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PERSPECTIVERacing Toward The Integration Of Complementary And Alternative Medicine: A Marathon Or A Sprint?
Health care opinion leaders concur that integration of complementary and alternative medicine (CAM) into the U.S. health care system must be based on strong supporting evidence of safety and efficacy. As others have pointed out, integration is under way, despite the lack of reliable, rigorous science supporting the use of most CAM treatments. We contend that optimal integration of CAM is a long-term endeavor—a marathon rather than a sprint. The evidence base does not now support its wholesale assimilation; market forces, although compelling, should not be the primary consideration in integration.
What is integrative medicine, and why is it growing in acceptance? Mary Ruggie addresses these questions in this volume of Health Affairs.1 She presents evidence that integrative medicine is popular now for several reasons: growing use of complementary and alternative medicine (CAM) by the public, establishment of the National Center for Complementar y and Alternative Medicine (NCCAM) at the National Institutes of Health (NIH), and scientific research on CAM’s safety and efficacy. These may all contribute to the conditional "integration" of some aspects of CAM by conventional health care providers.
Integrative medicine can be defined in many ways. Most definitions include, to some degree, the concept that the best of CAM is combined with the best of conventional medicine, based on evidence.2 They do not include the type and level of evidence that should be required. Nonetheless, evidence hierarchies place data collected from multiple randomized controlled trials (RCTs) or systematic reviews of multiple RCTs as the highest standard of evidence.3
An Institute of Medicine (IOM) analysis of all identified systematic reviews relating to CAM (N = 496) encompassed such widely used CAM therapies as chiropractic medicine, herbal medicine, and massage therapy, as well as lesser-used therapies such as the Alexander technique, biofeedback, and therapeutic touch.4 Two striking facts are apparent when this review is compared with data on the prevalence of CAM. First, the attention given to a CAM practice by the scientific community does not correlate with its use by the public. For instance, the IOM identified seventy-nine reviews of acupuncture and thirty-eight reviews of homeopathy (placing them third and fourth among all CAM therapies), yet less than 1.5 percent of the U.S. public uses these therapies in a given year.5 In addition, only one-fourth of the 145 Cochrane Collaboration reviews of CAM examined in the IOM report concluded that a given CAM therapy worked; two-thirds cited insufficient evidence to make a definitive determination. Interestingly, only 11 percent of the reviews supported the use of herbals and other nonvitamin/nonmineral dietary supplements, which are the most prevalent types of CAM used, other than prayer for health reasons.6 This indicates a disconnect between what people use and where the evidence lies. The second striking fact is that CAM therapies with relatively infrequent use by the public (such as biofeedback, hypnotherapy, and acupuncture) are those with the highest level of acceptance by physician groups, which typifies the inadequate communication between patients and providers concerning CAM.7
In support of Ruggie’s argument, surveys of health maintenance organizations (HMOs) indicate that the most prominent reason such organizations incorporate CAM into their coverage is market demand.8 This demand might derive partly from the public’s desire to take charge of their own health care.9 Comparisons of national surveys about CAM in 1990–1997 and 2004 suggest that visits to CAM practitioners have remained relatively stable on a percentage basis over time, while the use of dietary supplements has greatly increased.10 This increase, combined with the large number of people who practice one or more forms of mind-body medicine, suggests that the dominant forms of CAM are those used by the individual as part of self-care. In fact, half of those who used CAM said that they did so because they thought it would be interesting to try, not because of cost or efficacy.11 The public’s interest in CAM also derives from a belief that CAM approaches are more natural and safer than conventional medicine.12 On the contrary, some widely used herbal medicines can interact with certain pharmaceuticals and have life-threatening consequences. A well-documented example of this is the effect of a widely used herbal supplement, St. John’s wort, on the clearance of many prescription drugs by the liver.13 Ideally, everyone interested in using any form of CAM would seek the advice of a learned practitioner, but this is unrealistic given the way herbal supplements are advertised and sold in the United States. In fact, the IOM argues that U.S. regulation of dietary supplements needs substantial revision to increase public safety.
Given that integration of CAM is under way, one approach would be to gather epidemiological data on safety and outcomes using practice-based networks, rather than to wait for controlled trials. Recent medical literature, however, is marked with cases, such as hormone replacement therapy (HRT), where conclusions based on extensive epidemiological data from practices in widespread use were overturned by clinical trials. An added complication is the wide variation in the clinical application of many types of CAM, especially those using physical interventions. For instance, it has been found that there is little agreement in the choice of acupuncture points that various acupuncturists might use to treat the same patient with chronic back pain.14 Similarly, there is considerable variability in how licensed naturopathic physicians would treat a person with multiple sclerosis or breast cancer.15 Although individualized treatments might eventually prove advantageous when addressing patient heterogeneity, outcomes research on CAM needs to account for this variability. This leaves us with the following question: How can we integrate CAM when so many research questions remain unanswered?
Through the support of rigorous science, the NCCAM and other NIH institutes are committed to answering these and other questions concerning CAM’s safety and efficacy. Results of this research, disseminated through the literature and the NCCAM’s fact sheets, e-bulletins, and Web site, will help identify CAM therapies that are ready for integration. Even when evidence of efficacy is available, issues associated with translation into practice will remain. An Agency for Healthcare Research and Quality (AHRQ) report, Closing the Quality Gap, has detailed the difficulties of incorporating evidence-based recommendations into conventional clinical practice.16 These are likely to be magnified in the case of CAM, which has to overcome the skepticism of conventional providers and concerns regarding safety and efficacy. Conventional providers, unfamiliar with CAM, might require education as well as information dissemination. Optimal integration of effective CAM therapies would also require patient education, since self-care appears to be a current driver of usage. Increased communication between patients, CAM practitioners, and conventional providers is vital to protect patient safety. This is likely to necessitate some organizational change in the practice of both CAM and conventional medicine and in the current system of third-party reimbursement for health care costs. Just as a marathon is made up of many small steps, so too would be the integration of CAM into the U.S. health care system. With each new piece of information, the scientific base on CAM will increase. It is critical that conventional health care providers learn about CAM and begin conversations with their patients about its potential risks and benefits. Through continued awareness of the CAM scientific literature and support for their patients, providers will help us win the race for maximizing health care quality.
Richard Nahin (nahinr{at}mail.nih.gov) is senior adviser for scientific coordination and outreach at the National Center for Complementary and Alternative Medicine (NCCAM), National Institutes of Health, in Bethesda, Maryland. Carol Pontzer is a program officer at the NCCAM; Margaret Chesney is its deputy director. The authors are indebted to many members of the NCCAM for their advice on earlier versions of this manuscript.
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Required evidence.
Use versus evidence.
