Briggs, 2015, Complementary and Integrative Medicine
Briggs, 2015, Complementary and Integrative Medicine
Briggs, 2015, Complementary and Integrative Medicine
By Josephine Briggs
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Pages 56–64 Self-Empowered Aging
The most-used complementary health products absence of advice or guidance from healthcare
are dietary supplements (Barnes, Bloom, and providers. Consequently, busy clinicians regu-
Nahin, 2008). Obtaining accurate estimates of larly face difficult challenges in providing
the extent of use has posed a number of chal- patients with advice and education about com-
lenges. Survey estimates carry limitations: they plementary and integrative health practices.
depend upon the respondent’s memory, inter- Of particular concern to all clinicians are
pretation of the question, accurate identification practices of uncertain safety, and practices that
of the product, and willingness to report use raise inappropriate hopes. Cancer therapies,
accurately. The National Health and Nutrition anti-aging regimens, weight-loss programs,
Examination Survey (NHANES), in 1999–2000, sexual function, and athletic performance are
concluded that 52 percent of adults took some frequently targeted for excessive claims and
form of dietary supplement, using a definition irresponsible marketing.
that included multivitamins and other
vitamin and mineral supplements.
Use of complementary medicine is
The biggest increases in use of
complementary therapies in the last widespread, with prevalence estimates
decade have been in mind and body varying from about 35 to 50 percent.
therapies, including relaxation tech-
niques and meditative exercise forms such as A number of Internet resources provide
yoga, Tai Chi, and Qi Gong (Barnes, Bloom, and critical tools for patient education (see Table 1
Nahin, 2008). These practices are being widely on page 58). Because complementary health
used by Americans, both for fitness and relax- approaches often are used as self-care and
ation, and because of perceived health benefits. because many patients research these approach-
And such exercise techniques increasingly are es extensively on the Internet, directing patients
employed in health settings with some evidence to responsible websites can be very helpful.
of benefit—to improve balance and reduce falls There is evidence that a patient’s use of
in older people; to help manage back pain (Mo- complementary health practices frequently is
rone and Greco, 2007); to relieve anxiety for not communicated to healthcare providers.
people in stressful situations (such as under- According to a national survey, more than
going a medical procedure); and as stress- two-thirds of people who use these approaches
management techniques for cancer survivors. do not discuss their use with healthcare pro-
viders. The survey revealed the primary rea-
Patients’ Wide-Ranging Information Sources sons for this lack of communication: Patients
While conventional healthcare providers are believed it was not important for the provider
important sources for advice about health to know about their use of complementary
matters, patients also rely upon other sources. health approaches, and the providers do not ask
Family and friends, practitioners of complemen- their patients about their use. As more people
tary health approaches, traditional cultural use these practices, clinicians are encouraged
beliefs, and the Internet also are important. to ask patients about their use so they can ef-
Although a vast amount of information about fectively coordinate their care. The disclosure
complementary and integrative approaches is of use among minority populations is particu-
available in the public domain, much of it is larly low (Chao, Wade, and Kronenberg, 2008),
incomplete, misleading, inaccurate, or based on presenting a challenge for physician−patient
scientifically unproven claims. Much of the communication. Efforts to improve consistency
public’s use of these practices occurs in the of care and provider−patient communication
Copyright © 2015 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or
distributed in any form without written permission from the publisher: American Society on Aging, 575 Market
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Spring 2015 • Vol. 39 . No. 1 | 57
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distributed in any form without written permission from the publisher: American Society on Aging, 575 Market
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58 | Spring 2015 • Vol. 39 . No. 1
Pages 56–64 Self-Empowered Aging
across racial and ethnic groups may increase for symptom management, particularly for pain.
such disclosures. Therapies increasingly incorporated into
managing chronic pain include massage and
The Evidence Base spinal manipulation, hypnosis, acupuncture,
In general, the scientific evidence regarding mindfulness and meditative exercise forms such
complementary and integrative therapies is as Tai Chi and yoga, and relaxation techniques.
fragmentary and incomplete. Nonetheless, over Research on these mind and body approaches is
the past decade there has been increased still hampered by methodological issues, includ-
application of rigorous methods of assessing ing a lack of consensus on appropriate controls
evidence and growing attention to research and lack of intervention standardization. While
methodology. Because marketed products vary much of the clinical data are inconclusive, these
substantially, studies of herbal products and approaches evoke substantial patient interest
other dietary supplements face unique challeng- and may be helpful in reducing requirements for
es in characterizing such products—determining opioids. Such techniques may also help older
the product’s authenticity, or defining its source. adults maintain motivation to incorporate phy-
However, this challenge is being addressed, at sical exercise into their regular activities. For
least in part, with the establishment of Consoli- most healthy older adults, relaxation techniques,
dated Standards of Reporting Trials (CONSORT) Tai Chi and Qi Gong, and modified yoga practices
criteria for publication of herbal trials, and with have relatively few safety concerns (Morone and
the development of standards for National Greco, 2007).
Institutes of Health–funded natural
product research. Research on mind and More than two-thirds of people who use
body and manipulative therapies also
poses challenges because these inter- complementary approaches do not discuss
ventions often are complex and difficult their use with healthcare providers.
to standardize—and blinding of partici-
pants and practitioners is generally not practi- Several standardized meditative approaches
cal. Similar challenges exist in a number of other have been developed and applied in healthcare
clinical areas, such as in psychotherapy assess- settings, including transcendental meditation
ment methods. and Mindfulness-based Stress Reduction (Kabat-
Listed in Table 2 (on page 60) are a number Zinn, Lipworth, and Burney, 1985). Although
of valuable resources to aid healthcare providers evidence to date for health benefits is largely
in accessing critical assessments of the safety inconclusive, these interventions are attracting
and efficacy of complementary and integrative research to understand neurological mecha-
practices. These websites also provide access to nisms of altered mental states (Davidson et al.,
systematic reviews and clinical practice guide- 2003) and to identify whether or not these tech-
lines, and help with searching the peer-reviewed niques may contribute to pain management,
literature on complementary approaches. The care of cancer survivors, weight management
Cochrane Collaboration is a particularly valuable (Ludwig and Kabat-Zinn, 2008), and a number
resource, having undertaken more than 300 of mental health conditions.
systematic reviews of complementary therapies. Acupuncture has a venerable history as a
major component of traditional Chinese medi-
Mind and Body Approaches cine, with a tradition of use that extends at least
A number of systematic reviews point to the 2,000 years. The term acupuncture describes
potential benefit of complementary approaches a family of procedures, the most important of
Copyright © 2015 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or
distributed in any form without written permission from the publisher: American Society on Aging, 575 Market
St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications
visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join.
Spring 2015 • Vol. 39 . No. 1 | 59
GE NER ATIO NS – Journal of the American Society on Aging Pages 56–64
• Agency for Healthcare Research and Quality (AHRQ) Evidence-Based Practice Centers Report Summaries
The AHRQ website contains comprehensive evidence reports on select complementary health modalities.
Reports review data on meditation and omega 3 fatty acids, vitamin D, calcium, garlic, and melatonin for
specific health conditions;
www.ahrq.gov.
Copyright © 2015 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or
distributed in any form without written permission from the publisher: American Society on Aging, 575 Market
St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications
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60 | Spring 2015 • Vol. 39 . No. 1
Pages 56–64 Self-Empowered Aging
which is stimulation of anatomical points on results have suggested that the subjective
the body using thin, solid, metallic needles that experience is critical, and that a substantial
are manipulated by the hands or by electrical component of any benefit from acupuncture
stimulation. Ancient traditional Chinese medi- may be through non-specific effects, including
cine teachings place acupuncture points on effects of practitioner attention, a counter-
meridians on the body’s surface, linked with irritant, expectation of benefit, and changes
specific conditions and internal organs and in attention or vigilance.
postulate an internal energy, called de qi, that A number of other mind−body techniques,
is activated by the acupuncture intervention. including biofeedback, guided imagery (Reed,
2007), hypnosis, and deep breathing and
progressive relaxation techniques are
One troubling recurring issue for practicing being employed in healthcare settings.
physicians is the possibility of significant There is interest in these techniques for
stress management in cancer survivors,
interactions between dietary supplements
as part of stroke rehabilitation pro-
and conventional drugs. grams, and for symptom management—
particularly pain management (Morone
Acupuncture continues to be widely em- and Greco, 2007). Nevertheless, physicians need
ployed in China, in both conventional and tradi- to caution patients against relying upon these
tional healthcare settings. In Western practice, techniques as an alternative to effective con-
mechanistic evidence has developed for altera- ventional treatments; for example, studies of
tions in central pain processing and clinical biofeedback for hypertension have not demon-
evidence for impact on two important symp- strated effectiveness (see Table 3 on page 62 for
toms, nausea and pain. Cochrane reviews con- a list of practices).
clude that stimulation of the wrist acupoint, P6,
effectively reduces postoperative nausea and Natural Products
vomiting and that acupuncture has benefits for Epidemiological data point strongly to health
chemotherapy-induced nausea and vomiting benefits of a diet rich in fruits and vegetables.
(Ezzo, Streitberger, and Schneider, 2006), mi- The interest in complementary health approach-
graine treatment and prophylaxis, idiopathic es is a valuable opportunity to remind our
headache, and low-back pain. patients of the importance of a healthy diet, a
In spite of these results, acupuncture re- diet that emphasizes portion control, avoidance
mains controversial in Western medicine: Many of high-density–calorie foods, and incorporation
trials have not demonstrated benefit, even for of the natural variety of fruits and vegetables.
pain, and the specificity of the effects and the Counseling also should emphasize common
risk-to-benefit ratio is uncertain. By and large, sense with more restricted diets, such as vegan
meridian theory has not found convincing diets, the Paleo diet, or any fad diets.
confirmation. In many acupuncture trials, actual Many Americans elect to take a multivitamin
(verum) and simulated (placebo) acupuncture to supplement their diet, or use herbal teas for
have shown benefit relative to conventional common conditions such as colds. In general,
therapy, but simulated acupuncture, performed safety concerns about these agents are minimal.
with needles placed adjacent to (but not on) Although there is a widespread public percep-
meridians, has produced a response that differed tion that the botanical and traditional agents
little, if at all, from stimulation on meridians included in dietary supplements can be viewed
(Haake et al., 2007; Cherkin et al., 2009). These as safe, it is clear that these products can contain
Copyright © 2015 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or
distributed in any form without written permission from the publisher: American Society on Aging, 575 Market
St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications
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Spring 2015 • Vol. 39 . No. 1 | 61
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Copyright © 2015 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or
distributed in any form without written permission from the publisher: American Society on Aging, 575 Market
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62 | Spring 2015 • Vol. 39 . No. 1
Pages 56–64 Self-Empowered Aging
pharmacologically active compounds and have interactions and summaries of the strength of
the associated dangers. Toxicities are not com- the evidence. The botanical agent most frequent-
mon, but vigilance by healthcare providers in ly identified as producing significant changes
reporting suspected problems through Med- in drug metabolism is St. John’s wort (Hyperi-
Watch (U.S. Food and Drug Administration, cum perforatum); it is a potent inducer of both
2015) has been an important component for cytochrome P450 enzymes and intestinal
identifying serious health risks. P-glycoprotein (Hu et al., 2005; Izzo and Ernst,
Currently banned substances include ephe- 2009). Clinically significant interactions have
dra (Ephedra sinica), an herb widely used in been documented with St. John’s wort and
traditional Chinese medicine known as Ma cyclosporin, the anti-retroviral agent indinavir,
Huang; this herb contains ephedrine alkaloids oral contraceptives, coumadin, digoxin, and
and was implicated in a number of deaths prior benzodiazepines, among others (Hu et al., 2005;
to being taken off the market in 2005. Hepato- Izzo and Ernst, 2009). Other widely used
toxicity of herbal products is another regular botanicals such as ginseng (Panax ginseng),
concern; reports of hepatotoxicity associated Ginkgo biloba, kava (Piper methysticum), garlic
with green tea (Camellia sinensis) and black (Allium sativum), and licorice (Glycyrrhiza
cohosh (Actaea racemosa, Cimicifuga racemosa) glabra) have been implicated in occasional drug
have led regulatory authorities to limit sales interactions (Hu et al., 2005; Izzo and Ernst,
of these agents in certain countries, although 2009). The true frequency of drug−supplement
currently they remain available in the Uni- interactions, like the true frequency of drug−
ted States. drug interactions, is unknown, but this is an
A major category of safety concerns about important issue to explore whenever the thera-
dietary supplements is the possibility of drug peutic response is less than expected.
interactions. One of the recurring troublesome Another important category of safety issues
issues for practicing physicians is the possibil- for dietary supplements is the possibility of
ity of significant interactions between dietary contamination or adulteration. A major current
supplements and conventional drugs. Given concern, and the subject of frequent FDA recalls,
the large number of compounds that alter drug is adulteration with active pharmaceutical in-
metabolism, and the frequency with which gredients of dietary supplements marketed for
patients are exposed to many agents, the number weight management, “sexual health,” athletic
of potential interactions is formidable. Interac- performance, and bodybuilding (Cohen, 2009).
tions may occur between prescription drugs, The supplements involved typically have been
over-the-counter drugs, dietary supplements, multi-ingredient mixtures. Common adulterants
and even small molecules in food. It is a daunt- include steroids, diuretics, and phosphodiester-
ing challenge to identify all interactions that are ase type 5 inhibitors.
of clinical concern. Attention to this issue is, of
course, mandatory for drugs with a narrow ther- Conclusion
apeutic index such as warfarin, many cancer An array of unproven therapies will always be
chemotherapeutic agents, immunosuppressants used by patients under our care. As healthcare
such as cyclosporin, and anti-seizure medica- providers, we need to try to approach each
tions. And it is critically important to emphasize encounter as an opportunity to better under-
to patients taking these drugs that they need to stand our patients’ beliefs and expectations and
discuss supplement use. how they guide their personal healthcare prac-
Several useful services are available that tices. Complementary and integrative health
allow quick searches for drug−supplement practices generally reflect an active quest for
Copyright © 2015 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or
distributed in any form without written permission from the publisher: American Society on Aging, 575 Market
St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications
visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join.
Spring 2015 • Vol. 39 . No. 1 | 63
GE NER ATIO NS – Journal of the American Society on Aging Pages 56–64
health. Many of these personal choices are is important, not only to discourage ineffective
innocuous and do not conflict with conventional treatments, but also to harness a partnership
therapeutic interventions. Some will offer genu- with the patient in their active pursuit of health
ine benefits, particularly symptomatic relief, and wellness.
but some of these choices will be potentially
harmful and need to be actively discouraged. Josephine Briggs, M.D., is director, National Center
Understanding the range of health practices for Complementary and Integrative Health, at the
National Institutes of Health in Bethesda, Maryland.
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Copyright © 2015 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or
distributed in any form without written permission from the publisher: American Society on Aging, 575 Market
St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications
visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join.
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