Complementary and IntegrativeTherapies and Practices¶
Chapter 495 | Part 20: Emerging Topics in Clinical Medicine · Parts 19-20 – Consultative & Emerging Topics · Chapter 495
Key Clinical Points¶
- Integrative health care combines conventional and complementary therapies in a coordinated way to improve health in multiple interconnected domains (social, psychological, physical).
- NHIS 2022 data shows 36.7% of U.S. adults used at least one complementary health approach; yoga (15.8%) and meditation (17.3%) are the most common.
- St. John's wort upregulates pregnane X receptor, interfering with metabolism of HIV protease inhibitors (indinavir), topoisomerase inhibitors (irinotecan), and cyclosporine.
- Ephedra sinica was banned by the FDA in 2004 due to severe and fatal adverse events associated with ephedrine alkaloids.
- Homeopathic products are regulated as drugs under the FD&C Act; dietary supplements are regulated under DSHEA.
- Acupuncture is conditionally recommended by the American College of Rheumatology for knee, hip, and hand osteoarthritis.
- Cognitive Behavioral Therapy (CBT-I) is strongly recommended by the American College of Physicians as initial treatment for chronic insomnia.
- Natural products can be toxic; examples include misidentified mushrooms (liver failure) and Aristolochia (genitourinary malignancies).
- Melatonin ingestion reports to poison control centers increased from 8,337 in 2012 to 52,563 in 2021, with many gummy products inaccurately labeled.
- Multicomponent interventions (e.g., yoga, tai chi) often require pragmatic comparative effectiveness designs rather than classic RCTs due to individualization.
DEFINITION & OVERVIEW¶
• Complementary health therapies and practices:
Definition: Practices, interventions, and natural products not typically part of conventional medical care. • Integrative health care: Definition: Conventional and complementary therapies and practices used together in a coordinated way. • Whole person health: Definition: Looking at the whole person—not just separate organs or body systems—and considering multiple factors that promote either health or disease. It involves empowering individuals, families, communities, and populations to improve health in interconnected biological, behavioral, social, and environmental areas. • Alternative: Definition: Usage as a substitute for standard care (term increasingly avoided). • Integrative approaches: Definition: Use of complementary therapies and practices in care settings (e.g., pain management for military personnel, relief of symptoms in cancer patients, programs to promote healthy behaviors).
Glossary of Terms (Table 495-1)¶
• Acupuncture: A family of procedures involving stimulation of defined anatomic points; most common application involves penetrating the skin with thin, solid, metallic needles manipulated by hand or electrical stimulation. • Biofeedback: Use of electronic devices to help people learn to consciously control body functions such as breathing or heart rate. • Dietary supplement: A product intended to supplement the diet, taken by mouth, containing one or more dietary ingredients (vitamins, minerals, herbs, amino acids, etc.), and labeled as a dietary supplement. • Hypnosis: Induction of an altered state of consciousness characterized by increased responsiveness to suggestion. • Meditation: Practices based in Eastern spiritual traditions intended to focus/control attention and obtain greater awareness of the present moment (mindfulness). • Natural products: Products such as herbs (botanicals), vitamins, minerals, and probiotics; often marketed as dietary supplements. • Osteopathy: A clinical discipline incorporated into mainstream medicine that historically emphasized spinal manipulative techniques to relieve pain and promote health. • Relaxation techniques: Practices like progressive relaxation, guided imagery, biofeedback, self-hypnosis, and deep breathing to produce the body's natural relaxation response. • Tai chi: A mind and body practice originating in China involving slow, gentle movements (often called "moving meditation").
EPIDEMIOLOGY¶
• Usage Trends (2002–2022): ◦ Overall use of complementary health approaches increased. ◦ Yoga: 5% (2002) → 15.8% (2022). ◦ Meditation: 7.5% (2002) → 17.3% (2022). • Natural Products (2012): ◦ Estimated 18% of adults and 5% of children used nonvitamin, nonmineral dietary supplements. • Pain Management: ◦ Primary reason for use of complementary therapies. ◦ Patients spend >$14 billion out-of-pocket on complementary therapies for pain management. ◦ Percentage of users reporting use for pain management: 42.3% (2002) → 49.2% (2022). • Economic Impact (2012): ◦ Total out-of-pocket expenditure: $30.2 billion (1.1% of total health expenditures; 9.2% of out-of-pocket costs). ◦ Complementary practitioner visits: $14.7 billion (approx. 30% of what was spent on conventional physician services). ◦ Natural products: $12.8 billion (approx. 24% of what was spent on prescription drugs).
ETIOLOGY & PATHOPHYSIOLOGY¶
• Mechanisms of Action: ◦ Direct Action: e.g., Peppermint oil relaxing gastrointestinal smooth muscle to relieve IBS pain. ◦ Nervous System Effects: Probiotics may have effects on the nervous system as well as the gut. ◦ Immune-Mediated Effects: TCM components, omega-3 fatty acids, and derivatives have immune-mediated anti-inflammatory effects. ◦ Nervous System Targeting: Multicomponent interventions (meditation, acupuncture) target systems affected by pain conditions. ◦ Biopsychosocial Interactions: Integrative group therapy provides tools to manage anxiety/depression alongside pain. • Research Challenges: ◦ Multicomponent Therapies: Standard RCTs are often ill-suited for complex systems like naturopathy or Ayurvedic medicine due to inherent complexity and dynamic relationships. ◦ Methodological Solutions:
Use of pragmatic comparative effectiveness designs with "usual care" comparators. Development of validated, reproducible "manualized" treatment protocols to allow for individualization while maintaining study integrity.
CLINICAL FEATURES¶
• Classification by Primary Input: ◦ Dietary (e.g., herbs, vitamins) ◦ Psychological (e.g., meditation, CBT) ◦ Physical (e.g., massage, acupuncture) ◦ Combined (e.g., yoga, tai chi)
• Primary Dietary Input: ◦ Natural Products: Complex mixtures; activity influenced by individual diet, health, and metagenomic background. ◦ Melatonin:
Used for sleep problems (shift work, jet lag) and pre-surgery anxiety. Safety concern: High incidence of pediatric ingestion; many "gummy" products are inaccurately labeled. • Primary Psychological Input: ◦ Relaxation Techniques: Biofeedback used for stress, anxiety, and tension headaches. ◦ Cognitive Behavioral Therapy (CBT-I): Strongly recommended by the ACP as initial treatment for chronic insomnia. ◦ Mindfulness-Based Stress Reduction (MBSR): Reduces pain via nonopioidergic mechanisms; improves outcomes in low-back pain and fibromyalgia. • Primary Physical Input: ◦ Acupuncture: Evidence: Superior to usual care/sham for chronic musculoskeletal pain, headache, and OA. Recommendations: ACR conditionally recommends for knee, hip, and hand OA. ACP recommends as initial option for low-back pain. Oncology: Recommended to help relieve pain in cancer patients. ◦ Spinal Manipulation: Consideration as nonpharmacologic treatment for low-back pain due to concerns regarding opioid use.
DIFFERENTIAL DIAGNOSIS¶
• Conditions Treated and Indications: ◦ Pain management (musculoskeletal, neuropathic, cancer-related). ◦ Anxiety and depression. ◦ Sleep disorders (insomnia, shift work, jet lag). ◦ Gastrointestinal issues (IBS). ◦ Respiratory conditions (allergic rhinitis). ◦ Oncology support (nausea/vomiting, pain management). • Safety and Contraindications: ◦ St. John's Wort: Interaction with indinavir, irinotecan, and cyclosporine via pregnane X receptor. ◦ Ephedrine: Risk of severe/fatal events; banned in 2004. ◦ Melatonin: Safety concerns in children/teenagers; risk of inaccurate labeling. ◦ Natural Product Toxicity: Misidentified mushrooms (liver failure) and Aristolochia (genitourinary malignancies).
INVESTIGATIONS & DIAGNOSIS¶
• Assessment of Efficacy:
Evaluate based on specific clinical outcomes (e.g., pain scores, sleep latency, anxiety levels). Consider the "multicomponent" nature of treatments like yoga or acupuncture when evaluating results. • Diagnostic Tools and Resources: Refer to Table 495-2 and Table 495-3 for specific databases.
Resource Tables¶
• Table 495-2 (Drug Interaction Resources):
NCCIH: Information on drug-supplement interactions. Medscape: Free drug interaction checker for drugs, herbals, and supplements. NatMed: Subscription-based interactive natural product–drug interaction checker. • Table 495-3 (Information Resources): Cochrane Collaboration: Over 800 systematic reviews of complementary health interventions. MedlinePlus: A–Z database of science-based information on herbal/dietary supplements. NCCIH: Information for providers and consumers; includes "Herbs at a Glance" fact sheets.
MANAGEMENT & TREATMENT¶
• Therapeutic Input Categories: 1. Dietary (e.g., herbal supplements, vitamins, minerals). 2. Psychological (e.g., CBT, meditation, biofeedback). 3. Physical (e.g., acupuncture, massage, spinal manipulation). 4. Combined (e.g., yoga, tai chi).
• Specific Therapy Management: 1. Acupuncture: → Use as initial option for low-back pain. → Use for management of chemotherapy-induced nausea/vomiting. 2. CBT-I: → Primary recommendation for chronic insomnia. 3. Melatonin: → Use for sleep problems (shift work, jet lag) and pre-operative anxiety. 4. St. John's Wort: → Monitor for interactions with indinavir, irinotecan, and cyclosporine.
• Regulatory and Safety Management: 1. Verification of Labels: Especially critical for melatonin products (gummies) which are often inaccurately labeled. 2. Interaction Screening: Check for interactions with common drugs (e.g., St. John's wort and P-gp/CYP substrates). 3. Dosage Monitoring: Ensure "more is not necessarily better" regarding vitamins and minerals to avoid toxicity.
PROGNOSIS & COMPLICATIONS¶
• Safety Concerns and Adverse Events: ◦ Natural Product Toxicity: Risk of liver failure (mushrooms) or genitourinary malignancies (Aristolochia). ◦ Drug Interactions: St. John's wort can significantly alter levels of indinavir, irinotecan, and cyclosporine. ◦ Ephedrine Risks: Potential for severe/fatal events associated with ephedrine alkaloids. • Outcomes and Efficacy: ◦ Acupuncture: Evidence of benefit for musculoskeletal pain persists for up to 12 months. ◦ Mindfulness: Reduces pain via nonopioidergic mechanisms; improves cognitive/health outcomes.
SPECIAL CONSIDERATIONS¶
• Pediatric Considerations: → High risk of melatonin poisoning in children due to inaccurate labeling. → Use of biofeedback for pediatric migraines. • Elderly Considerations: → AREDS/AREDS2 protocols for age-related macular degeneration (AMD). • Regulatory and Marketing Considerations: → Difference between Homeopathy (regulated as drugs) and Dietary Supplements (regulated under DSHEA).
KEY PEARLS & CLINICAL TRAPS¶
• St. John's Wort: High yield for drug interactions (indinavir, irinotecan, cyclosporine) via pregnane X receptor. • Acupuncture: Strong evidence for OA and low-back pain; used in oncology for nausea/pain. • CBT-I: First-line treatment for chronic insomnia. • Melatonin: Useful for pre-op anxiety and shift work, but watch for labeling errors in kids (poison control reports increased from 8,337 to 52,563). • Ephedra: Banned in 2004 due to severe/fatal risks. • Safety Rule: "More is not necessarily better" regarding natural products; they are complex mixtures that can interact with modern medications.
Reference Tables¶
TABLE 495-1 Glossary of Complementary and Integrative Health Therapies and Practices Acupuncture¶
Harrison's 22e, p.3925
| Acupuncture | A family of procedures involving stimulation of defined anatomic points, a component of the major Asian medical traditions; most common application involves penetrating the skin with thin, solid, metallic needles that are manipulated by the hands or by electrical stimulation |
|---|---|
| Biofeedback | The use of electronic devices to help people learn to consciously control body functions such as breathing or heart rate |
| Dietary supplement | A product that is intended to supplement the diet, is taken by mouth, contains one or more dietary ingredients (including vitamins, minerals, herbs, amino acids, or certain other substances), and is labeled as being a dietary supplement |
| Hypnosis | The induction of an altered state of consciousness characterized by increased responsiveness to suggestion |
| Meditation | A group of practices, largely based in Eastern spiritual traditions, intended to focus or control attention and obtain greater awareness of the present moment, or mindfulness |
| Natural products | A variety of products such as herbs (also known as botanicals), vitamins and minerals, and probiotics, which are widely marketed, readily available to consumers, and often sold as dietary supplements |
| Osteopathy | A clinical discipline, now incorporated into mainstream medicine, that historically emphasized spinal manipulative techniques to relieve pain, restore function, and promote overall health |
| Relaxation techniques | A number of practices such as progressive relaxation, guided imagery, biofeedback, self-hypnosis, and deep breathing exercises, with the goal of producing the body’s natural relaxation response, characterized by slower breathing, lower blood pressure, and a feeling of increased well-being |
| Tai chi | A mind and body practice originating in China that involves slow, gentle movements and sometimes is described as “moving meditation” |
TABLE 495-2 Resources for Dietary Supplement–Drug Interactions National Institutes of Health National Center for…¶
Harrison's 22e, p.3927
- National Institutes of Health National Center for Complementary and
Integrative Health (NCCIH) - https://www.nccih.nih.gov/health/know-science/how-medications-supplements-
interact
The National Institutes of Health NCCIH Know the Science initiative provides
information for patients about complex scientific health topics such as drug-
supplement interactions. - Medscape
- http://www.medscape.com/druginfo/druginterchecker?cid=med
- This website is maintained by WebMD and includes a free drug interaction
checker tool that provides information on interactions between two or more
drugs, herbals, and/or dietary supplements. - NatMed
- https://naturalmedicines.therapeuticresearch.com/tools/interaction-checker.aspx
- This website provides an interactive natural product–drug interaction checker
tool that identifies interactions between drugs and natural products, including
herbals and dietary supplements. This service is available by subscription.
TABLE 495-3 Internet Resources on Complementary and Integrative Health Approaches The Cochrane Collaboration…¶
Harrison's 22e, p.3929
- The Cochrane Collaboration Complementary Medicine Reviews
- This website offers rigorous systematic reviews of mainstream and
complementary health interventions using standardized methods. It includes
>800 reviews of complementary health practices. Complete reviews require
institutional or individual subscription, but summaries are available to the public. - http://www.cochrane.org/evidence
- MedlinePlus All Herbs and Supplements, A–Z List
- MedlinePlus Complementary and Integrative Medicine
- MedlinePlus Dietary Supplements
- These National Library of Medicine (NLM) Web pages provide an A–Z database
of science-based information on herbal and dietary supplements; basic facts
about complementary and integrative health practices; and federal government
sources on information about using natural products, dietary supplements,
medicinal plants, and other complementary health modalities. - http://www.nlm.nih.gov/medlineplus/druginfo/herb_All.html
- https://medlineplus.gov/complementaryandintegrativemedicine.html
- http://www.nlm.nih.gov/medlineplus/dietarysupplements.html
- National Institutes of Health National Center for Complementary and
Integrative Health (NCCIH) - This National Institutes of Health NCCIH website contains information for
consumers and health care providers on many aspects of complementary and
integrative health products and practices. Downloadable information sheets
include short summaries of complementary health approaches, uses and risks of
herbal therapies, and advice on wise use of dietary supplements. - http://www.nccih.nih.gov
Resources for Health Care Providers: http://www.nccih.nih.gov/health/providers
NCCIH Clinical Digest e-Newsletter: http://www.nccih.nih.gov/health/providers/
digest
Continuing medical education lectures: http://www.nccih.nih.gov/training/
videolectures
Herbs at a Glance fact sheets: https://www.nccih.nih.gov/health/herbsataglance