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Winter 2011
The Need to Know — Alternative Medicine and Your PatientsBy Lindsey GetzAging Well Vol. 4 No. 1 P. 16 Complementary and alternative medicine therapies are becoming more mainstream and popular among older adults. But if your patients are taking them, you need to know. From the use of acupuncture to relieve arthritis pain to chiropractic techniques for back problems to drinking green tea for flu prevention, there are many complementary and alternative medicine (CAM) therapies that are becoming more widely accepted not only by the general population but also by many professionals in mainstream healthcare. Studies have shown that older adults are increasingly using CAM as well. The aging population, who may have once been skeptical about some of these less conventional therapies, are often the ones who can benefit the most. However, it can be dangerous when patients start using CAM to replace conventional medicine without first checking with their physicians. It’s an area in which physicians’ scrutiny and diligence can really pay off. CAM encompasses a diverse group of medical and healthcare systems, practices, and products, including herbal supplements, meditation, chiropractic, and acupuncture, that are not generally considered part of conventional medicine. While these types of treatments were once chalked up as “new age-y” or just plain quackery, approximately 38% of adults today use some form of CAM for health and wellness or to treat a disease or condition, according to the 2007 National Health Interview Survey (NHIS). And continued research has fostered growing understanding and acceptance. But in some instances, there can be detrimental consequences to your patients who embrace CAM therapies. For that reason, it’s critical to ascertain whether patients are using therapies of which you may be unaware. Regulation IssuesIt’s important to remember that CAM treatments don’t have to meet the same criteria for approval by the FDA that prescription medications and procedures do, says Steven T. DeKosky, MD, vice president and dean of the University of Virginia School of Medicine in Charlottesville. That means claims can be made on a certain product or procedure’s abilities without having to meet the same level of proof that a prescription drug or medical treatment would. This fact makes it even more important to ensure your patients are being cautious about introducing new treatments. “People buy into these things and there is money to be made by it,” warns DeKosky. “There are ads out there with products making various claims. Some are about avoiding aging and others might be about dealing with the disorders and discomforts of getting older.” DeKosky adds that there are also some unregulated combinations of drugs available that he strongly cautions against patients trying. “These are combinations of medicines that may have impurities and potentially may cause diseases or interact dangerously with other medications,” he explains. “Some may also bolster too much of a drug into the system. For instance, for Alzheimer’s disease, there is an over-the-counter extract of Chinese origin that has the same biological effects as prescription medications for the disease. It’s important that patients don’t take both the extract and the prescription drugs.” Older adults often make good patients for these treatments because they can be gentler than conventional medicines. In fact, they are often very helpful in terms of treating side effects of conventional treatments such as cancer therapies, notes Adriane Fugh-Berman, MD, an associate professor in the CAM master’s program in the department of physiology and biophysics at Georgetown University School of Medicine. “For example,” she says, “nausea is a common side effect of chemotherapy and there are some CAM therapies that may help control it. Acupressure point stimulation for nausea has helped some patients, and there are studies showing that ginger can also be effective.” But regardless of the CAM treatments in which your patients are interested, you need to consider them with respect to possible detrimental effects or interaction with other treatments. Pros and ConsThere are a number of studies that suggest CAM therapies can help prevent disease, according to Elizabeth Mackenzie, PhD, adjunct fellow of the Center for Public Health Initiatives at the University of Pennsylvania as well as coauthor of Healthy Aging: The Whole Woman Approach and a chapter in Integrative Women’s Health and coeditor of Complementary and Alternative Medicine for Older Adults, a book that helps health professionals understand CAM for older patients. Mackenzie says there are a whole host of benefits from engaging in mind-body practices. “Doing yoga, tai chi, or simply meditating can help keep people healthier,” she says. “It can not only help alleviate existing symptoms but can slow the progression of disease and prevent certain diseases from occurring.” Mackenzie also recommends massage for older patients. The Mayo Clinic has reported that massage can be effective for stress relief, stiffness, blood pressure control, managing anxiety and depression, and boosting immunity. It can also help alleviate some of the symptoms associated with cancer treatment. But Mackenzie says there’s another significant reason it can benefit older patients: the need for touch. “Human beings need touch,” she says. “Unfortunately, many older adults are touch-deprived—perhaps not touched often or even ever at all. Therapeutic massage can be a wonderful thing for those patients.” While these treatments can be extremely beneficial, it’s always important that physicians check in with their patients about what they’re doing or what they’re using. Just as many doctors have discovered patients who are cutting pills in half or skipping doses to save money, some may be trying CAM therapies in place of conventional medicine—without their doctor’s knowledge. That’s not to say it’s not possible that some of these CAM treatments could take the place of conventional therapy, says Tanya Edwards, MD, director of the Center for Integrative Medicine at the Cleveland Clinic. “I have older patients coming to me wanting to get off their medication by using CAM, and often times that’s possible,” she says. “It just needs to be done under a doctor’s supervision.” However, it’s important to note that although patients often turn to CAM thinking they may save money, it’s not always the cheaper route. Edwards points out that conventional medications are often covered by insurance, while alternative treatments often are not. “And for the most part, CAM treatments aren’t cheap,” she adds. “It’s a shame because acupuncture can do a world of good, but if insurance doesn’t cover it, patients may not be able to afford it.” Looking for Red FlagsAnother reason patients often turn to CAM lies in their hope of finding a cure for an incurable or life-threatening disease. Experts admit there is currently no reliable scientific evidence of this. Many patients have come across recipes for so-called cancer-curing soups or various concoctions and herbal potions described on the Internet. Fugh-Berman says she doesn’t have a problem with patients trying things that are inexpensive and won’t hurt them. “What I do have a problem with is the $10,000-per-week cancer-curing clinics that aren’t covered by insurance,” she says. “I don’t want to see people getting taken advantage of by those offering expensive treatments that may not be legitimate.” Fugh-Berman says while you can’t necessarily talk somebody out of trying the “quack cancer cure” they are totally set on, you can arm them with good questions. If a physician learns his or her patient is considering one of these treatments, he or she should encourage the patient to ask questions such as these: Are there records kept of successes and failures? Can you tell me the success rate for my type of cancer? Why does it cost so much? Besides treatments that may seem far-fetched or unaffordable, Mackenzie says that of all the CAM modalities, one of the trickiest to safely navigate is herbs because they have the greatest possibility of interacting with pharmaceuticals. “I’d have no qualms about telling patients to meditate, but I wouldn’t want them to start taking a bunch of herbs without knowing what they’re doing,” she says. “Herbs are chemically active. There needs to be communication with the physician.” Such communication is critical since patients often fail to include the herbal remedies they may be taking on a physician’s intake forms under lists of medications. “This is a pretty common occurrence, and it’s often because patients don’t think of supplements as medication,” says Edwards. “Fortunately, there’s an easy solution. Since the nurse often takes a medical history, I would say that physicians need to make sure their office staff is trained to not just use the word “medicine” because patients will automatically assume that means prescriptive medicine. The person taking the medical history should be thorough and ask about any over-the-counter drugs or supplements. They should stress that it’s important for the physician to know about these.” Without that knowledge, there could be serious consequences. St. John’s wort, for instance, can interact with various medications, including Xanax, Elavil, and Lanoxin. In addition, some herbs can have their own sets of side effects. Ginkgo biloba acts as a blood thinner and wouldn’t be safe for someone undergoing a surgical procedure. “It doesn’t mean these types of herbs can’t be used at all,” says Fugh-Berman. “It just means the patient should work closely with their doctor.” Though herbs can have some of their own side effects or interactions, when compared with pharmaceuticals, they are far less potent. Mackenzie says that makes them a great choice for mild ailments. “If I had a life-threatening infection, I’d absolutely go straight to the antibiotics,” she says. “But if I had a low-grade infection, I might try Echinacea first. Herbs will have fewer side effects than pharmaceuticals, but it comes down to education. A lot of patients wouldn’t know what to take, so it’s important to help educate and to talk to your patients.” Integrated MedicineThere are numerous reasons some physicians are still wary of CAM. They question the safety and effectiveness of certain CAM treatments their patients may be trying or don’t want their patients to build false hope. “Physicians are [also] upset that there is not demonstrated proof in many cases of CAM treatments,” says DeKosky. “But while physicians are still cautious, many, like myself, have no problem with CAM treatments as long as they meet a few criteria: They are not toxic; they will not interfere with other medications for the disease that have been shown to work by scientific methods and meet FDA regulations; and they are not so expensive that it becomes a hardship for the patient to afford.” While some in the conventional medicine community remain skeptical, overall, CAM is becoming more widely accepted. That alone is a big change, says Fugh-Berman. “Ten years ago, people did not embrace this,” she says. “There was almost hostility toward it. And while it does still differ in various parts of the country—it’s generally more accepted, for instance, on the West Coast than on the East Coast—I do think the awareness is growing everywhere.” In many places, CAM works side by side with conventional medicine. Patients try some CAM treatments in addition to what they’re already taking or doing with traditional medicine. Mackenzie says the Abramson Cancer Center at the University of Pennsylvania has volunteers who offer Reiki, a form of energy medicine, as part of patients’ treatment. DeKosky recognizes that physicians who are skeptical are just looking out for the best interest of their patients. He believes that mainstream physicians would embrace any CAM treatment that could be proven beneficial for their patients. “In many cases we’re not just out to prove these things don’t work but to prove they are safe and do work,” he says. “Heaven knows I would have been delighted to find out that ginkgo biloba delays Alzheimer’s, but studies have shown it does not. That’s something we were disappointed by. We want to find things that work. With that being said, it’s important to prove if something doesn’t work so that people aren’t wasting their money. The sales of ginkgo biloba dropped significantly in the U.S., partially in response to the trials that showed it wasn’t effective. In the end, it comes down to what’s best for the patient.” Looking AheadAs CAM continues to become more widely embraced, the experts see that trend continuing to expand into the future. “I definitely think its use will become more prevalent, especially as we learn more,” says DeKosky. “We will continue to do studies, hoping to get positive results. I think people will turn to [CAM] more and more as a complementary therapy to conventional treatments.” Mackenzie sees integration growing in the future. She expects that conventional medicine will work even more closely with CAM therapies in a variety of settings. “Thirty years from now, medicine is going to look a lot different,” she says. “We’re learning new things every day, and it’s exciting what possibilities are ahead of us. As more research is done on the mind-body connection, it’s continually becoming more apparent that they are definitely connected, and it makes no sense to treat the body in total isolation from the mind. As this awareness and interest increases, physicians will continue to have new ways to help patients get healthy—and even more important, to prevent disease from happening in the first place.” — Lindsey Getz is a freelance writer based in Royersford, Pa. A Guide to Common CAM TherapiesThere are many CAM treatments available. Here’s a simple guide with definitions and possible benefits to five popular treatments:
— LG Provider Perspective
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