidural steroids in the management of sciatica. Health Technol Assess. 2005; 9(33): 1 -58. Acupuncture • Thomas KJ, et al. Randomized controlled trial of short course of traditional acupuncture compared with usual care for persistent nonspecific low back pain. BMJ 2006 23; 333(7569): 623. • Ratcliffe J, et al. A randomized controlled trial of acupuncture care for low back pain: cost effectiveness analysis. BMJ 2006 23; 333(7569): 626.

Hopton, A. , et al. , Acupuncture, counseling or usual care for depression and comorbid pain: secondary analysis of a randomized controlled trial. BMJ Open, 2014. 33

Practitioner Effects Mc. Kay KM, Imel ZE, Wampold BE. Psychiatrist effects in the psychopharmacological treatment of depression. J Affect. Disord. 2006; 92: 287 -90.

NIH Placebo Research (Harvard, U of Wisconsin) ü Good Doc ü Bad Doc ü No Doc Page 28 in Binders: CARE MEASURE by Dr. Stewart Mercer Items for Empathy Scoring

Practitioner Effects on IBS Pts Randomized to: Improvement in Symptoms; • Wait List Control. . . . 28% • Limited Clinical Visit. . . 44% • Augmented Clinical Visit. . . . 62% Kaptchuk TJ. et al. Components of the Placebo Effect: RCT in patients with IBS. BMJ 336 (7651), 2008

Perception of Perfect Empathy 50/50 on CARE Score IL-8 No Visit Standard Neutrophils Enhanced No Visit Standard Enhanced

Effects of Perceived Empathy on Common Cold No Visit < Perfect P Value Duration 6. 75 days 7. 0 days 5. 89 days 0. 003 Severity 0. 04 262. 19 270. 58 223. 38 Rakel, Hoeft, Barrett, et al. Fam Med. 2009; 41(7): 494 -501 Rakel, Barrett, Zhang, et al. Patient Ed & Counseling. 2011; 1 -8.

Mnemonic for �Suffering Relationship Empathy and trust creates a positive environment where the clinician can Listen to a complicated story that creates Insight Explanation that is consistent with the patient’s Values Empowerment centered care built on into a problem that results in an leading to and action towards health Rakel, D. , The salutogenesis-oriented session: creating space and time for healing in primary care. Explore (New York, N. Y. ), 2008. 4(1): p. 42 -47.

From Jerusalem to Jericho: a study of situational and dispositional variables in helping behavior J Personality and Social Psychol. 1973; 27: 100 -108 Group #1 Group #2 Group #3

Reduction in Empathy with Medical School Training Newton et al. Acad Med, 83(3) 2008

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Nationalgeographic. com

When are you most… • • • Aware Present Centered Focused Calm http: //wallpapers 916. blogspot. com

Definition of Mindful Awareness • Way of being • In the present moment • On purpose • Nonjudgmentally

Mindful awareness is an opportunity to be in the wholeness of life… including suffering, joy, peace, unrest, creativity, fullness, emptiness – everything… …Not merely a technique for coping with a specific problem.

Drop beneath your mind’s thoughts and …. . observe Thoughts Judgment Emotions Awareness

Mindfulness and Medicine

Promega Study Methods: • 48 right handed subjects employees of Promega in Fitchburg, WI • Subjects randomized into Meditation group (N=25, 19 females) and a wait-list control group (N=16, 10 females) • Mean age 36 years • Wait-list controls were provided 8 -wk MBSR training program after completion of study Richard J. Davidson, Ph. D. , Jon Kabat-Zinn, Ph. D. , et al. Alterations in brain and immune function produced by mindfulness meditation. Psychosomatic Medicine. Aug/Sept. 2003

Negative emotions: • • right prefrontal cortex Anger Fear Anxiety Depression

Positive emotions: • • Enthusiasm Vigor Optimism Buoyancy Left prefrontal cortex

f. MRI Brefczynski-Lewis, et al. 2007104(27): 11483 -8

Mindfulness for Clinicians and Staff Fortney L, Luchterhand C, Zakletskaia L, Zgierska A, Rakel D. Abbreviated Mindfulness Intervention for Job Satisfaction, Quality of Life, and Compassion in Primary Care Clinicians: A Pilot Study. Ann Fam Med. 11(5); 412 -420. 2013

Significant improvements with depression, anxiety and stress

How can your clinical stool or chair become your meditation cushion?

Suggestions for practice Listen with your whole body Deep breath before each patient Threshold exercise Stethoscope use as a reminder to be mindful Call room/office centering – The moment you sit in your chair… • Supportive group • Daily practice • Others? • • • http: //www. virtualtoolbox. ca/

www. fammed. wisc. edu/mindfulness

Indicators of Clinician Burnout effects half of physicians, and even more nurses. Key indicators of burnout include: (the shadow side of resilience) 1. Emotional exhaustion 2. Depersonalization & decreased empathy 3. Lack of personal accomplishment http: //www. headingtoninstitute. org/Portals/32/Resources/Test_Are_you_bu rnout. pdf

Significant improvements with Maslach Burnout Inventory

What Contributes to Burnout? • • • Perfectionism Lack of coping skills for stress Personal bad habits (smoking, recreational drug use) Lack of control over office processes Lack of control over schedule Poor relationships with colleagues Lack of time for self care Difficult and complicated patients Not enough time in the day Excessive paperwork Regret over chosen career Eckleberry-Hunt et al, Acad Med 2009; 84: 269 -277. 61

Burnout—What helps? Strongest correlation medications Moderate correlation— • Use of meditation, relaxation, massage, etc. • Use of support group for physicians • Talking about feelings • Use of professional counseling • Feeling like one has some control over one’s schedule Eckleberry-Hunt et al, Acad Med 2009; 84: 269 -277.

What else? • Having a plan for the future • Having enough money • Having a supportive work environment • Feeling connected to, and compassionate toward patients • Shared mission at work • Having good coping skills • Being very happy with child care -Eckleberry-Hunt et al, Acad Med 2009; 84: 269 -277.

Resilience Can Be Learned! 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Positive attitude Cognitive flexibility Moral compass Role model Face fears Develop active coping skills Social support Physical well-being Train regularly Recognize and foster signature strengths Can also do a web search for “The Resilience Prescription” for a summary

Cultivating Resiliency – 3 questions 1. Am I living according to my values? * 2. Am I taking care of myself? 3. Am I making a conscious effort to cultivate resilience? From Nedrow, et al. , Family Practice Management, 2013; Jan/Feb: 25 -30. * http: //www. wellesley. edu/sites/default/files/assets/departments/cws/files/values. pdf

In Summary • To make your practice more ‘Integrative, ’ consider the following… 1. 2. 3. 4. 5. 6. 7. 8. Use the ECHO Approach Consider supplements that meet ECHO criteria Consider acupuncture for pain Explore the power of probiotics Remember the power of therapeutic presence Incorporate mindfulness Minimize burnout and enhance resilience Take care of yourself! 66