Complementary & Integrative Medicine:

What You Need to Know for

the Boards and for Practice

Delila Katz, PharmD • Suzana Makowski, MD MMMUniversity of Massachusetts Medical School, UMass Medical Center

Worcester, MA

We have no financial disclosures

Objectives

Review general concepts, utilization

trends

Address clinical challenges in palliative

care regarding CAM

Apply evidence to palliative care cases

What is CAM ?

A group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. Complementary medicine is used together with

conventional medicine.

Alternative medicine is used in place of conventional medicine.

"Integrative medicine" combines treatments from conventional medicine and CAM for which there is some high-quality evidence of safety and effectiveness.

http://nccam.nih.gov/health/whatiscam/

Prevalence & Use Patterns

Many Americans use complementary and

alternative medicine (CAM) in pursuit of

health and well-being.

The 2007 National Health Interview Survey (NHIS)

~ 38 percent of adults use CAM

CAM use was more prevalent among people with a

prior diagnosis of cancer

40-80% of cancer survivors reported using CAM

18 % had used multiple CAM therapies

Herbal and other natural products 20%

Deep breathing (14 percent), and meditation (9 percent).

http://nccam.nih.gov/health/whatiscam/

Use of complementary/alternative

therapies by women with

advanced-stage breast cancer

Background Pattern of complementary/alternative medicine (CAM) use among a

group of patients with advanced breast cancer Results 73% CAM; relaxation/meditative techniques and herbal medicine

were the most common. Most commonly cited primary reason for CAM use was to boost the immune

system Second most common, to treat cancer.

Friends or family members and mass media were common primary information source's about CAM.

Conclusions A high proportion of advanced-stage breast cancer patients used

CAM. Discussion with doctors was high for ingested products. Mass media was a prominent source of patient information. Credible sources of CAM information for patients and physicians are needed.

BMC Complementary and Alternative Medicine 2002, 2:8

Out of pocket costs of CAM in

the US

Must it be ?

Many patients who use

CAM still don’t tell their

physicians.

What is the responsibility

of the palliative

medicine clinician?

Patients Clinicians

Need to perceive openness Need to demonstrate openness

Need to perceive respect Need to demonstrate respect

Need to perceive interest Need to demonstrate interest

Use driven by cultural identity Need to initiate discussion

Use driven by family historyCan ask about TM/CAM in acute

setting

Use driven by proximity to homeCan still be clinical and evidence-

based

Do not have outward

characteristicsNeed not be content experts

’They Don’t Ask Me So I Don’t Tell Them’

Shelley BM et al. Ann Fam Med 2009 7: 139-147; doi:10.1370/afm.947

Responding to “positive

thinking”

You 43 year old patient with advanced hepatocellular carcinoma recently returned from South America where she was getting care at an alternative medicine center. She shares that her alternative care practitioner tells her to focus on the positive and not think about death, as this will allow it to become part of the possible.

Code status needs to be addressed – how to respond?

Types of CAM ?

Mind-body medicine

Natural products

Manipulative and body-based practices

Movement therapies

Energy medicines

Whole systems Chinese, ayurvedic, anthroposophical, homeopathy,

naturopathy

http://nccam.nih.gov/health/whatiscam/#types

Mind-Body Medicine

Question

Ms Johes is a 63 yo with

ovarian cancer, who has

recently experienced

increased difficulty with

insomnia. Her current medications include:

morphine SR 45mg bid,

morphine IR 15mg q2 hours

prn, dexamethasone 4mg

qam, and a good bowel

regimen. She shares that her mind is busy with worry, and

once she falls asleep, she

stays asleep. The chaplain has been working with her.

Which of the following

should you recommend

next?

a) Lorazepam before bed

b) Chamomile before bed

c) Sleep hygiene

d) Lavender footbath

before bed

e) Kava kava before bed

f) Metatonin before bed

Question

Ms Johes is a 63 yo with

ovarian cancer, who has

recently experienced

increased difficulty with

insomnia. Her current medications include:

morphine SR 45mg bid,

morphine IR 15mg q2 hours

prn, dexamethasone 4mg

qam, and a good bowel

regimen. She shares that her mind is busy with worry, and

once she falls asleep, she

stays asleep. The chaplain has been working with her.

Which of the following

should you recommend

next?

a) Lorazepam before bed

b) Chamomile before bed

c) Sleep hygiene

d) Lavender footbath

before bed

e) Kava kava before bed

f) Metatonin before bed

Insomnia and interventions Lorazepam (and other benzos) – may have a “hangover”

effect. Not first line. Behavorial approaches are

Chamonile is a mild hypnotic tea. Research is poor, limited. But it is generally safe and may be added as part of “sleep hygeine”

Lavendar foot bath – is essentially a means of sleep hygiene, with an added “twist”. Behavioral interventions – including sleep hygiene, CBT, are first line treatment with strongest evidence of support. Lavender aromatherapy has been shown to decrease delirium in the elderly.

Kava Kava and Valerian are two of the strongest hypnotics of the herbal-kind. Kava has been banned in EU due to risk of liver failure. Valerian has the strongest evidence as herbal treatment for insomnia.

Melatonin is a hormone that normalizes the sleep-wake cycle. It won’t help her “busy-mind,” but may be helpful if she had a sleep-wake cycle shift, or if on SSRI. (2- 7 mg)

Burnout

Dr. E. Is mid-way through

his hospice & palliative

care fellowship. He

confides that he has is

more distant and

detached with patients.

You have also noticed

this.

He is exhausted and also

shares that he is having

difficulty sleeping. He

wonders whether he has

made the right career

decision.

What would you recommend

to him?

a) Recommend St. John’s Wort

(hypericum perforatum)

b) Recommend an SSRI

c) Recommend bright light

therapyd) Recommend mindfulness

meditation

Burnout

Dr. E. Is mid-way through

his hospice & palliative

care fellowship. He

confides that he has is

more distant and

detached with patients.

You have also noticed

this.

He is exhausted and also

shares that he is having

difficulty sleeping. He

wonders whether he has

made the right career

decision.

What would you recommend

to him?

a) Recommend St. John’s Wort

(hypericum perforatum)

b) Recommend an SSRI

c) Recommend bright light

therapy

d) Recommend mindfulness

meditation

Natural products

QuestionYou are working at your local hospital on the Consultation

Service and meet a 47 year old man with metastatic

colorectal cancer. His oncologists asks you see him in the

clinic to help with goals of care, explaining, “He insists on using

alternative therapies. I can’t go through these bags of herbs

and want him to stop all. Maybe you can help.”

After clarifying with the patient that he would like to try some

first line therapies, he also is interested in maintaining his “herbal” approaches, that help give him a sense of control.

He is willing to stop some, but not all.

Which are safe and has the strongest evidence to provide

him some chemoprotective benefits and symptom relief?

a) Vitamin E

b) Tumeric (Curcuma longa)

c) Ginger (Zingiber officinale)

d) St. John’s Wort (Hypericum

perforatum)

Question

You are working at your local hospital on the Consultation

Service and meet a 47 year old man with metastatic

colorectal cancer. His oncologists asks you see him in the

clinic to help with goals of care, explaining, “He insists on using

alternative therapies. I can’t go through these bags of herbs

and want him to stop all. Maybe you can help.”

After clarifying with the patient that he would like to try some first line therapies, he also is interested in maintaining his

“herbal” approaches, that help give him a sense of control.

He is willing to stop some, but not all.

Which are safe and has the strongest evidence to provide

him some chemoprotective benefits and symptom relief?

a) Vitamin E

b) Tumeric (Curcuma longa)

c) Ginger (Zingiber officinale)

d) St. John’s Wort (Hypericumperforatum)

Link, A., Balaguer, F., & Goel, A.

(2010). Biochemical

pharmacology, 80(12), 1771-92. \

Ginger

Curcumin

Curcumin

1666 articles on curcumin in Pubmed (1/2012)

Doses: 1-4 g PO in divided doses daily.

MOA:

Curcuminoids induce glutathione S-transferase and are potent inhibitors of cytochrome P450.

Turmeric acts as a free radical scavenger and antioxidant, inhibiting lipid peroxidation and oxidative DNA damage. It also inhibits activation of NF-kB 17, 20, c-jun/AP-1 function, and activation of the c-Jun NH2-terminal kinase (JNK) pathway.

May decrease efficacy of cyclophosphamide-based chemotherapies

Used for: anti-tumor treatment, arthritic pain, IBD

Contraindicated in bile-duct obstruction

St. John’s Wort –

Hypericum perforatum

Clinical Pearls: St. John’s Wort is contraindicated for patients on HIV

protease inhibitors and non-nucleoside reverse transcriptase inhibitors.

Also caution with SSRIs – SSRI + SJW consider serotonin syndrome

Question

A nurse calls you from a

patient’s home. The patient

has a hospice diagnosis of end-

stage heart failure. She has

been on metoprolol, enalapril,

furosemide, morphine prn. Ptcomplains of new headaches,

increased thirst, edema despite

increase in furosemide, fatigue

and leg swelling

Other PMH includes: mild

asthma, GERD

On exam: BP 170/106, P98

irregular. Edema is significant bilaterally

An infusion (herbal

tea) with which of

the following is the

most likely cause?

a) Ginger

b) Licorice

c) Dandelion

d) Peppermint

Question

A nurse calls you from a

patient’s home. The patient

has a hospice diagnosis of end-

stage heart failure. She has

been on metoprolol, enalapril,

furosemide, morphine prn. Ptcomplains of new headaches,

increased thirst, edema despite

increase in furosemide, fatigue

and leg swelling

Other PMH includes: mild

asthma, GERD

On exam: BP 170/106, P98

irregular. Edema is significant bilaterally

An infusion (herbal

tea) with which of

the following is the

most likely cause?

a) Ginger

b) Licorice

c) Dandelion

d) Peppermint

Licorice

Licorice with glycyrrhizin

Licorice – pseudoaldersteronism (HTN, metab alkalosis, hypokalemia)

People with the following conditions should not take licorice: Heart failure Heart disease Fluid retention High blood pressure (hypertension) Diabetes Kidney disease Liver disease

Pregnant or breastfeeding women should not take licorice.

Use of any licorice product is not recommended for longer than 4 - 6 weeks.

What is the alternative? - Deglycyrrhized licorice (DGL)

Marijuana as a natural

product

48 yo woman who has stage IV colon

cancer and has increasing nausea, has

been smoking 3-4 marijuana

cigarettes/day to help. Patient also has

had recent radiation to the pelvis

What are your concerns?

Marijuana – commercially

available alternatives

Dronabinol

Nabilone

CME (available in Canada)

Medical marijuana

Not medical marijuana

Manipulative & Body-based

practices

Massage therapy

A nurse at your hospice has recently obtained a 2000 hour certification in massage therapy and would like to bring massage as a therapy to patients at home. The administrator says to you, “Anyone would want a massage, but before I invest, what’s your perspective as our medical director. The study by Kutner et al – showed some benefit, but questioned its efficacy because of a limited duration. What do you think?”

What is your response?

Acupuncture

Which of the following is reasonable to use acupuncture for? Pain

Nausea/vomiting

Xerostomia

Headaches

Movement

Therapies

Energy Medicine

Whole Medical Systems

Anthroposophical Medicine

Benign or Malignant

62 yo male with end stage pancreatic cancer has been using alternative medicine for 20 years, he has strongly held belief that the toxic environment is worsening his illness. To detoxify he uses Cholonics

Chelation

Herbal teas and fasting

What do you need to be concerned about ?

Question

You receive a call from Dr. Reyes, a local naturopathic physician

to refer one of her patients to your hospice. She has been the

primary care physician for Mr. Jones, an 81 year old gentleman

who has metastatic pancreatic cancer with liver involvement. He does not wish chemotherapy, and hopes to focus on quality

of life. He has no other physician.

Current medications: Morphine CR 80mg bid, morphine IR 15-

30mg QID prn, dexamethasone 4mg daily, deglycyrrhized

licorice, peppermint extract, curcumin, valerian prn anxiety or

insomnia.

What role can Dr. Reyes play when Mr. Jones is on your hospice?

What are your concerns?

Summary

There are similar challenges in integrative medicine as there are

in conventional medicine with regards to our field.

Communication is important – to avoid dangers, to enhance clinician-patient rapport.

Recognize that our field is perhaps the most integrated of all

Resources http://www.mskcc.org/mskcc/html/11570.cfm

http://nccam.nih.gov/ (National Center For Complementary and Alternative Medicine)

http://ods.od.nih.gov/ (Office of Dietary Supplements)

http://naturaldatabase.therapeuticresearch.com/home (Natural Medicines Comprehensive Database)

http://www.integrativeonc.org/ (Society for Integrative Oncology)

http://fitsweb.uchc.edu/student/selectives/atolsdorf/index.html

http://www.drweil.com/