“CAM is a SCAM!Complementary and Alternative ‘Medicine’

Has No Place in Rheumatology”

Steve Overman

the

“CON” Man

Con Man Disclosures• I make no money off CAM

therapies or through CAM investments.

• I do refer to CAM therapists.

• Our group has a “Mindfulness” therapist and naturopathic school trained dietician in our office.

• I have no CAM training or special expertise.

“CAM is a SCAMand has no place in Rheumatology”

CON position

• The first cannot be true if there is at least one example where CAM is not a SCAM

• CAM services are increasingly integrated into other conventional systems of medical care and so should rheumatology.

Robert

• 50 year man with 68kd + lupus like illness with cerebritis

• Cytotoxic meds and hospitalization with six grams of IV steroids

• Terminal care plan developed

• Two energy healing encounters

• He chose life over death

What is CAM?

Diverse medical and health systems, practices and products that are NOT Conventional

How do we decide what’s conventional?

What is “conventional” when …

"about half the general population in developed countries use complementary and alternative medicine (CAM).“

Edzard Ernst, Professor of Complementary Medicine at the University of Exeter, Medical Journal of Australia

Which Is “conventional”?The most prevalent? oldest? proven?

What is a SCAM?Wikipedia

• A British band• An Aussie album• A 1993 film• A “Soluble Cell Adhesion Molecule”• Supplementary CAM

• A Hoax or a deliberate attempt to deceive or trick people into believing or accepting something which the hoaxer knows is false.

Where are the SCAMs?

• $2.5 trillion spent US healthcare

• Estimated 10% or $250 billion is consumed by fraud, waste and abuse.

• Only $34 billion in 2007 was spent on all of CAM

Does a case prove a principle?• Are there CAM providers that take

advantage of patient and population fears?YES

• Are there nutraceutical companies that promote products that don’t have proven benefits? YES

• Are there therapies not covered for by insurance companies because they are considered as CAM and without proven benefits? YES

• Are there businesses with unethical CEOs that created huge SCAMs? YES

ARE ALL BUSINESSES AND ALL CAMs SCAMS?

Federal response to CAM• October 1991— The U.S. Congress provided $2 million in

1992 to establish Office of Alternative Medicine (OAM).

• December 1993—The Alternative Medicine Program Advisory Council was established.

• 1994 - Congress passed the Dietary Supplement Health and Education Act. DSHEA established the term “dietary supplement” and decreed that supplements are to be regulated similar to foods.

• October 1996— A Public Information Clearinghouse was established.

• 1997 - First large, multicenter trial of a CAM therapy – St. John’s Wort for depression.

Feds & CAM • October 1998— National Center for Complementary and

Alternative Medicine (NCCAM) was established by Congress and $48.9 awarded

• 2000 - The Consortium of Academic Health Centers for Integrative Medicine was launched and now has 46 members in the US and Canada.

• February 2001 — NCCAM and the National Library of Medicine launch CAM on PubMed, a comprehensive Internet source of research-based information on CAM, currently with 40,000 citations.

• January 2005 — The National Academies' Institute of Medicine released a report, Complementary and Alternative Medicine in the United States.

• July 2009—The first nationally representative figures were released on how much Americans spend on CAM, from a nationwide government study partly by NCCAM.

National Center for Complementary and

Alternative Medicine (NCCAM) • Director:

Josephine P. Briggs, M.D. • Deputy Director:

Jack Killen, M.D. • Established:

October 1998 • Funding:

$128.8 Million (FY 2010) • Staff:

Approximately 65 FTEs

CAM Therapies included in the 2007 NHIS

• Acupuncture • Ayurveda• Biofeedback • Chelation therapy • Chiropractic or osteopathic

manipulation• Deep breathing exercises • Diet-based therapies • Energy healing therapy/Reiki• Guided imagery• Homeopathic treatment• Hypnosis• Massage

• Meditation• Movement therapies• Natural products (non-

vitamin and non-mineral, such as herbs and other products from plants, enzymes, etc.)

• Naturopathy• Progressive relaxation• Qi gong• Tai chi• Traditional healers• Yoga

http://nccam.nih.gov/news/2008/nhsr12.pdf

http://nccam.nih.gov/news/camstats/2007/72_dpi_CHARTS/chart4.htm

CAM COSTS

1.5% of total health care expenditures

11.2 % of total $33.9 billion out-of-pocket expenditures are for CAM services• 2/3 on self-care costs [CAM products,

classes, and materials]• 1/3 on CAM practitioners

Why do people use CAM?

• Orthodox medicine– Didn’t work– Caused side effects– Didn’t acknowledge

their suffering

• Values the whole person

• Invites active participation in their treatment

• CAM helps

CAM is Scam

The “CON” Man

Overman

What’s the evidence?or

Where’s the tofu?

What rheumatologists in the United States think of CAM: national survey regarding chronic back or joint pain care

NJ Manek, BMC Complement Altern Med. 2010; 10: 5.

CAM Research GrowthReviews, Metas, and RCTs

Cochrane and Non-Cochrane Reviews

March 2004 Therapy Cochrane Non-Cochrane Acupuncture 10 69Alexander technique 1 0Art therapy 1 1Biofeedback 2 26Chiropractic 2 33Dietary supplements 71 46Electromagnetic therapy 3 11Herbal therapy 23 79Homeopathy 4 34Laser therapy 4 4Massage therapy 4 18Prayer 1 2TNS 1 1Therapeutic touch 1 3Yoga 2 4Other 27 91

What’s the bottom-line?Cochrane CAM Reviews

Conclusion Category Readers’ Consensus

(n = 145) (%)

Positive effect 36 (24.8)Possibly positive effect 18 (12.4)Two active treatments are equal 1 (.6)--------------------------------------------------------------------Insufficient/ inconclusive evidence 82 (56.6)--------------------------------------------------------------------No effect 7 (4.8)Harmful effect 1 (.6)

Cochrane Reviews

Conclusion category Readers’ Consensus

CAMCONVEN

Positive or possibly + 37% 41%

Insufficient/inconclusive 57% 21%

No effect 5% 20%

Harmful effect 1% 8%

Should the Rheumatology community embrace CAM?

Could there be

some

surprises?

To treat OA of the Knee?RCTs showing benefit

• Feldenkrais• Alexander technique• Massage • Qi Gong• Tai Chi• Transcutaneous Nerve Stimulation• Acupuncture• Water therapy

To treatment Fibromyalgia? Qualitative Review of RCTs of CAM

23 RCTs - 1992 to 2007

• Balneotherapy/hydrotherapy had best evidence in multiple studies.

• Mindfulness meditation showed mostly positive results in two trials • Acupuncture showed mixed results in multiple trials with a tendency

toward positive results.

• Connective tissue massage and osteopathy showed tendencies for improvement

• Qi Gong, biofeedback, and body awareness therapy showed no positive evidence.

Baranowsky J Rheumatol Int. 2009 Nov;30(1):1-21. Epub 2009 Aug 12.

To reduce costs of care?

“This analysis indicates that among insured patients with back pain, fibromyalgia, and menopause symptoms, after minimizing selection bias by matching patients who use CAM providers to those who do not, those who use CAM will have lower insurance expenditures than those who do not use CAM.”

Comparison of Health Care Expenditures among Insured Users and Nonusers of CAM in Washington State: a cost minimization analysis.

Lind BK etal,J Altern Complement Med. 2010 Apr;16(4):411-7.

To keep up with the rest of medicine?

• CAM & Medical centers – 72,000 • CAM & Cancer Centers – 81,00081,000 • CAM & Spine Center or

Pain Centers - 3693• CAM & Arthritis Clinics or

Rheumatology Centers – 617617

Google Search

NCCAM CAM Menu • Mind-body

medicine• Biologically based

practices• Manipulative and

body-based practices

• Energy medicine• Whole medical

systems

Mind-body Medicine

Techniques designed to enhance the mind's capacity to affect bodily function and symptoms. • Meditation or guided imagery• Biofeedback, progressive

relaxation or deep breathing• Prayer• Yoga [Tai Chi or Gi Gong]• Creative outlets such as art,

music, or dance.

Randomized Trials of Group Counseling & Support showing Survival Benefit

Study Cancer N Psychological Outcome

Spiegel et al 1989 Metastatic Breast 86 Less distress, pain

Richardson et al, 1990 Lymphoma, leukemia 94 Better rx adherence

Fawzy et al, 1993 Melanoma 66 Less distress, better

coping

Kuchler et al, 1999 GI cancers 271 Better stress management

McCorkle et al 2000 Solid Tumors 375 Less distress

Arthritis Self-Help Program

“We tested the patients’ perceived self-efficacy to cope with the consequences of their arthritis and found high correlations with the patients’ outcomes.”

Lorig K, Arthritis Rheum 1989;32:37-44.

Biologically Based Practices

Substances found in nature:• Foods• Vitamins• Nutraceuticals• Herbs• Special diets

Diet Issues in Arthritis

• Anti-inflammatory diet

• Inflammatory triggers – gluten, wheat, corn, dairy, nuts, alfalfa, beef, tartrazine

• Bacterial balance – probitotics & prebiotics

• Vitamins – Vit D, B12, B6

• Minerals – gold, zinc, calcium, selenium

• Special diets

• Herbs – Thunder god vineUp-To-Date

Anti-inflammatory DietMore Less

Whole grains Fresh fruits and vegetables Legumes (soy, lentil) Seeds and nuts (almonds,

walnuts)----- these provide ------

Fiber Isoflavones – genisten, daidzein, etc Carotenoids – a / b carotene, lycopene,

and lutein Flavonoids – quercetim epigallocatechin-

3-gallate, anthcyanindins Plant sterols Omega-3-fatty acids Monosaturated olives Probiotic-rich foods Other: curcumin, ursolic & oleanic acid

Trans fats/partially hydrogenated oils

Oils – sunflower, safflower, cottonseed, and corn oils

Refined sugar and high glycemic foods (high fructose corn syrup, candy, fruit juices, and soda)

High saturated foods – animal fats, cheeses, egg yolks

Fried foods – fast foods, doughnuts Highly processed – hot dogs, meats Refined starches – muffins, totillas,

pasta, rice Baked and pastry goods Alcohol and caffeine excess

NUTRITION AND DIETARY SUPPLEMENTS: Firestein: Kelley's Textbook of Rheumatology, 8th ed.

ResourcesNSF International

Not-for-profit organization that provides certification and safety audits for the food, water and consumer products

Certifies manufacturing facilities where the products are produced

U.S. Pharmacopeia, or USP Less comprehensive dietary supplement testing

program with primary focus on drug testingNatural Medicines Comprehensive Database

Provides evidence-based information on natural medicines

Regular email updatesMedline Plus

Drugs, Supplements, and Herbal Information

Energy Medicine

Energy therapies involve the use of energy fields.

• Biofield therapies are intended to affect energy fields that purportedly surround and penetrate the human body.

• Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields.

Disciplines that involveEnergy Medicine

• Qi Gong - A component of traditional Chinese medicine that combines movement, meditation, and controlled breathing. The intent is to improve blood flow and the flow of Qi.

• Reiki - A therapy in which practitioners seek to transmit a universal energy to a person, either from a distance or by placing their hands on or near that person. The intent is to heal the spirit and thus the body.

• Therapeutic Touch - A therapy in which practitioners pass their hands over another person's body with the intent to use their own perceived healing energy to identify energy imbalances and promote health.

“Warrior Reset Clinic”Fort Hood, Texas

• PTSD clinic run by Jerry Wesch, PhD, Psychologist & Reike master

• Foundation to Reike healing is that all healing is self-healing

“We don’t know why it works, but we know that it works.”

Whole Medical Systems Western cultures • Homeopathic medicine

Small doses of toxic substances to stimulates the body’s ability to heal itself.

• Naturopathic medicine Originating in Europe, it aims to support the body’s ability to heal through dietary and lifestyle changes, along with other CAM therapies.

Non-Western cultures • Traditional Chinese medicine - A

whole medical system with practices such as herbs, meditation, massage, and acupuncture seek to aid healing by restoring the yin-yang balance and the flow of qi.

• Ayurveda - A whole medical system of herbs, massage and Yoga from India that aims to integrate the body, mind, and spirit to prevent and treat disease.

Why are Rheumatologists afraid to jump into CAM?

The

Seattle

Arthritis Clinic

did ..did ..

After jumping we …• Surveyed our patients and published books• Brought medical family therapy interns and

counselors into the office• Offer a Mindfulness based Pain Management Group • Hired ARNP who initiates TNS unit trials, teaches

about medications and assists with psycho-social care coordination

• Added alternatively trained Registered Dietician• Screen all new patients - function, pain, depression,

panic, 10 domains of stress, alcohol, sleep, bipolar, self-care effectiveness.

• Screen follow-up patients - RAPID-5 questionnaire, ROS, pain diagram, self-care, medical update

• Lecture to local naturopaths, chiropractors & ARNPs • Refer to acupuncture, Tai Chi, massage, Feldenkries

and other therapists

CAM Conclusions

• CAM is not an “it”

• CAM is not a SCAM

• More total system health services

research is needed

• If we are not careful when studying CAM,

we just might learn something

This Con Man is DONE !

Why I embrace learning more about CAM?

• To better understand my patient’s values and why he/she is involved

• To better know which CAM therapies my patients is using and how that therapy might interact adversely with my care, or be a SCAM, or have toxicity

• To use some CAM therapies to improve “dynamic homeostasis” and promote self-healing

• To learn more about whole systems of care and create a “whole” program for each patient

• To create more cost-effective care strategies

“Crossing the Quality Chasm: A New Health System for the 21st Century”

National Academy Press: Institute of Medicine. 2001

Rules to Redesign and Improve Health Care:

1. Care based on continuous healing relationships.2. Customization based on patient needs and values.3. The patient as the source of control.4. Shared knowledge and free flow of information.5. Evidenced-based decision making.6. Safety as a system priority. 7. The need for transparency.8. Anticipation of needs.9. Continuous decrease in waste.10. Cooperation among clinicians.

Integrative Medicine and Public Health

2009 Institute of Medicine Report that recommends how Integrative Medicine can work to

transform the health care system

• patient-centered care• personalized, predictive, preventive• participatory medicine• mind-body relationships• the expanding science base in genomics,

proteomics, and other fields• health care financing reform• shared decision making• value-driven health care• team-based care processes

What does the future look like?How might Rheumatology “Integrate”?

• Develop more integrated rheumatology practices• Services offered• Services coordinated• Outcomes measured

• Develop an MSK / Rheumatology Home• Manage a population

TSAC Patient Survey Survey: 160 consecutive patients from our

community-based, 100% referral practice

Results: top 7 areas of interest:Living well with your illness – 75%

Managing fatigue - 65%

Exercise Therapies - 64%

Managing pain - 63%

Understanding fibromyalgia - 52%

Stress management - 49%

Diet therapies - 48%

Interests in Patient-centered Care

Mind-Body Books

Are Probiotics ready for use in IBD & IBS?

• Competitive exclusion

• Enhanced epithelial barrier integrity

• Antimicrobial activity

• Regulation of mucosal immune responses

• Regulation of systemic immune response

R. Fedorak, AGA Perspectives, www.gastro.org

Resources• National Center for Complementary and

Alternative Medicine [NCCAM]• www.nccam.nih.gov/health/whatiscam/ • Complementary and Alternative Medicine:

MedlinePlus• www.nlm.nih.gov/.../

complementaryandalternativemedicine.html • Complementary and Alternative Medicine• www.noah-health.org/en/alternative/ • Complementary and Alternative Medicine -

National Cancer Institute• www.cancer.gov/cancertopics/treatment/cam

Complementary and Alternative Medicine in the USCommittee on the Use of Complementary andAlternative Medicine by the American Public

Copyright © National Academy of Sciences. ISBN: 978-0-309-09270-8, 360 pages, 6 x 9, hardback (2005)

NCCAM Online Education Series Chapter I: Overview of Complementary and Alternative Medicine Chapter II: Herbs and Other Dietary Supplements Chapter III: Mind-Body Medicine Chapter IV: Acupuncture: an Evidence-Based Assessment Chapter V: Manipulative and Body-Based Therapies: Chiropractic

and Spinal Manipulation Chapter VI: Complementary and Alternative Medicine and Aging Chapter VII: Integrative Medicine Chapter VIII: Health and Spirituality Chapter IX: Studying the Effects of Natural Products Chapter X: Neurobiological Correlates of Acupuncture Course Evaluation

This educational activity for a maximum of 10 AMA PRA Category 1 Credit(s)TM is free [http://videolectures.nccam.nih.gov/main.php]